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APS Supervisor Core: �Understanding Trauma Informed Care for APS Supervisors

We create experiences that transform the heart, mind, and practice.

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About the Academy & APSWI

The Academy is a project of San Diego State School of Social Work. Serving over 20,000 health and human services professionals annually, the Academy’s mission is to provide exceptional workforce development and learning experiences for the transformation of individuals, organizations and communities.

APSWI, or Adult Protective Services Workforce Innovations, is a training program of the Academy that provides innovative workforce development to APS professionals and their partners.

Academy programs: APEX, A P S W I, C W D S, Lia, Rise, Saks, and Tribal Star.

ACADEMY PROGRAMS

San Diego State University

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About APSWI & The Academy

Adult Protective Services Workforce Innovations (APSWI)

Training program of the Academy for Professional Excellence, a project of the San Diego State University School of Social Work.

APSWI provides innovative workforce development to APS professionals and their partners.

The Academy provides workforce development and learning experiences to health and human service professionals.

We create experiences that transform the heart, mind, and practice.

Academy Programs include:

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Housekeeping

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OUR PROGRAMS

San Diego State University

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Exploring Trauma Informed Care…

What are some of the benefits, skills, tools or tips you hope to gain by the end of the training?

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Introduction

The population

we serve

has lived through a traumatic experience

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Trainer: Now, how do we define trauma?

Trainer: Trauma is defined initially by exposure to a negative event, series of events, or set of circumstances. but exposure alone does not create trauma. Added exposure is demonstrated as “+E.” If we then add a lack of systems of coping for the individuals, shown as “-C”, and chronic neuro-dysregulation, shown as “-S”, we then find trauma. Therefore, trauma results from exposure that has lasting adverse effects influenced by a lack of systems of coping available and resulting in chronic neuro-dysregulation after the exposure. Chronic neuro-dysregulation refers to long-term effects on the person’s ability to function. That’s the impairment. The impairment of trauma is that the individual is unable to function and be well.

This is the piece that we are very much interested in, in terms of APS:

What is impairing function?

What’s prohibiting well-being with this particular individual?

So let’s talk about Exposure to the negative event. Exposure is a variable. How much exposure to the trauma has the individual experienced? That’s the variable. The exposure can be seen as a constant perhaps something that can’t be changed with the client but what can be changed is how much exposure the client has to the trauma. The client can have more or less exposure to the event. A key for us to use is whether the client is able to reduce or increase exposure from the trauma.

To better deepen our understanding of Exposure +E, Systems of Coping –C, and Chronic Dysregulation –S, let’s read the case study of Mrs. X and do a group activity together to see how these concepts can be applied.

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Activity #1 Mrs. X Case Study

Small Group Activity #1

The Case Study of Mrs. X

Read the case study of Mrs. X

Discuss in your small groups the following questions…

What are some examples in the story that Mrs. X has had exposure to a negative event?

What are some of Mrs. X’s reactions, examples of her beliefs and behaviors that she’s been exposed to a traumatic event

If Mrs. X were on your staff’s caseload, what would your staff be able to change regarding her exposure to trauma? What would they be unable to change?

Group Activity: Read the Case Study of Mrs. x and participate in a group discussion – 20 min. Moderator: Provide a 5 min warning

Moderator: If the training is virtual, Moderator will create Break Out rooms with 4-5 participants each. In-person, Moderator will break up participants into small groups.

Trainer:

Each participant in a small group is tasked with responding to the questions below. The participant whose birthday is the closest to today’s date will lead the other participants in the discussion and be the spokesperson for the group when the large group re-convenes to debrief.

Discuss in your small groups the following questions…

1. What are some examples in the story that Mrs. X has had exposure to a negative event?

2. What are some of Mrs. X’s reactions, examples of her beliefs and behaviors that she’s been exposed to a traumatic event

3. If Mrs. X were on your staff’s caseload, what would your staff be able to change regarding her exposure to trauma? What would they be unable to change?

(Facilitator debriefs exercise with participants by asking 1-2 Spokespersons to unmute themselves to share their responses with the group or invites other group spokespersons to share if they have something different to add . Facilitator assigns a different group spokesperson to respond to each question .)

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Case Scenario of Mrs. X

Mrs. X’s son verbally and often physically abuses her when he gets angry. When discussing the situation with the APS caseworker, Mrs. X states that she does not want her son prosecuted. She feels that, no matter how mean her son is, she has to protect him "because she didn't when he was a child". The APS caseworker asks what Mrs. X means and she says her now deceased husband drank a lot and was violent with her and the children. She feels her son learned his violent behavior from his father and it is her fault. Mrs. X also feels guilty that she let her husband “drink up every paycheck” which left her unable to provide for her children.

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Chronic Neuro-Dysregulation

Trainer: Trauma can involve a single event, numerous or repeated events, or sustained or chronic experiences. A single trauma is limited to a single point in time. An automobile accident, the sudden death of a loved one, rape, all of these are examples of a single trauma. Some people who experience a single trauma can recover without any intervention; their systems of coping are capable of handling it. But for others, especially those with histories of previous trauma, mental illness, substance use disorder, or those for whom the trauma experience is particularly horrific or overwhelming, a single trauma can result in traumatic stress symptoms and trauma- and stress-related disorders. Now, let’s look at the final part of the three-part definition of trauma: chronic neuro-dysregulation. Neuro-dysregulation is a result of tension on the nervous system that causes an imbalance of neurological function. Many factors may cause neuro-dysregulation, including unresolved physical or emotional stress, poor nutrition, use of substances or medications, posture and body alignment stress, and trauma. Neuro-dysregulation can result in a wide range of psychosocial, developmental, psychiatric, and medical impairments. In the next lesson, we’ll explore some behaviors that may indicate neuro-dysregulation.

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Polling Activity Question 1

Check Your Learning

Which of these statements about trauma are true?

Select the best answer, then click submit.

Whether an event is traumatic to an individual depends on their experience of it.
Trauma involves an event or events that induce physical harm
An event that threatens harm is less traumatic than an event that causes harm
If you do not perceive an event as traumatic, you can assume nobody would.

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Polling Activity Question 2

Check Your Learning

Neuro-dysregulation is

Select all that apply, then click submit.

A result of tension on the nervous system
Caused by trauma, stress, or substance use
Resolved with healthy nutrition
An imbalance of neurological function

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Polling Activity Question 3

Check Your Learning

True or False. Exposure to a negative event is not necessarily traumatic.

True

False

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Adverse Childhood Experiences

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Why Look at Childhood Trauma

Trainer: You’re an Adult Protective Services supervisor, so why are we looking at childhood? It comes back to neuro-dysregulation. Children who have traumatic experiences while their brains are developing become adults with chronic neuro-dysregulation. This can manifest in high-risk behaviors including elder abuse, development of diseases in adulthood, disability, and even early death.

ACEs, or adverse childhood experiences, are traumatic events that occur in childhood, that can lead to lasting effects across someone’s life. Some examples include:

Physical abuse or neglect
Emotional abuse or neglect
Sexual abuse
Growing up with a parent who misuses substances
Incarceration of a household member
Living with a family member experiencing mental illness
Domestic violence
Loss of a parent, and
Parental separation or divorce

You may have experienced some of the ACEs on this list. Around 62% of Californians have experienced one or more ACEs. Does this necessarily mean that over half of all Californians are living with chronic neuro-dysregulation? No; remember that trauma comes both from exposure to negative events and a lack of coping systems. Healthy support systems, coping skills, and personal resilience all play a role in minimizing the impact of ACEs.

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Why Look at Childhood Trauma

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What is Collective/Historical Trauma?

Historical Collective Trauma is a wounding across generations

The Lakota (Teton Sioux) historical trauma is associated with massive group trauma across generations.

Similar traits have been identified among Jewish Holocaust descendants.

Trainer: Dr. Maria Yellow Horse Brave Heart, PhD, conceptualized Historical Trauma in the 1980’s. She defines Historical Collective Trauma as a wounding across generations. This trauma impacts people of the same cultural group well beyond the initial traumatic events. For example, collective traumas perpetrated against the Lakota (Teton Sioux), from the Massacre at Wounded Knee, loss of ancestral land, and the forced removal of native children to federal and mission boarding schools, are felt throughout generations, even by people that didn’t directly experience these events. Some of the feelings experienced by people who are affected by historical trauma include Transposition, or the feeling of living in the past. Identification with the dead, or feeling psychologically and emotionally dead or unworthy of life. Maintaining loyalty to dead ancestors and Survivor’s guilt. Fixation on traumas, and fantasies about undoing atrocities of the past.

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What is Collective/Historical Trauma

Specific features include:
Transposition-Living simultaneously in the past
Identification with the dead
Maintaining loyalty to dead ancestors
Survivor’s guilt
Fixation on trauma
Fantasy and attempt to undo the past

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What are the Manifestations of a Collective/Historical Trauma Response

Manifestations include:

Depression

Self-Destructive Behavior

Psychic numbing

Elevated mortality rates

Cardiovascular disease

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Historical Collective Trauma and the African American Population

Post Traumatic Slave Syndrome (PTSS)

A condition resulting from centuries of chattel slavery

Institutional racism and oppression results in multigenerational adapting behavior

Behavior can be resilient or destructive

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Historical Collective Trauma and the African American Population

Jim Crow Segregation

Occurred between 1896-1960’s
Racially traumatizing events included rape, lynching (loss of life) and loss of land

Segregation Stress Syndrome

Unable to protect their family or themselves in dangerous situations
Underlying aspect is that an individual or their family could be killed or harmed at any time

Trainer: The United States government, and the governments of the states, perpetuated this belief of African Americans being genetically inferior with far-reaching consequences: generations of government-sanctioned oppression, from slavery, to Jim Crow segregation, to redlining, to institutional factors that still impact people today. This doesn’t even include hate crimes, lynchings, and other racially motivated attacks, or casual interpersonal racism. African Americans are dealing with the long-term trauma and psychological consequences of these experiences over generations. These consequences can manifest in something called Segregation Stress Syndrome, in which African Americans, having experienced being unable to protect themselves or their families across generations, feel that they, or their family, could be killed or harmed at any time, without warning or reason.

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Historical Collective Trauma and the African American Population

Emotional, Psychological, Behavioral responses
Fear, mistrust, and avoidance
Memories triggered by symbols of Jim Crow (i.e. voting sanctions, police brutality)

Physical Indicators (i.e. emotional numbness, crying, sweating, trembling when reflecting on events)

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�Collective Trauma Among Adults with �Disabilities�

Emotional/Behavioral Communications of betrayal and violation have often been mistakenly associated with person’s disability

Consequences of physical and sexual assault are worsened by the fact that complaints made are often not taken seriously

Trainer: Adults with disabilities who experience physical or sexual assault may not be taken seriously when they attempt to report it.

According to research conducted by Sinason in 2002, frequently, emotional and behavioral communications of betrayal and violation by adults with disabilities have been mistakenly dismissed. The consequences of physical and sexual assault are made worse when the person who experienced the assault is invalidated. In terms of trauma, a disability may be experienced as something called a “strain” trauma; a cumulative experience of invalidation and frustration that compounds over time. Abuse perpetrated on adults with disabilities results in compound trauma. In particular, sexual abuse perpetrated against individuals with learning disabilities can cause damage to their psychological functioning, including impacting their sense of self and identity.

According to a study by McCarthy and Thompson in 1992, 61% of women and 25% of men with a learning disability have experienced sexual abuse. It’s important for workers to have an understanding of trauma theory when working with abuse survivors, and to take the time to ensure their experiences are validated and not dismissed or mistakenly attributed to a function of their disability.

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The ACEs Ratio of Risk Scale

Weak/modest (Ratio of Risk > 2

Moderate (Ratio of Risk 2-3)

Strong (Ratio of Risk 3-6)

Strongest (Ratio of Risk <7)

Trainer: Now that we’ve got an understanding of both adverse childhood experiences and adverse community experiences, let’s identify the ACEs Ratio of Risk Scale. Exposure to ACEs increase risk factors for negative health outcomes. The more ACEs a person experiences, the higher the risk. If a person has experienced four or more ACEs, this is a major risk factor to their health. The Ratio of Risk scale introduces negative health outcomes and behaviors, organized by both the strength of their connection to trauma exposure of four or more ACEs and the urgency with which we, as providers, need to address these risk factors. Even the outcomes with the weakest connection to trauma, with concerns like obesity and diabetes, are twice as likely to occur if someone has experienced four or more ACEs.

According to Gabriela Grant, Director of the California Center of Excellence for Trauma-Informed Care. trauma. Four or more ACEs is a major risk factor to health. There's some that are a "weak" or "modest", where yes, these are of concern, but you know they're less connected to trauma. There’s not as much concern for immediate intervention. It's more changes over time. So if you notice being overweight or obese, and/or having diabetes, has an increased odds ratio risk of two, which is actually quite significant, that's two times but it's lower than some of the other ones depicted. It's also a situation where intervention looks like incremental changes over time. Physical activity, being overweight, having diabetes, we want to make changes over time. These are behavioral level changes.

When we go up a level where we're looking at odds ratios of two or three, which is two or three times. If there is an ACE exposure of four or more, smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, respiratory disease. These are behavioral changes that also should happen sooner Now, notice "strong. Some examples of strong are " Sexual risk taking, mental ill health and problematic alcohol use. Now we're in the stronger association with ACEs exposures. So we're confident that it's ACEs that are driving these behaviors. This is a person that has four or more ACEs exposure. These are behaviors that we probably need to be dealing with more immediacy. Sexual risk taking, mental ill health, and problematic alcohol use has serious complications. We're now in the more serious zone. Now, let’s look at the "strongest" with an odds ratio of seven or more, meaning seven times likelihood increased risk of these behaviors if a person has four or more ACEs exposure. Problematic drug use, interpersonal violence and self-directed violence, that these are the areas of most concern. Where we want to intervene most strongly. So not only are the unsafe behaviors noticed and their context but also the intensity. The intensity level and how dangerous the behaviors are. Depending on the assessment, intervention may need to happen much more quickly.

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Trainer: The purpose of the ACE screening is not specifically to identify the ACEs a person has experienced. It’s a recognition that ACEs are risk factors for the development of the toxic stress response. We understand that the toxic stress response comes from repeated exposure to adversity, and leads to changes in neuro-development, in the development of the immune system, and the development of hormonal systems. All of these together lead to behavioral and physical health problems.

There is research underway to identify clinical diagnostic criteria and biomarkers for the toxic stress response. Currently, we don’t have those criteria. The best indicator of whether someone is at risk for toxic stress response, or is currently experiencing toxic stress, is an understanding of their cumulative adversity. This is why it’s imperative to screen for ACEs

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ACEs and Older Adults and Adults with Disabilities

Studies of older adults and abuse or neglect at the hands of a caregiver or partner found childhood abuse to be a notable risk factor for re-victimization.

The experience of a prior traumatic event was associated with increased risk of elder mistreatment, a finding observed in the literature on younger adult mistreatment.

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Increased Unsafe Behaviors �in the Present

Substance abuse and addiction
Promiscuous sexual behavior
Lack of personal boundaries
Isolation and difficulty trusting others
Humiliation and self-blame

Shame, low self-esteem
Inability to form meaningful relationships
Inflated sense of power due to the caregiving demands made on the survivor as a child
Sense of not belonging anywhere

Trainer: The negative behaviors and health outcomes explored so far affect both men and women. However, older women who experienced child abuse may also report unsafe behaviors or emotional impacts in adulthood. So increased unsafe behaviors are a measure. Older women who experienced child abuse report more substance abuse and addiction, more promiscuous sexual behavior, more lack of personal boundaries, more isolation and difficulty trusting others, more humiliation and self-blame, more shame, lower self-esteem, more inability or less ability to form meaningful relationships, and taking on increased responsibility due to the caregiving demands made on the survivor as a child. Also an increased sense of not belonging anywhere. Subsequently the toxic stress response results in behaviors that are socially punished, for example “She's a drug user, she's promiscuous, or she doesn't have boundaries.” Instead of seeing it within the individual what we want to do now is see the individual and their behaviors within the context of "older women who experienced child abuse are more likely to engage in this behavior." This allows our staff to have more patience, more perspective, more safety orientation, and more solutions when working with these individuals.

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Adult Disease

ACEs contribute to Adult Disease by 2 mechanisms:

It happens externally…

1. Poor coping skills of engaging in Unsafe Behaviors (i.e. Substance Abuse, isolation, and a lack of personal boundaries) increase an individual’s risk of developing disease.�

It happens Internally…

2. The effects of chronic stress and other stress responses on the developing brain and body systems create a greater risk of the development of disease.

3.If an individual realizes why they are engaging in these unsafe behaviors they are better equipped to stop the behavior.

Trainer: ACEs contribute to adult disease by two causal mechanisms: the external and the internal. External expressions of the effects of ACEs are often unsafe behaviors, also called conventional risk factors. These include substance use, isolating from others, or difficulty with setting and maintaining boundaries. These behaviors are attempts at coping through unconscious, unsafe strategies, and increase an individual’s risk for experiencing negative health outcomes and adult disease. The internal effects of ACEs are best understood by looking back at SAMHSA’s three-part model of trauma: exposure to traumatic events without ways to cope and recover result in chronic neuro-dysregulation. People who experience more than four ACEs in childhood are more likely to experience dysregulation of their stress system, leading to problems with immune responses, increased infections, more inflammation, and higher risk of disease. We can’t change existing neuro-dysregulation, but we can educate clients on the relationship between ACEs and unsafe behaviors. If someone understands why they’re engaging in an unsafe behavior, they’re going to be better prepared to stop

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What is Immunosenescence & Inflammaging?

Immunosenescence: Age-related changes in immune system functioning and the process of how aging affects the immune system.

Immunosenescence:

Inflammaging:

Inflammaging: Inflammation that develops with advanced age that can impair the immune system.

Older patients are particularly vulnerable to poorer outcomes after traumatic injury

It’s important for APS staff to understand normal age-related shifts cognition as well as more extreme disease related declines

Trainer: Immunosenescence is age-related changes in immune system function, collectively termed. The entire process of aging and how that affects the immune system. This is already a very age-related medical concept. What immunosenescence causes is inflammaging. Inflammaging is the chronic subclinical systemic inflammatory state of older adults. PTSD and other trauma-related diagnoses have been described as a form of accelerated aging. Understanding normal age-related shifts in cognition as well as more extreme disease related declines, provides an important baseline of knowledge for professionals working with survivors of elder abuse. So we need to understand the normal process of aging and that there is this low rage inflammation. There is a low level of inflammation over time and that that impairs the immune system. Older patients are particularly vulnerable to poor clinical outcomes after traumatic injury, non-emergency interventions and impacts of environmental conditions. Data has recently indicated that individuals who have that higher level of inflammation or inflammaging, have poor clinical outcomes after a hip break, after a non-emergency intervention, after some sort of an environmental condition like a wildfire or, a pandemic. We understand that there is this immunosenescence, which is the aging process of the immune system and one of the markers or measures of it is inflammaging or how much inflammation is occurring internally in the individual.

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Polling Activity Question 1

Check Your Learning

The toxic stress response is repeated exposure to adversity, which leads to changes in the development of which systems?

Select all that apply, then click submit.

Neurological
Immune
Hormonal
Sensory

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Polling Activity Question 2

Check Your Learning

According to a 2009 study, experience of a traumatic event in early life was associated with increased risk of:

Select the best answer, then click submit.

Elder Maltreatment
Problematic drug use
Domestic violence
Divorce

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Polling Activity Question 3

Check Your Learning

Some examples of ACEs include:

Select all that apply, then click submit.

Physical or emotional abuse by a parent
Poverty or economic instability
Divorce, parental separation, or loss of a parent
Sexual abuse

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Trauma Across the Lifespan

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What Does Being Trauma Informed Mean?

N

Near Universal Trauma Exposure

Being trauma-informed means being able to inform, detect early and treat or refer to treatment in a manner that increases the physical and emotional safety of the individual

Trainer: As ACEs Principal Investigator, Dr. Vincent Felitti said, “Adult diseases can best be understood as the manifestations of distant childhood events.” A trauma-informed lens helps us to understand that many adult diseases started earlier in life. As we’ve explored ACEs, you might have seen some that are familiar to you, your family, your friends, or your community. You may have recognized some ACEs from your staff’s caseloads.

One of the key concepts for adult protective services to grapple with is that our population has a near-universal trauma exposure rate. Meaning that the vast majority, if not all, of our clients in APS have already been exposed to a significant negative situation. So it's not so much about finding out what exactly happened. It's having precautionary skills that allow us to work with a population that we know has near-universal trauma exposure. So being trauma-informed is an ability, a skill where your staff is able to inform their clients about this connection between earlier in life trauma exposure and later in life challenges.

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Trainer:

Trauma among older adults and adults with disabilities needs to be understood in developmental terms. This diagram can help: developed in 2009, by Brown et al, describes the way ACEs influence health and well-being throughout a person’s life

But what is developmental traumatology? Well, if we look at the graphic we see a pyramid that begins with Adverse Childhood Experiences (ACEs) that then may lead to disrupted neurodevelopment, social/emotional/cognitive impairment, up to adoption of health-risk behaviors, disease, and even early death.

So the implications of this framework for the practice of medicine in general and pediatrics specifically are potentially transformational. They suggest that many adult diseases should be viewed as developmental disorders that begin early in life and that persist and that persistent health disparities associated with poverty, discrimination or maltreatment could be reduced by the alleviation of toxic stress in childhood.

So what we see that it's exposure to adverse childhood experiences along with those adverse community experiences that then disrupts the nervous system, the neurodevelopment of that unique individual. The individual then starts to display social, emotional and cognitive impairments. Because, up until very recently, this was not seen as a developmental aspect. The individual was seen as having these impairments, and the individual was told that they have to improve or stop or change or do something different without acknowledging the trauma exposure.

Nonetheless, the adoption of these health risk behaviors increased disease and disability and social problems, and what the ACE study showed was that individuals who were more exposed to ACEs, higher numbers of ACEs-- more exposed to ACEs had fewer years of life.

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Advancing Trauma-Informed Responses to Elder Abuse: Practice, Research, Education and Policy Symposium, October 2018

“A relatively new and highly interdisciplinary field of study and practice: trauma-informed care for older victims of abuse.”�

“Fundamentally, providing trauma-informed care to older victims of abuse is about supporting healing and hope among people who may have years more to live and much to give.”�

“Most important takeaway: trauma among the elderly needs to be understood in developmental terms.”

�

Intersection of APS and Trauma-Informed Care

Trainer:

The intersection between trauma-informed services and adult protective services is relatively new, but at the same time, part of the story of APS. It's new in certain ways because the science is new, but it's old in certain ways because Adult Protective Services has always been struggling with aspects of often unacknowledged and therefore invisible impacts of trauma. I

In 2018 there was a symposium called Advancing Trauma Informed Responses to Elder Abuse: Practice, Research, Education and Policy.

In addition to some very knowledgeable speakers, there were a couple of takeaways. One of the first takeaways is that this is a relatively new and highly interdisciplinary field of study. Trauma-informed care for older victims of abuse is a new area, and it's going to bring all kinds of new fields together in new ways. APS is going to be central to that conversation. What they said in the symposium was that, fundamentally, providing trauma-informed care to older victims of abuse is about supporting healing and hope among people who may have many more years to live and much more to give. And the most important takeaway at the symposium was that trauma among the elderly must be understood in developmental terms. So it's new. It's really about providing hope and not going back into some sort of distressing history and for us to really start to understand trauma on the developmental level.

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Small Group Discussion Activity

Discussion

Activity # 2:

If we looked at APS practice in terms of supporting healing and hope how might that change the way your staff works with clients?

As a supervisor how would you support your staff in making this shift?

Group Activity: Discussing a shift – 15 min. Group Activity Producer: Provide a 2 min warning

Producer: If the training is virtual, Moderator will create Break Out rooms with 4-5 participants each. In-person Trainer will break up participants into small groups. Trainer will designate a spokesperson for each group to report out for their group when we debrief together as a large group. The participants in the break-out groups will respond to the two questions on the slide.

Trainer:

Consider-if we looked at APS practice in terms of supporting healing and hope. This aligns with 2nd prong of APS practice which is to provide services, intervention, and prevent future abuse.

How might that change the way your staff work with clients?
As a sup, how would you support your staff in making this shift?

You will meet together in your small groups and discuss the 2 questions on the slide. You will have 15 minutes for the group discussion and the Moderator will give you a 2-minute warning.

(Trainer debriefs exercise with participants by asking the spokespersons to share with the large group or unmute themselves and share their responses to the question.

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Identifying Trauma Among Older Adults

Trainer:

When identifying trauma among older adults, we want to focus on multiple areas, using multiple tools. The ACEs questionnaire is a good tool for accessing exposure, the first part of the three-part model of trauma. However, APS focus isn’t a full trauma history; it’s ensuring the safety and well-being of the people we’re serving in the moment. For that, we look at behaviors that might be trauma symptoms. One tool used to assess the symptoms of trauma is the Trauma Symptom Checklist, or the TSC-40. This is a forty-question survey asking about physical and emotional discomfort, with a frequency scale from 0, never, to three, often. You will find the TSC - 40 in your Participant Manual.

Gabriela Grant Director for the California Center of Excellence for Trauma-Informed Care explains why focusing on ACEs isn’t capturing the whole picture. When we are assessing for trauma we are doing it in the moment with the APS client. The word trauma itself however is a past-focused word, it seems to harken back in time. So clients are asked “Have you ever experienced, in your past, any of these traumatic experiences?" So basically what's going on is we are asking people to count and disclose, how much exposure they had, although we're having them identify the experiences. We're not actually measuring exposure. The other thing about the past, in addition to the fact that we're not accurately assessing for it, is that we can't change the past. It's a constant. But what we can do is we can change how much exposure there is to the past, and how safe the individual is when exposed to it. In some cases, it is very unsafe to be exposed to the past and in other cases it is very safe to be exposed to the past.

Another way to measure trauma in older adults is symptoms. Symptoms in the moment, what are their trauma related symptoms for example like insomnia or agitation. These symptoms can change. However, the client may not disclose these symptoms to the APS Worker. So sometimes symptoms can be counted and they can change. But the subjective experience of being able to measure them and kind of hold them as something measurable is challenging.

There is a third way and that’s to look at unsafe behaviors. Well, what is it about unsafe behaviors? We can count unsafe behaviors. Unsafe behaviors can change. Unsafe behaviors are much more objective than the subjective symptomology that a person discloses. Individuals engage in enough unsafe behaviors that we can kind of find an unsafe behavior to work with, and these skills are transferable. Meaning, if the client tells the APS worker that they're having a hard time paying bills, low level safety, unsafe behavior, staff can work with the client to build safety skills around addressing this unsafe behavior. These safety skills can then be transferred for a person who is a problematic gambler or other, kinds of, more serious situations. So keep in mind that when staff are working with clients engaging in unsafe behaviors, the skill around any unsafe behavior is transferable to any other unsafe behavior. So it really doesn’t require disclosure that much because unsafe behaviors are so common that we can generally agree on something to work on.

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Addressing Trauma

Context

Sensation

Perception

-E

+C

+S

Protection:

Reduce exposure to overwhelming events

“No!”

Action:

Act autonomously to cope and care for self

“Safe!”

Awareness:

Measure increase in physical and emotional safety

“Now!”

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Trainer: Now, what are the policy implications of ACEs? There is clearly a need for best practices and guidelines for asking about trauma that is standard.

The guidelines need to incorporate universal precautions first, then universal screening. Universal precautions mean that the same precautions are followed for each client regardless of what we know or do not know about their history. We universally screen, which means we do not only screen certain people based on what they disclose but we screen all clients.

It must be invitational: Your staff can ask about exposures. Yet, it must be voluntary: clients do not have to disclose their stories. The process should be informative, with all persons being provided trauma-related information. It should be solution-focused and data-driven.

There should also be established guidelines and best practices as to how to respond when a client discloses their trauma history. An APS worker should always redirect to the present and recognize the bravery of the person. For example, the APS worker could say, “Based on what you just told me, how does that affect you today?” They can ask what they would like the APS worker to do to support them.

All persons should also be made aware of mandated reporting laws and, if unsure if the APS worker should always reach out to their supervisor.

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Trauma Survivors’ Bill of Rights

A policy or procedure that guides the APS worker to use the handout will result in more use of the handout.

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Threat Versus Risk

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Distinguishing Between Threat and Risk

Immediate and Physical

Threats

Future and Emotional

Risks

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Skill: Decision Tree to Balance Threat and Risk

Activity developed by Grant, 2015

Physical Safety (Threats)	Emotional Safety (Risks)
Expectation of bodily integrity	Expectation of personal respect and autonomy
Absence of (threat of) physical injury	Absence of humiliation
Objective: general agreement	Subjective: often debated
The threat is immediate or imminent. �Right now!	The risk is not immediate. There is some time
Follow rules/laws, procedures, practice, system response and correction	Identify choices, agreements, support, progress, review – repeat over again
ACTION! RUN! YELL! HIDE! FIGHT! PRAY! (FOLLOW POLICY)	CONSIDER: ALL OPTIONS AVAILABLE – (SAFETY PLAN)

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Decision Tree Activity Polling Questions 1-5

Mrs. Jackson is crying because her husband has passed and her friends are “all gone.” She tells you she wants to die.
While walking through his neighborhood Mr. Martinez gets stung by a bee and he’s allergic to bees.
On Friday morning Ms. McMillian tells you she will be going out on Saturday to meet in person a gentleman she has only communicated with over the internet.
Mr. Hadid collects cleaning solvents in his garage. He does not use them to clean his home which is growing increasingly dirty.
Ms. Zhang has lost power to her home. Without power, she is unable to use her oxygen concentrator.

Is this an example of a risk or a threat?

Select the best answer.

Moderator Note: Create a poll (if virtual) for Questions 1-5 with two answer choices prior to the presentation. Two possible responses: Physical Safety (Threat) or Emotional Safety (Risk).

Trainer: Now, let’s put this into practice with (5) Decision Tree Activity Polling Questions to help us discern if a situation is a Physical Safety threat or an Emotional Safety Risk.

Let’s start with question # 1

1. Mrs. Jackson is crying because her husband has passed and her friends are “all gone.” She tells you she wants to die.

Answer: Mrs. Jackson’s emotional safety is at risk. The risk of harm is not immediate, and you have some time to review the situation and provide her with choices.

2. While walking through his neighborhood Mr. Martinez gets stung by a bee and he’s allergic to bees.

Answer: Mr. Martinez’s physical safety is threatened. There is no time to create a safety plan. It requires immediate action while following policy.

3. On Friday morning Mrs. McMillian tells you she will be going out on Saturday to meet in person a gentleman she has only communicated with over the internet.

Answer: Right now, Ms. McMillian is not in immediate danger, so you have time to safety plan. This is a risk, not a threat.

4. Mr. Hadid collects cleaning solvents in his garage. He does not use them to clean his home which is growing increasingly dirty.

Answer: This is an example of a risk. There is some time to review the situation and create a plan. However, there are many ways this situation could quickly escalate to a safety threat.

5. Ms. Zhang has lost power to her home. Without power, she is unable to use her oxygen concentrator.

Answer: This is an example of a threat to physical safety. Act, following rules, procedures, and policy.

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Partner Activity: Safety Talk Screening

Do you feel safe speaking to me today?

If not, what would help you feel safer?
Safety strategies in the moment.
Action plan. �

Do you feel safe at home today?

If not, how can we help you feel safer?
Safety plan for coming days or weeks.
Short-term safety plan. �

Did you feel safe in your home as a child?

If not, how does that affect you today?
In general, struggles in childhood can re-appear later in life, sometimes unsafely like hoarding.
Tailored, individualized plan to remain safe, independent and active.

Developed for County of Ventura 2015 by G. Grant

Trainer:

In 2015, Gabriella Grant and Ventura County, CA developed a short safety screening called “Safety Talk.” This screening consists of three main questions:

Do you feel safe speaking to me today?
Do you feel safe at home today?
Did you feel safe in your home as a child?

If the client says no to any of these questions, there are then follow up questions:

What would help you feel safer?
How does your childhood affect you today?
How can we come up with safety strategies in the moment, for the coming days, or weeks, and for your future?

This is a tool that you can demonstrate using with your staff in a 1:1 supervision conference prior to your staff going out on a face-to-face initial visit or on an open case. You will be broken up into dyads for this activity and will practice with a partner using the Case Scenario 1 in your participant manual. One person plays the role of Mrs. X and the other plays the role of worker. We will give you 10 minutes, come back, and process the activity.

Moderator:

For virtual delivery, you will need to create partner groups of 2 participants via your platform and list the instructions in the chat box prior to sending them to breakout groups. They have 10 minutes to role play. Moderator will give participants a 2-minute warning. Moderator gives participants a minute to read the Mrs. X case study prior to opening break out rooms.

Trainer:

Welcome back everyone! (Trainer asks for volunteers and if virtual will ask volunteers to unmute themselves or type in the chat).

How did that go?
How was asking the 3^rd question. Any discomfort? Great responses everyone.

Clients usually answer the first and second one without issues, and may be a little taken a back by the third one. If they do, in that moment you can talk about how our coping mechanisms we develop as children impact how we cope as adults. They may not have even realized this before! In all, this screening is meant to evaluate safety and increase safety and is intended to be brief. Remember the earlier slide on child abuse victimization and increased risk of abuse or neglect in later life.

Safety planning in the moment is a skill you develop. The better you understand how to safety plan in the moment, the more effective your safety screening, and ultimately your safety planning will be.

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Case Scenario of Mrs. X

Mrs. X’s son verbally and often physically abuses her when he gets angry. When discussing the situation with the APS caseworker, Mrs. X states that she does not want her son prosecuted. She feels that, no matter how mean her son is, she has to protect him "because she didn't when he was a child". The APS caseworker asks what Mrs. X means and she says her now deceased husband drank a lot and was violent with her and the children. She feels her son learned his violent behavior from his father and it is her fault. Mrs. X also feels guilty that she let her husband “drink up every paycheck” which left her unable to provide for her children.

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Skill: Safety Planning in the Moment

Environmental awareness using the senses

Use a scale (like a pain scale)

0 (= no bad or painful feelings) through 10 (= worst ever)

Reduce emphasis on talking or processing feelings
Physical environment awareness
Ask to notice feet on ground, back against chair, object in hand
Keep eyes open, breathe while squeezing and releasing hands

�Goal is measurably decreased dysregulation by creating visceral homeostasis and thus increasing physical and emotional safety.

Trainer:

Let's talk about a safety scale. It is safety planning in the moment. Safety planning in the moment is an environmental awareness skill-building tool. Some examples could be using a pain scale, reducing emphasis on talking/processing feelings, and instead increasing awareness of physical environment. This activity applies to yourself, taught to your staff, and staff can share this process with their clients. The scale is a zero no distress, to 10 most distress scale. It's similar to a pain scale: zero, no pain, 10 worst pain. We're doing this because this is how the nervous system operates, the nervous system operates on that kind of a scale, zero is homeostasis and 10 is total dysregulation.

Staff can ask clients to notice or kind of touch their feet to the ground, spreading their toes, even if they have shoes. Also noticing their back comfortably seated up against the backrest of a chair. Or ask clients to breathe, with eyes open, while squeezing/releasing their hands. Also noticing if there's a window to look out or an object to focus on and notice the details or artwork on the object. The goal of this skill is to measurably decrease one's own dysregulation by creating visceral homeostasis in the moment. By decreasing dysregulation, we can increase physical and emotional safety in the moment

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Transfer of Learning Activity:�Statement of Commitment

Draft a Statement of Commitment to trauma-informed care for your team. Reference Handout.

Share with your team in the next two weeks.

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Written Statement of Commitment

1. Connect trauma exposure/effects to the service or populations being served

“Given the clear connection between the developmental impact of trauma on aging and age-related vulnerabilities, illnesses and diseases, and older adults’ quality of life outcomes….”

2. Express specific goal of the commitment

“…are committed to becoming trauma-informed (as defined by SAMHSA and other experts in the field)….”

3. Specify actions that agency staff will take, and the measures used

“…by incorporating safety and recovery skills into the standard set of skills of each employee, we aim to protect older and vulnerable adults, create a safer community for aging in place, and provide resources to promote older and vulnerable adult community and independence….”

4. End with a vision or values statement designed to inspire hope.

“We believe services grounded in safe connections are a vehicle for �safety, healing and wellbeing.” (Add date of approval)

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Trainer:

Now that we have come to the end of this presentation, I would like to summarize some of the key points and takeaways from today. In the beginning of this course you discovered, you would learn about the critical intersections between adult maltreatment and trauma over the life course and why training for caseworkers and supervisors from a trauma-informed framework is so important.

In this foundational training on a trauma-informed framework for APS supervisors, you learned about trauma-informed care, the definition of trauma, the ACE study and its impact on our understanding of trauma across the lifetime, the link between trauma and adult maltreatment, and some practical tips and tools for you and your staff to use on the job, including safety planning in the moment and using a decision tree to balance threat and risk. We hope you’ll take what you’ve learned in this course, and your statement of commitment, to share and support trauma-informed strategies with your staff and the clients and families they serve.

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Closing Thoughts

Questions?
Reflections?
Takeaways?

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Plus/Delta

What worked?

What would you like to see more of?

What didn’t work?

What would you like to see less of?

What would you like us to change the next time we deliver this training?

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Evaluation

Date of Training

Online Evaluation

Link:

Activity ID:

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Thank You!

We envision a world where �the quality of life for individuals, organizations, and communities �is transformed into a healthier place.