SOAR Webinar: Improving SOAR Applications with  the Essentials of Trauma Informed Care

– Hello everyone and welcome
to our webinar this afternoon. Today’s topic is improving
SOAR applications with the essentials of
trauma informed care. Today’s webinar is
presented by the SAMHSA SOAR Technical Assistance Center
Policy Research Associates and under contract to the Substance Abuse and Mental Health Services Administration of the U.S. Department of
Health and Human Services. My name is Pam Heine,
Senior Project Associate of the SOAR TA Center and I will be moderating today’s event. So quick disclaimer, we need to remind you that this training is supported by the Substance Abuse
and Mental Health Services Administration and the U.S. Department of Health and Human Services. The contents of this presentation
to not necessarily reflect the views or policies
of of SAMHSA or DHHS. Just a couple of webinar
instructions before we begin, your lines will be muted
throughout the webinar. This webinar is being
recorded and will be available for download on the SOAR
website in about a week. You may download the PowerPoint slides and a couple of handouts by
going to the SOAR website and click “webinar” and
you will see the slides and two handouts, you can download it now. After the webinar there
is a quick evaluation you’ll be directed to, we
really appreciate your feedback which informs future webinars so we really encourage you
to take the brief evaluation. And finally we will save all questions until the end of the presentation then we’ll review instructions
for asking questions via the Q and A function at that point. Just a couple of learning objectives. It is our intention that
by the end of this webinar, we will increase your awareness
of trauma and its impact and also learn how to integrate
trauma-informed principles when providing SOAR services within a variety of settings which include justice involved, veteran,
youth, homeless shelters, domestic violence and also
mental health settings. And also applying
trauma-informed principles to gather a thorough
history and greater amount of information which in a way
minimizes re-traumatization. And we’ll also briefly touch on SSA’s new mental disorder
listing, 12.15 for trauma and stressor-related disorders. So we’ll talk a little bit about that. So the agenda this afternoon, you’ll hear from Dr. Lisa Callahan, Senior Research Associate
here at SAMHSA GAINS Center. Next you’ll hear from Kim Davidson, Director of Clinical
Services at Deborah’s Place in Chicago, Kim will talk
about the 10 principles of trauma-informed care. And then you’ll hear
from Eleni Marsh who is a SOAR Case Manager at Deborah’s place who will share a few SOAR vignettes about how she’s been able to apply trauma-informed care principles
to the SOAR applications she works with and as I said I’ll touch on the new trauma listing as well. – Should I start? – Yep, so now I’m gonna
hand it over to Dr. Callahan who will talk about what does
it mean to be trauma informed. – Hey everybody, thank you for inviting me to do this presentation today. What we’re talking about
is generally what SAMHSA has been made on in terms of incorporating trauma-informed practiced
into all of their programs and technical assistance centers, and also to give you just
some broad brushstrokes in terms of how trauma
and the trauma experiences of people who you come into contact with by being a SOAR provider will change your practices if
you put this in the forefront of your approach to people
you’re working with. Also I wanna just put
a footnote here too is, one of the areas that
we won’t have much time to talk about today, but
it’s something I’d like you to keep in mind is the
importance of not only thinking about the trauma experiences
of people you’re working with in terms of the clients
you’re working with, but also your coworkers, because (inaudible)
trauma and primary trauma is certainly a high risk for people who work with individuals who are at risk for homelessness, at risk
for justice involvement, people with mental health disorders. So keeping in mind this
applies not just to the people that you’re working with
in terms of doing SOAR work but also your coworkers. Recently had a lot of inquiries, there’s a lot of interest
in knowing and learning more about trauma and depending
on which field you’re in the actual specific reasons
are going to differ. But there really are three
global or national reasons why trauma has become really
part of the conversation in many, many social service systems. One is, the science has
changed dramatically around what we know about the brain. And we’ll talk about this
a little bit more later on but we know that exposure to trauma, and this is not necessarily
but it does also include physical trauma, but emotional trauma. We know that it can have
an impact on the brain and on brain development. We also, through our work, have observed that trauma has a
significant impact on adults. Those of you who are in direct practice see this on a regular basis. We also know that untreated trauma has a pretty significant
cost to our social systems whether it’s the legal, medical system, our social networks, it not only causes sometimes a (inaudible) of resources but it also through re-traumatizing people often leads them into more
and more deeper involvement in the various social systems. While that’s a somewhat (inaudible) we shouldn’t talk about
money all the time, but it does have a financial
cost to the systems. And finally, politics,
depending upon, as I said, depending upon what area you work in, there’s been a movement
nationally it’s called Raise the age, and that’s to make the age of legal responsibility,
raising it to 18 or above. There’s a few states
who still have it at 15 which happens to be,
New York is one of them. That’s one of the reasons why we’re really paying attention to the
impact of trauma on the brain but also and probably
an area that most of us are very familiar with is
the acknowledgement that our soldiers who have been
returning from deployment in the most recent wars have really had a lot of difficulty and a lot of concerns about high suicide rates among soldiers, so it really has pushed
us to address the impact of trauma and how we
can better address it. So, let’s now about what is trauma. I’m not gonna read this slide to you but I would like to point out to you the three words that
are highlighted, event, experience, and effects,
these are what we refer to as the three Es, many times
I’ve read this definition and I couldn’t recite it to you, but I do think the easiest
way to think about this is that individual trauma, it is an event but that isn’t what makes
it a traumatic event. What makes something a trauma is the way in which someone experiences and the effect that it has
on a person’s functioning. This is important to keep in mind because sometimes if more
resilient than others we might be (inaudible) or
perhaps even in our minds critical of why someone seems to be stuck in something that happened
to them a week ago, a year ago, or a decade ago. And what we know about trauma is that there is no expiration date. If an event has had a
traumatic effect on someone, it stays with them and the
way in which they go forward depends on a lot of factors, both individual and social factors. So what I wanna make sure
that we all keep in mind is that our resilient
selves aren’t necessarily, it shouldn’t be the standard against which we’re judging other people’s reactions to things that have happened to them or events that they’re
living through right now. We’ll go back to this
definition as we go along. So here’s some examples
of traumatic events in a general sense. There’s intentional trauma,
unintentional trauma, and then other types of trauma which often these are a little harder
to dig deeply into. I think we all can understand why different kinds of abuse,
different kinds of violence, would be considered trauma, and certainly those of us who’ve experienced
the loss of a loved one especially when it’s sudden, or injury that we or someone
close to us has experienced would understand why that is a trauma, unintentional but a trauma nonetheless. But the last grouping here,
other types of trauma, historical trauma, community
trauma, vicarious trauma, these are all just as
potentially toxic to someone as something that was done
intentionally to them. An example of historical trauma and the importance of understanding it be the kinds of experiences that people who are refugees experience. Their loss of homeland, their
moving to a new culture, their lack of safety in their new home, we know we have many examples
historically from that, we certainly have some in
contemporary terms as well. There are community traumas that occur, whether it’s a natural
disaster like a hurricane, a fire, 9/11, that people, everyone living in the community
experienced to some degree. And I mentioned vicarious trauma before and I’ll want you to keep this in mind, vicarious trauma is that trauma
that you don’t experience directly but through your work with people who have had direct
experiences with trauma it begins to have the same
kind of effect on you. And so people who are in direct service, emergency services and anyone working in an emergency room
really are at high risk for vicarious trauma so
it’s something certainly to keep in mind, the type
of work that all of you do. I mentioned earlier that
trauma affects the brain, and I am not a brain scientist, I don’t even play one on television, but I do know that
trauma affects the brain and I think that if we even
think back a little bit to some of our own experiences, we know that in times when
we’re under just intense stress, our systems shut down,
and often what shuts down is our good judgment. When I do trauma training,
I refer to it as, the lizard brain kicks
in, and that really is our preservation brain, not
our thinking logical brain which is what we intend
to use most of the time and I refer to that as the wizard brain. But when we’re under a lot of stress, our brain is being flooded
with these stress hormones, our lizard brain kicks in
and we often don’t make the best judgment, so
for people who are either living in current traumatic situations or have had numerous traumatic
events through their past, their brain has really been
flooded with stress hormones which alters the course of their ability to make the kind of
judgments that we imagine they should be, or many
of us wish we could. Also here, I won’t go into it because we don’t really have time here, but traumatic brain injury
and PTSD (inaudible) overlap. Some of the symptoms are similar in which you would be observing,
such as attention problems sleep problems, difficulty
controlling anger, but TBI and PTSD are different phenomena and someone who’s suffered
a traumatic brain injury is more likely to have
physical somatic ailments such as headaches, ringing
in the ears, nausea, dizziness, whereas people who have PTSD are more likely to have
psychological effects such as flashbacks and nightmares and being startled
easily, so there’s overlap is something just to keep in mind but they are two distinctive
phenomena that are going on in the brain, and certainly someone with a traumatic brain
injury also can have PTSD. Exposure to trauma and traumatic events can have a long-term
effect and when you look at this five-pointed, I
guess it’s a pentagon here, the way to think of this
is the external factors, physical health issues, going clockwise, mental health issues, behavioral issues, poor relationships, substance abuse, those are what you see, those are the observable
outcomes of trauma. What we don’t see is what is underlying it and that’s the fear and powerlessness that someone often develops
if they’ve experienced trauma, the sense of anger, the sense of pain, both physical and emotional pain, and so we don’t see those emotions but we just see the
manifestations of those often through, that’s
why they come to see you that they have mental health problems or that they have behavioral problems such as justice involvement,
or that they’re unable to remain housed and so
they’re constantly experiencing risk for homelessness, that’s what we see. But what’s underlying it are really the psychological effects of trauma. Just quickly, this slide is I guess if there’s a take-home message this is it that trauma really is pervasive, and with populations
that you’re working with what I would suggest is that you go in, always go in with the
assumption that there’s trauma. There’s nothing to be lost by doing that. It’s a way of approaching people which we’ll talk about in a little bit but it’s a way of approaching people of being trauma-informed
with the intention of not traumatizing them. We don’t know what
nightmare they lived through the day before, we don’t know what difficulties they had
coming to see us today, we don’t know what riding
public transportation might trigger into their experiences so keep in mind that trauma
is practically universal with some of the populations
that you’re working with is a safe assumption and really a mindset to go into interactions with. Oops, okay. There, most of you probably heard of the Adverse Childhood Experiences Study it’s referred to as the ACEs, it was originally
conducted in California by Kaiser Permanente which
is a healthcare provider, it’s been taken over by the
Centers for Disease Control. And the type of items you see listed here from physical abuse down to
witnessing domestic violence are considered the ACEs. These are events that
adults over the age of 18 endorse happened to them when
they were a child or not. And I don’t want us to take
too much time with this but what this does indicate is, this is the general population, that many people in the
population have experienced at least one if not more than one ACE. Now this is the general population. Populations that you’re
coming in contact with through your work, the ACE
experience is much, much higher. Just to give you one example, one of the research studies that I did was with youth who are
in a specialty course in one representative
county in the United States, I’m not gonna name it, but we administered the ACE to them and the average age of
these children was 15 and half of them had
experienced at least five ACEs by the time they were 15. Now these are all court-involved children, all of whom have a mental health or substance abuse disorder, so if you have contact with
any specialty populations the likelihood that they’ve experienced many more ACEs than the
average adult is quite high. There’s also some other, you may have seen some
that have additional ACEs, those are all add-ons and
there certainly is a wealth of information about them. If you would like more information, I can give you those references. Okay, there we go. One of the areas that the
research is very, very clear on is that it can be said the more ACEs someone has,
the likely they are going to develop physical health
problems as an adult. And without exception, every poor outcome, I think most of us would agree
that this entire list here are outcomes none of us would want, each of these physical health outcomes is directly related to the number of ACEs adults experienced as a
child, without exception. These are all statistically significant. So one of the messages is is that if you have people
who you’re working with who have one or two of these, chances are they may have five or six of these health problems as well. It’s multiplicative,
it’s not just additive. This is true with substance abuse and mental health issues and trauma. People who experience ACEs, the more ACEs you experience as a child, it significantly increases the risk for all of these mental
health and substance abuse outcomes as well. Many, many of these are overlapping. If there are terms on
here you don’t understand, certainly send a message
to us, ask the question, but these are all diagnostic categories that have been observed in people who have higher rates of
ACEs as children than others. This is also true with
people who become involved in the criminal justice system. The more ACEs someone experiences a child, the more likely they’re going
to be arrested in adulthood. The more like they’re going
to experience depression, anxiety, substance abuse
disorders as the last slide said which often gets them into trouble with the criminal justice system, and other behavioral outcomes
such as domestic violence again gets them into contact with the criminal justice system. So this isn’t, I don’t want to leave this by sort of having sort
of a fatal view of that, but I think what’s important
to keep in mind is that as you’re working with
people, if you learn that they have experienced a number
of these childhood risks if you will, they may
not be revealing to you in the course of your interaction all of the other experiences
that they’ve had, something to keep in
mind it may be something that (inaudible) over time. One thing we know for
people who’ve experienced a lot of trauma, they don’t feel safe, and certainly don’t feel emotionally safe with revealing information to people, certainly people they’ve just met. Often times it’s people
who work with people who experienced a lot of trauma, it’s six months to a
year before they reveal what actually happened to
them earlier in their life. So it may be very deep in there, so if you see a lot of somatic problems, if you see a lot of behavioral problems, you may want to pay close attention to their trauma history
and may want to refer them quickly to someone who specializes
in trauma-informed care. I’m going to the point
of, trauma is pervasive, we know that in the
national co-morbidity study which is a representative sample of adults across the United States, more than half of men and women report at least one traumatic event. In Detroit, and this was
before the (inaudible) problem, I would argue that if you were
a parent living in Detroit in the last year, every
one of those parents has experienced a trauma being concerned about their child being
exposed to toxic water. So it isn’t geographically
equally distributed, there are certain communities,
certain neighborhoods that have higher rates
of trauma than others higher mental and other trauma. Let’s focus just for a second on PTSD. Most people who experience
trauma will not develop PTSD. A person who goes to war
is exposed to trauma. Only around 20, and I don’t mean only, but about 20% of soldiers
develop PTSD over their lifetime so an average. I break it out a little
bit here with regard to previous wars, we have more to say about Vietnam-era veterans
because it’s longer since we’ve been out of the Vietnam war. So think about the prior slide, that over half of men and
women have experienced trauma but only 10% of women
develop PTSD and 4% of men I think you’ll understand
sort of the proportions there. It’s something to keep in mind, that’s just general population. For veterans, other factors that affect whether or not they’ll
develop PTSD are here, those include all the
different contexts of the war that they’re involved in, where they were, how many deployments they had, other things that happened to them, and one experience that
has really come to light in the most recent wars
that we’ve been involved in is military sexual trauma. And it’s something that
we know is a risk factor for men and women who have been in war and who have experienced
military sexual trauma it experiences their
risk for developing PTSD. I just want to circle
back to this diagram here so you can think about, again, the different manifestation of trauma that you may see in the
course of your work. It may not say trauma, but if you see any of these
physical manifestations through various assessments that are done, you should keep and eye on whether or not trauma might be underlying
some of those problems. That by experiences, how
someone has to experience a traumatic event is
going by person to person. We’ve all had the experience
and maybe within our own homes where children can grow up in relatively identical circumstances experience exactly the same events but the impact that it
has on them is different, the effect that it has
on them is different. Because of their individual composition, their individualized experiences
have kind of led them to a different effect of that event so it’s important to keep that in mind. Things I like to stress
here is that some of these, some of the factors here which pull people toward resilience or risk, you can change, you could work through the
result of case management for example, you can’t
choose someone’s parents, my children that all the time, they didn’t get to choose their parents, you can work on primary relationships. You can work on providing
meaningful activity for people through providing
employment or volunteer work so you build on those factors
that may be risk factors but become resilience factors and that’s really an important part of knowing what dynamic factors are part of an individual’s experience,
and those that are static. Thinking about how to develop
a trauma-informed work habit, it is a habit, is to think
when we talk about RISC, R-I-S-C, specifically
think about RISC, R-I-S-C reduces risk, R-I-S-K, so that’s conducting ourselves
in a respectful manner, (inaudible) people with information, information is free,
answering questions in a way that someone understands, giving a sense of safety, and then giving them
choice where possible. Sometimes choice isn’t possible. When it is, even though it may seem like a really small choice to use, such as, do you want to meet me at 9:30 or 10:30? It may make a huge
difference to the person that you’re meeting with,
so whenever possible really have these sort
of guiding principles in the way that you
personally conduct yourself. I always talk about, we have
habits and we have policies. Change your habits, you may
not be able to change policies but you certainly can
change your own habits around how you conduct yourself and we conduct ourselves
in the course of our work. This really is the heart
of what a trauma-informed interaction looks like, it’s
building trustworthiness, it’s doing what we’re
saying we’re gonna do, not making promises that we’re
not willing or able to keep, showing respect, and very culturally whether calling someone
by, sometimes people think that they like to be
called by their first name because it’s familiar. In some cultures, you never
call someone by their first name so being culturally competent
is really important here and letting someone guide you in terms of how respect can be gained and given. Again, choice, collaborating,
really built into choice and of kind of (inaudible)
informed interaction is empowering people to be able to be accountable really in the
course of their own lives. So this circles back here
to the SAMHSA definition of what trauma is, (inaudible)
about it’s any kind of event that you might, or
believe others might think would be traumatic, asking about that. What your experiences were, and then what the effect of that event or those events were on them. One metaphor that a police officer used with describing a trauma
was that it shatters you. And you can’t reconstruct
the same person again, you can reconstruct yourself, but it won’t be the same person you were before a traumatic event. And so trauma-informed
care then helps people reconstruct that
shattered person narrative and story that they have. So become a trauma-informed organization. I know the other speakers are
gonna speak directly to this, so I will touch on it rather lightly. These are the principles of
a trauma-informed approach, this really speaks to your own practice and the policy surrounding your practice. You’ll notice that safety is at the top, that is not a coincidence. If someone is not safe, both
physically and emotionally safe in their perspective, everything you do isn’t really gonna matter. If they’re always scanning the environment for a way out, for danger,
or for something threatening, they’re not really paying attention to you or to the work that you’re doing. So a trauma-informed
approach is being trustworthy and transparent, using
peers whenever you can, and I’m assuming there are
many people on this car who are themselves peers. I’m a really strong
believer in having peers be involved as much as possible
in helping gain that sense of safety and participation for people when you’re coaxing them into service and into
participation and into engagement I think it’s a very valuable resource. Collaboration and mutuality, voice and choice, again we
talked about that before and lastly making sure
that not only your language and your policies, but the way
in which you even construct the physical presence of your organization making sure that it is culturally and historically and gender competent. These are the 10 principles
of trauma-informed programs and the next speaker’s gonna
talk about these in detail. I will just take a look at these and we’ll focus on them again. Some of the same concepts
represented here. How do you go about, what
are the guidelines for implementing these 10 principles? There are two slides here that all comprise 10 guidelines. The first is governance and leadership, you need someone to
make this their mission, someone who actually has
the status and the respect of your peers and
coworkers to take this on that you’re going to become a
trauma-informed organization. You need to examine your policies. Just as a quick anecdote, when
I talk to judges about this which I do quite often, I
ask them how many of them have visited every
provider that they require their participants to go to. Some of them haven’t visited,
they kinda look sheepish when I ask this question, so I assign it as a field trip. Go and visit every
program that you require your participants to go to. And they all like, yeah, they’re nodding, that sounds like a good
idea, and then I wait, and then I say, and take
public transportation to each of those programs and then you see the
embarrassment on their face. So you need to make sure
your policies are doable, that someone can actually accomplish what you’re setting out for them. Making sure your physical
environment is safe, if someone has a history of sexual assault they’re not going to take a bus at night and walk three blocks
through a dark parking lot to come to your facility,
that is not gonna happen. Making sure your physical
environment is safe and is responsive, making
sure that you have policies around engagement and
involvement, and as I said using peers is a great way to do that. Making sure that all of the, you really use a wide lens who you think your collaborators should
be in the community, a very wide lens, even if you aren’t in the justice system or
don’t have contact with them your CIT office should
be part of your program and should be part of your collaborators. Making sure that you have
screening and assessments and treatment services available
for people with trauma. I know Pam’s gonna talk
about at the end I think. We certainly can provide you
at the GAIN center with tools, free screening assessment
tools that you can use in sessions for trauma-informed services that you can provide to your
participants or clients. Training, such as this,
and other kinds of training and workforce development around trauma, and this not only has
to do, as I mentioned, with trauma with regard to your clients but also your coworkers,
you’re also doing really, really hard work and you’re exposed to really difficult life situations and it’s really important that your, whoever’s in charge of
your HR understands that and allows for some development around dealing with trauma
in the course of your work. Making sure that there’s, these last three really go hand-in-hand,
that you have some way to reflect back and look back to make sure that you are working towards
the goals that you have set as an organization to
become more trauma-informed and that’s obviously through evaluation and in many cases requires some financing or a graduate student who needs a Master’s or Doctoral
thesis will do it for free. Which I always think is a great idea. So, I like to thin things down to thinks I can remember,
like the three Es, these are the four Rs in terms of a trauma-informed approach. First of all is realizing the prevalence of the trauma and why
it’s important to have a trauma-informed approach. Within the populations
that you’re working with, the universal assumption of trauma, everyone who you come into contact with in the course of your
work has trauma history. They may be living it today, and unless we’re trauma-informed, we’re not going to give it the importance and the centerpiece that it needs to have for someone to recover. Recognize how trauma affects somebody, as I mentioned not just clients
but your workforce as well. Respond effectively and with compassion when we’re more compassionate
with our clients than we are with our coworkers, and I think that’s something
which we all can work on more proactively, and ultimately to resist re-traumatizing people. I don’t think anyone goes into any kind of human service field with the intention of re-traumatizing our clients, but sometimes our policies and
our habits do exactly that. So by turning a lens on the organization, you can really begin to
examine how policies, how your workspace, et cetera, how they may in fact be
re-traumatizing for people who you come into contact with. I think that’s my last slide, okay. – Well thank you so much Dr. Callahan for sharing your research
and your knowledge on trauma and becoming trauma-informed. The folks on the line, many
of whom are SOAR providers understand that many who enter
the homeless service system have experienced violence, loss and disruptions to important
relationships from an early age and people who lack housing experience a loss of
place, as you discussed, safety, stability and community, and those losses are traumatic and they require services and responses that are uniquely
sensitive to their needs, so this is a great time
to hear from Kim Davidson who’s gonna talk about how she’s able to implement trauma-informed care throughout her agency, so
I’m gonna hand it off to Kim who will talk about Deborah’s place. – Thank you, so I’m
actually going to start out by just giving everyone
a little background on Deborah’s place, who
we are and what we do. So we’re a supportive
housing provider in Chicago and we provide both
permanent and interim housing to our participants and we do that in both project-based and
(inaudible) apartments and we serve roughly
about 250 a women a year. In Chicago, we were one
of the first agencies that started adopting
harm-reduction strategies and making sure that abstinence
was not a requirement for our housing, and to also implement some of those housing-first approaches and have a pretty
comprehensive service model and trauma-informed care
is really the anchor that kind of holds it all together. It’s a key component of everything we do. And at Deborah’s Place I’m
a Clinical Services Director so I supervise our Case Managers and our Health Services staff. And constantly talking to
them about how we want to see our participants through
trauma-informed lenses. Think of it as like glasses, so if anyone is in need of
wearing glasses or contacts to navigate the world, we
know that when we put them on we see everything differently. And if we are applying
trauma-informed care and all the things that
we just learned about to our population, we’re recognizing that if we see someone one who
may lose their temper, storm out of our office, or stop a social security
application once they started it, when we put on those
trauma-informed lenses we’re able to see them through
the experiences they’ve had and what they’ve been through and can see everything
differently as we move forward. At Deborah’s Place, our
Case Managers and myself are trained in SOAR as well and we have done the online
training, face-to-face and have had a lot
assistance from the TA center so I’m going to go through
those six key principles of a trauma-informed approach, but for each of them I’m going to talk about some of the
strategies that we have used in our SOAR applications
at Deborah’s Place. So as we already heard, oh my slide is, oh, okay,
as we already heard, safety is really the key principle. If you don’t have safety, you really don’t have anything else and we know that especially
for our population for many who’ve experienced homelessness, a lot of times their
experiences are really dominated by physical and sexual
violence on the street and so they come in, the
biggest thing we wanna do is make them feel safe and
that’s both physical safety, feeling like they have a
door that they can lock, and emotional safety, feeling
that they can trust the staff. So some of the strategies
that we have used when doing SOAR application are really, and I know this sounds obvious, but building strong,
trusting relationships, and trusting relationships
that aren’t just based on telling people what they want to hear, but instead based on honesty. So when we’re helping people with their security applications we need to tell them the good and the bad. That they’re gonna have to
disclose a lot of information, information about bad days, information about hard days, also going to possibly get
denied and this could be a long process, and telling them that, we’re basing these relationships on truth which allows them to feel safe. We also allow our
participants to interview with whoever they choose, so
when I was an administrator in one of our housing programs, we had a participant that
wanted to do their MSR with me, and not my role, but that was what we did because we wanted that to
feel as safe as possible. We also sit down, before we
ever do the MSR interview and answer all those questions ourselves so we are not asking for more information than we might not already know. Sometimes someone has told
us something in the past and disclosed a really traumatic story and we don’t need to
have to go through that all over again and ask
them more questions, possibly triggering them. We (inaudible) to do the
application or interviews in spaces where they feel safe, so that could be their apartment, maybe an office or maybe a meeting room, we’re flexible about that. Sit down to do the MSR, we disclose fully all of the things we’re going to ask about and then have a
conversation about triggers. How will you know if
this is too much for you, and what will you need
if you feel overwhelmed? I once did an MSR with someone and we made an agreement
that if they feel overwhelmed they would just get up and
walk out and smoke a cigarette and that was totally fine. They did that a couple times, and I didn’t ask any questions, I just knew what was happening. Also, normalize breaks and talk
about them at the beginning. You know, you’re gonna
need lots of breaks, what do you wanna do? So that they don’t feel like
they have to ask for that. Try to give options of
things in the staff, there are offices that
could make the experience more comfortable, so all of
my staff have candy dishes, my staff members will actually
bring up YouTube videos of animals if they know a
participant really likes a certain kind of animal to kind of make the
experience a little bit fun. We have coloring pages, we actually made these
jars that people can shake and watch the glitter settle
and then take a deep breath as the glitter’s settling,
so we have lots of things in our office that can
make people feel supported. And celebrate every single step. We have notice that even
filling out the releases of information, or that
authorized representative form is a challenge for people
and so we do lots of games and incentives and just celebrate with people those victories. Okay. (inaudible) is trustworthiness
and tranparancy and we know that if someone
has experienced a lot of trauma their boundaries have always
probably been violated and they may not know or have
a difficult time understanding the roles of people in their lives, so if you’re helping someone get an income you want to be very clear
about your role in their life because you’re gonna be
getting a lot of information and you have a lot of responsibility. So from the start, we
give lots of opportunities for information to be learned, so we had social security
come out and do info sessions so people can hear about
social security benefits not just from our staff. We also take people into
the social security office just so they can ask questions and give them (inaudible),
we want everyone to feel like they have as much
information as possible. So clearly explain every
step of the process and everyone’s role in it, and our Health Services
department helps with, again, documents and so we make
sure that we are talking about all of those things and we explain the positive and negative of applying for benefits for people. So one thing that we do is we want to have a
conversation with people recognizing that
sometimes getting benefits is a good thing for
them, but also sometimes it can be very, it can be a trigger especially if someone has
a history of substance use or hasn’t been able to manage
their money in the past and so we wanna let them
talk about all of that. So we attached documents, the motivational interviewing worksheet, it’s called the Decisional Balance, and it’s a fancy pros and cons list that goes through the pros
and cons of making a change, or letting stay the same, and I think it’s a great way to facilitate those conversations about that benefit, so that is there for you to use. So the next principle is peer support, and we think it’s very
important that we are honoring the fact that our
participants are the experts in their own lives, and want them to have the
opportunity to share information so have forums where
participants using benefits can share their stories of the process, and also we want to give every opportunity for our participants to
tell us about their life. Educate us, they’re the
experts, and we’re not. Then collaboration and mutuality. As we are entering into
these applications, we want to make sure that
everything is a partnership and there’s every opportunity
for autonomy to be shared. So some things that we’ve done is give our partcipants the opportunity and the option to cancel
an application anywhere in the process and to tell
them that from the beginning. So one of the very first applications that I did with someone, I
was so excited when they made this step and then we had our
phone application scheduled and appointment, and I got
to work and they canceled. Not only did they decide
they didn’t want to do it but they wanted me to call
social security and tell them that we were withdrawing their application and it was devastating for me, I had so hoped for this
person and this application and we did it, and then I
told them I would be there for them if they ever wanted
to do it again or not, and I went in my office
and I had a few moments to myself because it was a hard day. But then three months
later, they came back and said they wanted to reapply. And so I don’t know if
that would have happened if I wouldn’t have responded
as openly from the beginning. I said biggest thing, and I
cannot stress this enough, are really motivational
interviewing skills because it really stops our
staff from giving advice and instead it allows us
to guide conversations. Those core skills, the open-ended
questions, affirmations, questions and summaries, really guide most of the discussions we have around benefits. And open-ended questions
allows us to ask less and more, narrative, more
story that will give us a better idea of what
someone’s really experiencing. Principle, empowerment, voice and choice. Traumatic experience often
involve someone’s voice being taken away, or their
power being taken away, and then if someone’s
finally applying for benefits that is an incredible
vulnerable experience and they can easily feel like
they’re losing that power all over again, and so
some things that we really try to do are explore the
meaning of those benefits for people, the positive and the negative, and we already talked about
the decisional balance, but (inaudible) the benefits. Sometimes it’s having
conversations with people about the meaning of “disability.” that’s usually the biggest
thing I hear over and over again are participants not wanting to apply because they’re afraid
of what it would mean to have a label assigned to them. And so, they can be afraid
of those conversations but a lot people talk about it and also you can even
do decisional balance around those conversations. The way to use that decisional balance is to sit with someone, have
them give all the pieces and then circle the things
that are most important to them ’cause it may look like one
side has a lot more things than the other, but if
(inaudible) in there has one thing in it and that’s
the most important thing to someone, you wanna know
that as you move forward. So we also wanna make sure our
participants don’t feel like they have to do anything
they aren’t comfortable with (inaudible) their application, seeing a doctor they don’t want to see, have a conversation
they don’t want to have. And one of the biggest things about trauma-informed care,
we spend a lot of time talking about triggers, we
don’t spend as much time talking about skills, and I think
that’s the most important piece is we will see people heal and recover, and so in everything that you’re doing, trying to find small
ways that you can infuse your intervention with these
(inaudible) activities. Simple things like breathing exercises, seconds breathing in,
hold for four seconds, breathe out for four seconds,
hold it for four seconds, these techniques, simple things like, hey, this is a lot, but let’s
get into this room. What are four things you see? What are four things you can touch? What are four things you hear right now? These things that people
can do on their own. Our self-care plans we do with our staff so we also can do them
with our participants, sitting down and saying, this is gonna be a hard period
of time, what do you need? The last principle is
the cultural, historical, and gender issues, and I’ve
already talked a little bit about how we view gender
and homelessness here, we really have to see everything through this larger
systematic lens of oppression. And so we’re helping
someone with this process, (inaudible) everyone is impacted
by this oppressive world which we live in, and
some of our participants are experiencing traumas more than others based on their identities. You want to think about what
those additional barriers are and give people the opportunity
to tell you what they are in their words and validate that, and then figure out how
you can use your privilege just as a social service
provider to advocate for them and minimize those barriers. Principles, but as we’re doing all of this and talking about (inaudible) practice, we also recognize a lot
of this is about absorbing the pain of others, listening
to these stories of trauma and helping them heal also
means that we have to have room within ourselves to hold them,
those things that they share so I think for every provider
we have to figure out ’cause it’s different for everyone, what makes space for you. And how to have daily practice, it’s (inaudible) a lot of
times doesn’t have to be huge but we often set goals for ourselves just like we do for our participants and so stepping back and saying, what is a meaningful step I can do? ‘Cause I, myself, I’m like,
I’m gonna go to the gym five days a week, and then if I skip a day then I’m like, oh screw it! And then I stop everything, so think about the small
things you can do every day. Can you do a breathing exercise
for five minutes every day? Can you sit down at the end
of the day and make a list of things you let go of? And recognizing your signs
of burnout and hopelessness and seeking support. Whenever I’m not feeling hopeful, I know it’s time to take some time off. And we also at our
staff find creative ways to do the MSR and all of that work so sometimes that means
you may work from home, listening to music while they’re doing it, taking lots of breaks, so that is an important piece as well. I’m gonna hand things off
to Eleni, my coworker, who will talk about some specific
cases that she’s worked on and some of the challenges. – Thank you Kim, so
good afternoon everyone, I’m Eleni Marsh and I am a Case Manager at Deborah’s Place, and I
actually work at the building that was pictured on the first slide when Kim was talking about
who we are at Deborah’s Place. And yes, I have been SOAR trained. So, a couple of vignettes here that talk about SOAR applicants who
were not able to really talk about their mental health issues early in the disability
determination process or even at all. The first thing I’m
gonna talk about, S.S., initials, of course, for confidentiality, S.S. decided she wanted
to apply for benefits for physical issues, leg swelling, and that’s actually exactly
how we filled out the 368, the disability report, nothing
about mental health issues was included in that. It wasn’t until we got to
the medical summary report where I put in our observations of her signs and symptoms that we observed and mental health issues, like significant issues of impairment that kept her from keeping jobs. It does say this on the slide, but she did have her consultative exam and by luck I was able
to go in the office place with her, and I think that
the attending physician was able to (inaudible)
the mental health issues and I think request another exam. And her claim was awarded,
no appeal or anything needed. So that went well. Then this case, it didn’t have the outcome that we would have hoped for, but it still is I think
a really good learning, it has learning things in
here for me and for all of us. A.G., her initial SOAR application included a lot of medical
records showing a long history of admits for seizure activity, so over a long period of time
and at multiple hospitals. It was quite the thing
getting all these records. Her initial claim was denied. As I spent more time with
her and more time delving into her MSR, it became clear to me that her claim might be
strengthened by including some of the behavioral health issues, the signs and symptoms I observed and that were sometimes
noted in hospital records. She was not really on-board with this for the purpose of turning the focus into more psychiatric, mental health, her appeal was denied and she
decided to do other things. I’ll talk more about that shortly. Vignette is an applicant that Kim and I worked on together, S.M., she had a serious cardiovascular issue, but she was also quite
fearful and anxious, I had known her for a period of years and you know, quite to
the point of paranoia, like she would take turns
being paranoid about Kim or me, so there’s that. She didn’t have a formal
mental health diagnosis, and she decided to apply
based on medical issues only. She was so fearful that
she could not even attend both CEs that were scheduled for her. However, she was awarded her disability and I believe on the strengths
of the the (inaudible) of her hospitalization records
for those medical issues. I really want to talk about the importance of the