Hello, and welcome. I'm Dr. Amy Cohen, Program Director for SMI Advisor and a clinical psychologist. I am pleased that you are joining us for today's SMI Advisor webinar, Cultivating Trauma-Informed Organizations and Services for People Living with Disabling Mental Health Conditions. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now, I'd like to introduce you to the faculty for today's webinar, Gabriela Zapata-Alma. Gabriela is a licensed clinical social worker, a certified alcohol and drug counselor, and the Director of Policy and Practice on Domestic Violence and Substance Use at the National Center on Domestic Violence, Trauma, and Mental Health, as well as faculty at the University of Chicago, where they coordinate the Advanced Alcohol and Other Drug Counselor Certification Program at the School of Social Service Administration. Gabriela brings over 15 years of experience supporting people impacted by trauma, violence, mental health conditions, substance use disorders, housing, instability, and HIV-AIDS, providing bilingual and bicultural counseling, training, advocacy, and policy consultation, and leading programs using trauma-informed approaches, motivational interviewing, harm reduction, gender-responsive care, Housing First, and third-wave behavioral interventions. Gabriela, thank you for leading today's webinar. My pleasure, and thank you so much for inviting me to share this information today. So, here's my disclosure, which, you know, there are none. And then, I want to say a little bit about my center. So, I'm representing the National Center on Domestic Violence, Trauma, and Mental Health and sharing this information today. And we're funded through HHS, the Administration on Children and Families, and we're a special issue resource center dedicated to the intersection of domestic violence, trauma, mental health, and substance use. And here you see some more information on our center. And of course, our disclaimer that the things I say don't necessarily represent the views of HHS. And so, I'm actually going to pop off screen now, and I'll come back on screen towards the Q&A. So, everything we do at the center is rooted within this integrated framework, survivor-defined approaches that people are the experts on their own lives, that this is all based in physical and emotional safety, relationship, and connection, and that this is what fosters hope and resilience. And so, with this as our core foundation, we then are able to engender, or I should say strive to engender, trauma-informed approaches, an approach that is informed by domestic violence and sexual violence advocacy, which is also known as an empowerment framework, a human rights and social justice-based approach, and an approach that has an awareness of and responsiveness to cultural, historical, and community context. Here are learning objectives. Hopefully, you had a chance to also see them when you registered for this session. So, starting out by defining a trauma-informed approach. So, really looking, there are a lot of different definitions of trauma-informed approaches, and this is what we'll be using for this session. So, recognizing the pervasiveness and impact of trauma and victimization on persons accessing services, staff, organizations, and communities, ensuring that this understanding is then incorporated into every aspect of administration, culture, environment, and service delivery, provides guidance on and actively works to decrease free traumatization, while also supporting resilience, healing, and well-being, and that this occurs at every level of the organization through the work we do, as well as the way we work. That we also foster an awareness of what we, as service providers, bring to our interactions, including our own experiences of trauma, as well as the ways that we are affected when we're truly open to the experiences of others, and that all of this also entails recognizing ongoing and historical experiences of discrimination and oppression. And so, a part of a trauma-informed care approach is also the obligation and the commitment to work to address social conditions that perpetuate abuse, trauma, discrimination, and disparities. So, first, we're going to talk about trauma. We want to begin by building our understanding of trauma so that we can then integrate this knowledge into not only what we do, but how we do it. And so, here are some working definitions. The first is SAMHSA's working definition of individual trauma, and I'm just going to read it out loud here. Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening, and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. So we can see that this is a really holistic working definition of individual trauma. And then also recognizing the existence of collective trauma. And so, understanding collective trauma as cultural, historical, political, and economic trauma that impacts individuals and communities across generations. And very often, people accessing our services may be experiencing a combination of these different kinds of trauma. And this definition of collective trauma, as you see, comes from the National Indigenous Women's Resource Center in collaboration with our center. So, now looking at subcategories of trauma. And this comes from the National Child Traumatic Stress Network. So we have acute trauma. This is a single event that lasts for a specific period of time. It has a beginning, middle, and end. We can point to it many times and go, this thing happened, right? And there's chronic trauma, which we can understand as many traumatic events over a prolonged period of time. And here, the trauma can be of different types or of the same type over a period of time. Many times, chronic trauma begins in childhood. Then complex trauma, we can understand as chronic trauma beginning in early childhood, often experienced at the hands of caregivers. And then finally, neglect. And so, understanding that neglect is not just that we were missing something. It's not just that the absence of something that we needed. But that neglect in and of itself can be traumatic, that it can produce life-threatening and terrifying situations which are traumatic, and that it also can reduce our resilience and increase risk of developing trauma-related disorders. Something that I want to share, take a moment to share right now, is that nothing in the next hour-long presentation is meant to be graphic or is meant to be distressing. That said, we are talking about trauma. And so, any one of us may experience what we're talking about as potentially distressing or may potentially remind us of our own experiences which can also potentially increase discomfort or lead to experiences of distress. And so, to that, I say, you know, just kind of putting it out there that we're all humans having a human experience and bearing witness to this life. And so, if you find yourself experiencing distress, that just means that we're human and that we're talking about something that can be distressful. And I invite everyone to use whatever kind of, to engage anything that feels grounding, that feels centering, that helps you feel like yourself again. And so, even if that means at some point you do need to step away for a moment and come back, that this is a space, although we're physically distant, that this is a space where all of that is, that, you know, self-care and self-nurturing and self-protection are really encouraged and welcomed. And then, going a level further, to help define the kinds of trauma that can happen within organizations and institutions that are specific to institutions. So, we have this definition of institutional betrayal. An institution that's meant to protect instead creates a dynamic or behaves in a way that causes harm to those who rely on them for safety and well-being. And this can occur on a matrix from committing the actual betrayal or the kind of trauma to just a lack of responsiveness to when this trauma has occurred within the institution. And this can also run the matrix from isolated to systemic. And this is associated with increased risk of experiencing effects of trauma. Then looking at sanctuary harm. So, while sanctuary trauma refers to events in psychiatric settings that meet the DSM criteria for trauma, for criterion A for trauma, sanctuary harm refers to experiences in these very same settings where people in these, who are accessing our services, experience fear, helplessness, distress, humiliation, or loss of trust due to the abusive, neglectful, inappropriate, or even just insensitive actions by staff or another authority figure within our setting. And that sanctuary trauma and sanctuary harm, this concept came from both quantitative and qualitative research in response to people living, people with lived experience, highlighting the need to examine the safety and dignity of people being served in psychiatric settings. So, these forms of trauma can especially impact those who experience any form of oppression or targeting or marginalization based on a social identity, including based on level of ability. As you can imagine, the use of seclusion and restraint is a common theme in all of this. And one that SAMHSA speaks directly to minimizing and eliminating. Seclusion and restraint is not trauma-informed and it's associated with increased harm both to persons in our services as well as staff. So now I'm going to share the kind of quickest neurobiology of trauma that you'll probably ever hear. And so there's, you know, the neurobiology around trauma and just like anything that has to do with neurobiology and neuroresponses, there are many complex effects and interactions. So I'm just going to focus on a very simple part of the equation to highlight how some of the common cognitive behavioral effects of chronic trauma are connected to our neurological responses. So we have our thalamus. Our thalamus processes the sensory input and alerts different areas of the brain. I often think of the thalamus as like the oldie time phone operator, taking in, you know, stimuli and then routing it to where it needs to go. The amygdala, we can think of that as the brain's alarm system. So very quickly responds to danger and shuts down all non-essential brain and body functions that really aren't needed to confront the immediate threat to either, you know, fight and overcome or flee from the immediate threat. And so it kind of shuts down those non-essential parts and then sends the power to physical functions needed to either flee or fight. And then our hippocampus is our memory center. And our hippocampus tends to become very passive. It's unnecessary in fight or flight. And this is why a lot of these memories can appear as fragments, as sensory having to do with the senses or body-based rather than verbal or thought-based. And memories can also be connected to intense responses. And so if we've ever, so this can come up in many different ways. One of the ways is when somebody is, you know, experiencing an intense emotion, right? And emotions aren't dangerous, right? When someone's experiencing an intense emotion, it can, for example, kind of unlock a piece of trauma memory or trauma response. And that kind of memory was not really encoded the way that regularly our kind of verbal memory is encoded and then kind of gets brought up with that intense response. Some other things that can happen here. Well, let me say this first. So the trauma stress pathway is reinforced with repetition. So what this means is that there is a stronger link and this pathway from stimuli to alarm system and fight or flight response becomes not only strengthened and quicker, but also more sensitive and that this will just come, will bypass our frontal cortex, which is our kind of higher reasoning, higher decision-making, our kind of planning, a lot of our judgment and just problem solving. And so what can end up happening is that our filtering can become compromised. So when we're impacted by, when we're experiencing these kind of like neurological impacts of this traumatic stress pathway being reinforced, we will likely notice things that other people don't. So this is the reason why, for example, having, you know, service environments that are clutter-free is a part of trauma-informed care because to the counselor who is busy running from appointment to appointment and just kind of has those papers stacked up in the corner of the office that they just haven't gotten to filing and they know there's no personal or private health information there. For a person who has experienced trauma, that can feel very, that like clutter, that stack of papers in the corner can feel really distracting. It can feel, and then all of these kinds of ideas can start coming up, for example, like what is all of this clutter? Who is, is it even a professional service? Whose papers are those? Is my private information going to end up stacked in some corner of an office? And we can see how, you know, that can really take up a lot of space within a person and create a sense of lack of safety. And that kind of plays a role in how our filtering systems, we can't only just turn away from that stimuli if that stimuli is making us feel unsafe and threatened. This also shows up as a difficulty with focus and engaging in everyday situations. So you know, a lot of times we put a lot of value in our treatment plans and our service plans and if somebody is having kind of trouble with that, then many times it's because we haven't really created a collaborative service plan that is realistic, that speaks to that person's cognitive strengths and that we're not taking into account how the effects of trauma may be showing up in their ability or in, that we're not taking into account how the effects of trauma are impacting this person and what we may need to do to make this service plan or this treatment plan really relevant and mutually understandable and meaningful. Something else that comes up is that experience of self can become muted. So this really shows up typically as feelings of emptiness or numbness to a sense of self and positive experience. And so I often think about this as so much of the trauma work we do is that we are trying to help people become a reliable container of their human experience. Because one of the tragedies of trauma is that not only has that external world, do we have a sense of danger in the external world, we also have a sense of danger just within ourselves. And so a big part of the trauma work is that a person won't need to hide from any part of themselves, from their internal reality. Because otherwise what ends up happening is that we have a really hard time accessing a sense of self and a sense of joy as we try to protect ourselves from all of the kind of negative cognitions and negative emotions that come with experiences of trauma. But developmental trauma, stress that overwhelms a child's ability to cope in the absence of a supportive caregiver, attachment, can have effects on neurodevelopment. And this is often referred to as rather than a child being able to access and develop within a learning brain, they are put in a position of needing to exist and function from a survival brain. And so for more information, I highly recommend checking out Harvard's Center on the Developing Child. So this is a really important question, because within all of this, we also know that people have an incredible capacity to continue learning, developing, that within all of this neuroplasticity, the brain's ability to adapt and continue to grow and learn and heal, as well as resilience, our capacity to adapt to really adverse circumstances in a way that still results in positive outcomes. And so it's really important for all of us within our teams, within our organizations, as well as reflecting within ourselves, to really look at how are we supporting resilience within our services, within our programming. So from trauma to PTSD, not everybody who is exposed to a potentially traumatic situation will experience effects or meet criteria for a trauma-related disorder. So there's several risk factors here, and this is from the DFM, and these are individual risk factors. So these are things we wanna be aware of so that we can help mitigate risk factors as well as build up protective factors. I would love to be able to go through these in depth, but we do have a short amount of time and a lot of things to cover, so I won't be going through each of these. One thing I'll say here is when it comes to interpersonal risk factor, there's a couple layers here. One is the experience of betrayal, that betrayal has a particular effect on increasing our risk for trauma, and that this comes into play as we're asking people many times to engage in services that require some level of openness, of vulnerability, of trust. And of course, this is where we need to have the focus on building trustworthy services and relationships rather than expecting or demanding trust from anyone. And that also, something to keep in mind here with the interpersonal piece is that a really common experience of trauma results in the avoidance of anything that may remind us of that trauma, and that when we've experienced interpersonal trauma, humans become a trauma reminder. And so, we are social creatures. We cannot really avoid humans. And I speak from experience, I've tried. And at the end of the day, we are social creatures. We exist in community, in society, and especially if we're trying to access any kind of service, we especially are in contact with humans, and humans that we may not always really know or trust or have a choice in who we get to kind of have as a service provider. And so, really taking into account both the challenges of connection, but then also the importance of that interpersonal connection in healing trauma. And then here are the protective factors when it comes to trauma. And unfortunately, it's a much shorter list than the risk factors. Something that I'll note here is that when we talk about access to medical and mental health care, that we're talking about real access. That if I have, you know, and let's say I have access to insurance, but my deductible is so high that I can't possibly go get mental health care or access mental health care. That's not real access. Or, you know, let's say I live in a community where I can't find, I don't have access to a provider who is culturally affirming, who is affirming of my sexual orientation or gender identity, then that's not real access. So here, really going beyond just ticking a box and thinking about what does access really mean for folks, for real folks who exist within an ecosystem of identity. And so I wanna take a moment and just invite everyone into this grounding exercise to connect with the present moment and internally name, or you can name it out loud because, you know, you might be in a private space. Five things you can see. Four things you can feel. Three things you can hear. Two things you can smell. And one thing you can taste. Grounding is really helpful in helping folks who may be experiencing any kind of dissociative effects of trauma, can, you know, anxious effects of trauma. And, you know, I've had folks who, we've made cards and laminated it and they carry it in their wallet or in their pocket or their purse. Folks who with the advent of smartphones have made it their kind of screen. And it can also be simplified to be a three, two, one. So here, I wanna just highlight real quick within the diagnosis of PTSD, the category of hyperarousal. Here we see irritability and angry outbursts with little or no provocation. And that this is something that's really important for us to be aware of as a symptom of PTSD, because otherwise many of our systems create barriers and punitive responses when what people are really experiencing is a part of their trauma. And that a big goal within trauma-informed care is to create access and enhance effectiveness for survivors of trauma. And the same goes for reckless or self-destructive behavior. That many times it's enormously understandable how substance use is uniquely tied up with experiences of trauma. And that if we are, you know, trying to use rules to change health condition like a substance use disorder, then we're really setting people up to fail because the hallmark of a substance use disorder is of course continued use despite consequences. And so really taking in that trauma lens includes being able to understand how what somebody is experiencing is within their experience and response potentially to trauma. And also I wanna mention when it comes to a diagnosis that we wanna make sure to make room for a range of experiences. Some people may experience a diagnosis such as PTSD as affirming, as empowering, like I finally have a word for what I've been experiencing. And other people may find it really othering or forcing a westernized problem definition. So it may not be very relevant for many people. And they may just feel kind of labeled or boxed in. And so I wanna be really open to people's experience and how they define their own experience on what they find helpful. And then of course, reflecting on adverse childhood experiences. That adverse childhood experiences groundbreaking study in the mid to late 90s, really found that experiences of childhood adversity such as physical violence within the home, sexual violence, et cetera, can increase risk across the lifespan. And in addition to this original groundbreaking research, we also have expanded ACE study. So the original ACE study all focused on adverse experiences within a household and was tested with nearly 80% white sample. The expanded ACEs developed and tested in Philadelphia with a racially diverse sample, included the original ACEs and added community-based adverse experiences including witnessing violence, community-based adverse or excuse me, living in an unsafe neighborhood, being bullied and living in foster care. And some of the findings included a slightly higher rate of the conventional ACEs, 70% versus 66%. A higher rate of ACEs when including both conventional and expanded, that 50% experienced both and 83% experienced either conventional or original and that 50% included both, had experienced both. And that expanded ACEs are also common, 63% of respondents had experienced at least one and that they were correlated with increased risk of substance use disorders and other health conditions and were moderated by socioeconomic stability. And so here really highlighting how poverty is really a structural form of violence. And here's the conceptual framework. Additionally, there's limited studies that exist on the ACE prevalence and health disparities in culturally specific groups. But what does exist point to disproportionate impact and burden on black indigenous and other people of color. And that looking at the studies that race-based differences were largely accounted for by structural violence, including social and economic disenfranchisement. So looking at prevalence, we know ACEs are common, that acute stress disorder prevalence following a stressor differs based on whether it is non-interpersonal or interpersonal and that the PTSD lifetime prevalence is much higher for people who are living with a disabling psychiatric condition or living with a substance use disorder when compared to the general population. And so here, something that we need to be aware of is the cumulative trauma and the impact of cumulative trauma, both on increasing risk as well as exacerbating existing mental health conditions. And so here we see a lot of data, a lot of large community population level data looking at how the relationship between trauma and then going on to experience a disabling mental health condition, as well as how experiencing a disabling mental health condition or really any mental health condition also increases the risk of interpersonal victimization and victimization by violent crime. And including intimate partner violence. We know that intimate partner violence, a large body of research has demonstrated that victimization by an intimate partner increases a person's risk for many mental health conditions and a substance use disorder, and that there are high rates of intimate partner violence among women accessing mental health treatment. And when I say women, that's trans-inclusive and inclusive of people who are feminine identified, but may identify also as gender non-conforming. We also know that men and other gender non-conforming individuals in mental health settings are also disproportionately impacted by domestic violence when compared to the general population. So for survivors of ongoing intimate partner violence, responding to trauma raises an additional set of concerns, because here we don't wanna necessarily, we wanna help folks differentiate between hypervigilance and necessary vigilance. The last thing you wanna do is reduce somebody's vigilance response when that may be in fact what is helping them to survive. And so here we need to have a skillset around not only trauma-informed approaches, but also what it means to support people who may be experiencing ongoing targeting, danger, and coercive control. So here we see a true kind of multiple kind of bi-directional risk, where trauma increases the risk for developing a serious mental health condition, which in turn increases an individual's risk for being abused or victimized. And that this has been tied back to stigma, because then people are not believed, they're marginalized, and they're met with kind of control tactics, which then reinforce any kind of coercive control or victimization that someone is trying to exert over them. And so stigma associated with a mental illness contributes to the effectiveness of abusive tactics and creates further barriers for survivors when they seek help. And that this is further amplified in the context of structural violence. So within this approach, we need to be able to reflect on and appreciate how interpersonal violence exists within structural violence. And that if we ever hope to eliminate and transform, to really prevent and eliminate interpersonal abuse and violence, that we also need to change the conditions that perpetuate abuse, discrimination, and structural violence. And then looking specifically at the impact of trauma and disabling psychiatric conditions, really know how all of these increase the risk of experiencing institutional trauma, as well as traumatic effects associated with symptoms of psychosis. And that we can understand these as a core threat to a person's safety and wellbeing increase, so do threat responses, that we can contextualize mental health and substance use symptoms really as threat responses within a trauma informed framework. And so here's a framework that helps us do exactly that. This is the Power Threat Meaning Framework. And it came from a collaboration between mental health providers and people with lived experience, who came together and said, all of the mental health diagnoses, a lot of us share experiences, a lot of us share symptoms, and that the different diagnoses don't necessarily inform that there aren't zones of rarity, right? That there's actually a lot more similarity between us that we find than difference. And the piece that we really find similar between us that isn't getting spoken to in this kind of systematic manner is the experience of trauma. The experience of both interpersonal and community level and structural trauma. And so together, they came together and created this framework within which to really understand and contextualize mental health symptoms, including substance use. And so from here, we look at the impact of power what happened? How is power operating in this person's life? From there, what was the impact of this power? What kinds of threats does this power pose in this person's life, in this person's community? From there, what sense do they make of it? What's the meaning and discourse, both the kind of public and social discourse, the ideological meanings, as well as the personal meaning? Of course, we then take into account both protective and risk factors and different kind of mediating biological processes. And then after taking in all of that, then we are prepared to really look at what has helped them to survive? What kinds of threat responses are they using? And that within a trauma-informed approach, we understand symptoms as threat responses, as something that has helped somebody survive. And that so many times, the very thing that people may be coming to us for seeking some help is also something that has had some form of function in their life, some form of protective function. And this is where we really use resilience as our foundation, that adaptive strength that people have to really adapt in very aversive and dangerous circumstances. So how does trauma affect access to care? There's an avoidance, there's a reluctance. Of course, with intimate partner violence, there can be treatment interference by an abusive partner, and then the threat is ongoing, so the trauma is not posed. And then the impact of our own responses and settings. And what helps alleviate these systemic barriers? A universal precautions approach, approach that each person, clients, and staff, as someone who has likely experienced some form of childhood adversity, trauma, and or relationship-based or gender-based violence. So here, I like to really say, there is no us and them, there's just us and us. Including people with lived experience in creating, informing, and delivering, and improving services, policies, practices, and program environments. Resources that help prevent and address secondary trauma among staff. Balanced workloads and productivity demands. Comprehensive workforce development. And using an integrated, accessible, culturally responsive, and trauma-informed approach. Here, I just wanna mention a resource we have that is available for free on our website, Tools for Transformation, Becoming Accessible, Culturally Responsive, and Trauma-Informed Organizations. So here, really looking at integrating accessibility as a fundamental goal. Safety is not universally defined. The importance of individualization and collaborative approaches. Restoring those dignity, respect, choice, nurturing empathic connections, really being able to connect with people. And peer and step into the reality, come alongside them in their reality and their experience. And of course, recognizing ongoing and historical experiences of discrimination and oppression, as well as recognizing the role of culture in social context and sources of healing, resilience, and community. So that we're not just taking a problem-focused approach to thinking about culture and cultural responsiveness. Anti-oppressive frameworks are incredibly important, but we don't want to miss all of the cultural sources of resilience and strength, right? We don't just wanna focus on the historical trauma, we also wanna focus on the cultural strengths and resources. So now moving into trauma-informed. And this is just, again, kind of that first definition from the beginning. So attention to a physical and sensory environment. It's accessible. Accessibility here from a disability justice lens, having things like gender-neutral bathrooms, attending to a sensory impact, thinking about what might be challenging, noise, chaos, clutter. What's the level of sensory stimulation? What's the physical space and how are we attending to privacy needs? Confidentiality is absolutely a trauma need and as well as privacy needs. And here, really also that while we want to attend to potential trauma reminders, we also need to be aware that we will never be able to anticipate every trauma reminder. And so it's important to invite people to let us know if they ever feel unsafe with us or in our services, to ask on the front end how we might notice if they're not feeling safe, what would be helpful or not helpful for us when we go to offer support. Looking at the cultural and linguistic environment, are all parts of me welcome and affirmed here? Or do I need to pretend to be someone else in order to access the services I need? What are the experiences of discrimination that are felt by people in our services? What are the kind of implicit bias that gets communicated within our services? And understanding that experiences of discrimination are commonly cited as a barrier by people of color and LGBTQ individuals. Is the space not only safe and accessible, but is it culturally relevant and resonant? Or am I having to conform to cultural values of providers or majority culture in order to access services? And understanding how this can be a form of cultural destructiveness. The relational environment that we, you know, many times the hurt happened in relationship and the healing happens in relationship, that everything is rooted within those relational approaches. And that all the same things that go into fostering relationship and connection and trauma-informed approaches are the same things that foster relationship and everyday life. You know, trustworthy, being trustworthy, caring, respectful, transparent. And of course, employing people with lived experience throughout the organization and fostering community, that some of the most healing things that we can do within our programs and within our centers is fostering community among people. The programmatic environment, and here there's a real balance to strike between being predictable and consistent while also maximizing flexibility and responsiveness. And so I want to offer this mind-body practice from Capacitar, healing trauma and empowering wellness and it's finger holds to manage emotion. And so one would just take, you know, one hand and just firmly wrap a finger from the other hand and each of the fingers is associated with a different kind of emotional experience, emotional reality. Common self-awareness and trauma stewardship, that here, you know, a trauma-informed approach fosters an awareness of what we as service providers bring to our interactions, including our own biases and experiences of trauma, as well as the ways that we're affected when we're truly open. And understanding experiences of trauma are common, particularly among helping professionals, that we tend to have a higher level of adverse childhood experiences and trauma than the general population. And that past trauma is not a deficit and it's not a liability. It's not something to be managed, actually to the contrary, that survivors of trauma make great contributions to our field and that post-traumatic growth can inform the meaning we infuse in our work, our connection to our vocation. And then moving beyond self-care to community care, that staff are able to create a healing environment for community members when organizations are able to create a healing environment for staff. Here, I like to think that people generally know what they can do to take care of themselves if they have the time and the resources to do so. So as clinical leaders and managers, our role is not to tell people that they need to take care of themselves or to tell people, you know, kind of like go take a bubble bath, right? We want to go beyond that. We want to create systems where people have the access to resources and support needed to be able to take care of themselves, as well as really systematizing these opportunities for self and community care throughout our workday, throughout our work structures. And that active trauma stewardship helps prevent and address secondary trauma. So now in my last couple minutes, before I move into the question and answer, I'm going to talk specifically about trauma care. So moving beyond trauma-informed approaches, which of course are necessary to then build on that foundation to actually offering services and resources that aid in the healing of trauma care. And that any trauma-informed approach needs to be able to create access to trauma care. So first, reflecting on limitations of current research, that there's a lack of racial and ethnic diversity in samples, that exclusionary criteria often used in research has disproportionately excluded people with more severe psychiatric conditions, more severe courses of substance use disorders, people who are low income, as well as black individuals. And that there's also a complete glossing over of racial trauma in SMI research. There's a history of abuse and exploitation of people of color in research, and women continue to be underrepresented in clinical trials. And there's an erasure of transgender individuals in research. Even with diverse samples, outcomes are insufficiently reported by gender, racial, or ethnic identity. So for example, contingency management is considered to have a strong evidence base. When outcomes were analyzed and reported according to race, as well as substance use versus non-substance use status at intake, it was found that contingency management was not as effective for black individuals who were using substances of treatment entry. So there are real barriers here to evidence-based practice. Another barrier is that racial and ethnic identities are categorized into broad categories. So even when treatment outcomes are reported by racial and ethnic identity, this really ignores what could be the salient experience or identity of that group, and really engages the risks of homogenization of a group of people. So for example, black and Latin American urban youth may have more shared salient experiences than Latin American youth in rural versus urban settings. So we really have to get clear in our research around how do we counteract homogenization and counteract these assumptions around salient experiences. And so this all points to the need for the expansion of participatory research, qualitative methods, strengths-based inquiry, as well as inclusion of a diversity of ways of knowing, including lived experience and ancestral wisdom. Bernal and Sharon del Rio describe an orientation to research for ethnic minorities that combines quote, hypothesis testing and discovery-oriented research approaches, end quote. And ultimately, we should always be using evidence-based practice as a verb where each individual is an N of one, as well as program level and organizational level evaluation that then informs our quality improvement. So looking at from available research, what to highlight. First off, cognitive behavioral therapy, particularly cognitive restructuring for PTSD, and that it was found just as effective despite the presence of any potential cognitive impairments. There's also promising evidence around exposure-based therapies. Something to note about this is that people who had active symptoms of psychosis, substance use or suicidality have not been excluded from these studies, which is really important. And some notable mentions that aren't in the slide, but I want to make sure to mention as well, particularly for women with complex trauma, are cognitive processing therapy and DBT for PTSD. Now looking at the treatment of trauma-related disorders and early psychosis, here research is still needed. And so what we have and what I want to point to is guidelines based on expert consensus. So treatment modalities of choice include family and conjoint therapy, as well as individual therapy. Treatment approaches for addressing both symptoms of trauma and psychosis includes anxiety or stress management and psychoeducation. And then treatment intervention for addressing symptoms of psychosis include case management, which we know we have so many great evidence-based models around assertive community treatment and community-based support. And then when it comes to enhancing effectiveness for survivors of intimate partner violence, since we know that many people that are in our care or accessing services with us may also have experienced intimate partner violence in the past or may continue to experience intimate partner violence and coercive control. So this is based on a systematic review done by our center, and that these five ingredients can enhance existing evidence-based practices. Psychoeducation around intimate partner violence and its traumatic effect, awareness of mental health and substance use coercion and how these seek to sabotage recovery efforts, attention to ongoing safety, cognitive and emotional coping skill development, and a focus on survivor strengths as well as including cultural strengths. So here's my summary slide. And because we only have six minutes left, hopefully, you know, feel free, you have this for your reference, but I'm actually going to flip forward and just, you know, point out that we have a whole web page on our website dedicated to mental health and substance use treatment and recovery support providers. Some of our different products, my contact information, please feel free to reach out to me. And then I'm going to go through all the references and resources and say thank you and pass it back. Thank you so much for such an interesting and very important presentation, Gabriella. How do I even begin with my residence to ensure improved skills, knowledge, and attitudes to trauma-informed care? Help me. Where do I start? Residence, I'm guessing in this context, refers to like medical school residence. I think the person is talking about, yeah, medical school residence, psychology, fellows, you know, people coming out of school, but may not have the foundation, but are coming into a clinic where they really need to enter with this knowledge. So that speaks to the need of this becoming part of the core curriculum in every single academic institution. And at the University of Chicago, I've actually partnered with the Dean of Students to create a trauma-informed certification program that all students have access to. And so they get a trauma 101 foundational piece, and then they get multiple specialty pieces on top of that, that range from clinical practice to administrative practice to really that self-work. One of my favorites is survivors practicing trauma-informed approaches. So I think that that speaks to that need, but the reality that folks aren't coming in with that, and what do we do? I think that a lot of how we learn is based on modeling, is based on those interpersonal and relational kind of experiences. And so having, you know, all of those shadowing experiences, when we ourselves are striving to encode and weave this in all the parts of our systems, and we ourselves are striving to inhabit trauma-informed care and come from this approach, people take that in. Even if they can't say, okay, these are the core foundational pieces of trauma-informed care and kind of naming them, kind of a cognitive, you know, approach to learning. People learn by watching us. People absorb what we, what our felt presence is, and people respond to that much more many times than what they necessarily, like, read in a handout, right? And so the more that we can inhabit that place, and then also help invite people to reflect and to engage in these ways, and that's where having team meetings, having clinical supervision, how we're all having all these structures in place, are not only the cornerstone of good clinical care, but are also really necessary ingredients in trauma-informed approaches. One thing that comes to mind for me, when I was working in formal treatment, our medical director, and I just adore him, I learned so much from him, one of the things he said was when we have a clinical staffing, we're going to invite, you know, he proposed, let's invite every person to their clinical staffing, so that they, you know, so there's transparency in our services, that, you know, the most important thing is to really hear from them, how they feel their services are going, how they feel that they're doing in their own goals, and what we can do better in really offering more relevant and individualized services. And the team just loved it, I mean, we just, we absolutely loved it, and I just had never had somebody kind of suggest that to me before. And something else that we also instituted was, in all of our staffing meetings, and all of our huddles, our staffing meetings, that, you know, in addition to inviting people to their own clinical staffing, that even if they didn't attend, or if we were discussing someone's situation, they weren't present, that we would still always discuss people as if they were present, that we would always discuss people from that place of compassion, empathy, dignity, respect, humanity. And it seems like such a simple change, but it's a change that I think has huge ripple effects in how we approach people. Terrific. And one thing that it made me think of while you were talking was, we've had other people write into SMI Advisor and say that they've used, for example, like this webinar that you're talking, that you've done today, or webinars, maybe from your center, or from other sites, as, let's say, homework before a meeting. So they'll say, everybody watch this one-hour webinar, and then they'll have their usual resident training meeting, and they'll discuss it, and they'll role play, and they'll really use it. And I think people can visit your center's website, they can visit SMI Advisor. I've also had luck looking at the Alaskan and American Indian Native, they have a tele-mental health website that has a lot on historical trauma, and I myself have learned a lot from watching some of those. So I think there's a lot of resources out there. And like you said, you can sort of have those, and then you can do some modeling, some shadowing, you can do some role playing. You can really sort of sprinkle it in throughout the training years, you know? Absolutely. And I like that. And that reminds me of the importance of onboarding as well, that we really, this needs to be a part of onboarding. Right. Do you have any sense of how you begin to understand if a client of yours has experienced trauma? Do you wait for them to reveal it? Do you ask about it? How do you sort of broach that with a client? So here, I'll say reasonable people will disagree. For many years, people have thought that kind of a universal screening is best practice. And I will tell you that in my clinical experience, as well as the position of the center, is that a universal screening is actually not very helpful when it comes to trauma experiences. And I'll tell you, as an experience as a clinician working in community mental health, that I would get like, no, no, no, no, no, right? And then like the very next session, it would be like, here's all this stuff that now I feel safe enough to talk with you about. And so really expecting or demanding folks to kind of reveal all this about themselves at that very first juncture, I think is really not, it's not how we get to know each other as humans, right? And so my approach, both personally as a clinician, and then also as a center, is that rather than going out on like a fact finding mission, to focus on building the programmatic and the relational environment where people feel safe enough that not only are we a supportive listener, but that we'll also be a helpful listener, that we're somebody that can actually be responsive and help them with whatever they kind of want some support around. That said, what I do feel is important and helpful is screening for potential trauma symptoms. So a lot of times someone is much more ready to tell me about their nightmares that they're experiencing or their trouble sleeping versus what happened 20 years ago when they were, you know, a child. Right. I really, that really resonates with me because certainly as a clinician, I've had clients who it's come out years later after the relationship. And it's the point at which they're ready to, I never take it as a feeling about whether we've been connected or not, but it's the time at which they're ready to reveal and to maybe address it. And so I think you're right that it's, it really is a sort of a follow along and to have a place in a relationship where when, and if they're ready, they can share it. So I really, I really appreciate that response and, and, and revealing that there's tension in the field about screening versus coming out later. Thank you for joining us today and until next time, take care.

trauma-informed care

disabling mental health conditions

prevalence of trauma

impact of trauma

culturally responsive environments

building trusting relationships

supporting resilience

intimate partner violence

evidence-based practices

safe environments