trauma informed care: impact of adverse childhood effects ... informed care impact of...ds...

DS BigFoot, 2016© 1

Trauma Informed Care: Impact of Adverse Childhood Effects

in Indian Country

Dolores Subia BigFoot, PhDIndian Country Child Trauma Center

University of Oklahoma Health Sciences CenterOklahoma City, OK

Trauma Informed Care Resources• SAMHSA Making Integrated Care Work

http://www.integration.samhsa.gov/clinical-practice/trauma

• NICWA Trauma Informed Care Factsheet http://mecptraining.org/wpcontent/uploads/2015/03/Trauma-Informed-Care-Fact-Sheet.pdf

• Webinar: Trauma Informed Care in Indian Country http://www.acesconnection.com/event/webinar-trauma-informed-care-in-indian-country


http://www.integration.samhsa.gov/clinical-practice/trauma

http://mecptraining.org/wpcontent/uploads/2015/03/Trauma-Informed-Care-Fact-Sheet.pdf

http://www.acesconnection.com/event/webinar-trauma-informed-care-in-indian-country

American Indian/Alaskan NativeNational Statistics

• Approximately 5.2 million self-identified American Indians and Alaska Native (2010 Census)

• 29.9% under the age of 18• 9% of the population is under the age of 5• 78% reside off reservations: urban, rural or

near reservations boundaries

3DS BigFoot, 2016©

American Indian/Alaskan NativeEconomics and Poverty

• 29.9% of all families live below poverty line vs 18.8% for general population

• 48% of single female head of household live below poverty level vs 41% for general population of single female head of household

• 15.9% unemployment overall with 22.8% on reservation

4DS BigFoot, 2016©


American Indian/Alaskan NativeEconomics and Poverty

• 10.53% of the WIC participants• 1.2% of TANF participants• 3.2% of SNAP participants

• 56% live with adult children, grandchildren and share child care responsibilities


Child Maltreatmentand Trauma

• American Indian and Alaska Native families had the highest re-referral rates for sexual abuse, physical abuse, and neglect relative to other ethnic categories (Stevens et al., 2005)

• AI/AN children make up less then 1% of the total child populations, but represent 2% of the children in foster care

Adverse Childhood Experience Study(http://www.cdc.gov/violenceprevention/acestudy/prevalence.html)

• Recurrent physical abuse• Recurrent emotional abuse

• Sexual abuse• An alcohol and/or drug abuser in the

household• An incarcerated household member

• Household member who is chronically depressed, mentally ill, institutionalized, or suicidal

• Mother is treated violently• Parental loss

• Emotional or physical neglect• Household


Sensory integration

Immune System

Domestic / Family Violence

Relationships

Child Abuse / Neglect

Mistrust

Depression Suicide

Attachment

Learning

Incarceration

PTSDSubstance

Abuse

Recognizing the Impact of Historical Trauma

Source: D. Bigfoot (2008). Child Trauma Treatment Center, University of Oklahoma, Oklahoma City, OK.

vimeo.com/8486687

Historical Trauma and Epigenetics Originally, epigenetic changes

were believed to occur only during fetal development. But pioneering studies are suggesting that “molecular bric-a-brac” could be added to DNA in adulthood, setting off a cascade of cellular changes.

Trauma experienced by earlier generations can influence the structure of our genes, making them more likely to “switch on” negative responses to stress and trauma.

Read more at http://indiancountrytodaymedianetwork.com/2015/05/28/trauma-may-be-woven-dna-native-

Grandma's Experiences Leave a Mark on Your Genes. Discover: Magazine of Science, Technology and the Future (May 2013).

http://indiancountrytodaymedianetwork.com/2015/05/28/trauma-may-be-woven-dna-native-americans-160508

"The connectedness of past to present to future remains a circle of lessons and insights that can give us both the consciousness

and the conscience to heal ourselves.

Understanding the interrelationship with our past and how it shapes our present world will also give us the courage to initiate healing.”

Maria Yellow Horse - Brave Heart, 1988

Vulnerability of American Indian and Alaska Native Children and Youth (ACE Comparison)

• Physical abuse (over represented in foster care system)

• Emotional abuse (higher rates of disruptive behavior and substance use disorders than other same age children and youth)

• Sexual abuse (over 75% of US Attorney’s caseload)• Alcohol and/or drug abuser in household (12–16%

vs. 4–6%)• Incarcerated household member (estimated 3 out of

5 males incarcerated, on probation, or other legal condition)

Vulnerability of American Indian and Alaska Native Children and Youth (ACE Comparison)

• Someone who is chronically depressed, mentally ill, institutionalized, or suicidal (injuries, suicide & homicide leading causes of death; high levels of depression, anxiety, PTSD)

• Mother is treated violently (highest rate of all populations, 50% higher than Black males)

• One or no parents ( 40% living with one parent)

• Emotional or physical neglect (highest rate of all populations)


Trauma in Indian Country

Historical Events &

Historical Trauma

Oppression and cultural trauma

Incarceration

Substance Abuse

SuicideDomestic/ Family Violence

Child Abuse and

Neglect

Violence

AccidentalDeath

Cumulative (Collective)

Trauma

Poverty

Individual Situations

Physical Impacts• Avoidance• Hyperarousal• Hypervigilance• Sleep Difficulties• Poor Coping

– Risk-Taking– Substance Abuse– Self-Injury

• Fear• Sadness• Anger• Anxiety• Shame• Emotional

Dysregulation• Numbing/Emotional

Disconnect

Emotional Impacts

• Isolation• Trouble developing/

maintaining healthy interpersonal relationships

• Violence/Aggression• Bullying• Sexualized Behaviors

Relational Impacts

Complex PTSD

• Affective dysregulation• Interpersonal difficulties• Self-esteem issues• Self-injurious behaviors

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DS BigFoot, 2008 1818

Trauma-Informed Principlesfor Children Indian Country

• Need for Safety• Need for Supervision• Need for Protection• Need for Guidance• Need for Monitoring• Need for Teachings• Need to know they are Sacred• Need to know they are Honored

Our grandparents, elders, and ancient ones have long prayed and offered sacred words to the Creator to watch over all things from the

past, the present, and the future.

We are taught to pray for all things because we are all connected. The air we breathe

comes from the trees. The food we eat comes from the earth. The rain that cleanses us

comes from the sky.

Through sacred words comes healing from the past, strength for the present and hope for

the future. DS BigFoot, 2011 19

Trauma Informed Care-is an approach to engaging people with histories of trauma in which you recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. In all of the different environments in which a traumatized person would find themselves, each person encountered would seeks to change the paradigm from one that asks, "What's wrong with you?" to one that asks, "What has happened to you?"

DS BigFoot, 2010 20

National Center for Trauma-Informed Carehttp://www.samhsa.gov/nctic/ Retrieved and revised 09/06/2011

http://www.samhsa.gov/nctic/

Trauma Informed CareUnderstanding and reacting with intent to greatly lessen or eliminate the impact of

prior trauma exposure especially as a child may be responding to current perceive or

actual threat, harm, reminders, restrains, or other conditions either emotionally,

physically, cognitively, or environmentally resulting in their aggressive or other wise

undesirable behaviors. DS BigFoot, 2010 21

Interventions

• Trauma Focused Cognitive Behavior Therapy

• Parent Child Interaction Therapy• Treatment of Child with Inappropriate

Sexual Behavior• American Indian Live Skills

Curriculum• Motivational Interviewing

DS BigFoot, 2008 22

Treatment of Trauma with American Indian Children

Culturally AdaptedEvidenced Based

Treatments



Great Mystery

WisdomReflections

BeliefsPracticesRelationalKinships

Awareness

Known Science

Formal Education

Evidence Based

Technology

Western Based Medicine

Western knowledge


Observers of stars, plants, animals, movement, ice, water, wind, earth

Understandings of who we are, where we came from and, where we are going

Indigenous Knowledge

Indigenous KnowledgeCommunity is essential for survival.” In indigenous societies, “concern for the greater good and respect for the community are embedded in Indigenous legal, political, social and economic structures.”

“Life is sustained through balance and harmony.” This means indigenous people “give and take from nature in synchrony with natural cycles, ensuring that our sources of life remain healthy and abundant.”

“Nature is a source of knowledge… Indigenous science and knowledge are based largely on bioindicators, or natural signs.”

The importance of spoken language, given that most indigenous societies do not have a literary heritage.

Presence of rich artistic tradition that is found within most indigenous societies, such as the visual arts, dance, and song.For most indigenous people, the arts are a form of communication, both between themselves, and with the metaphysical world.

Size of traditional societies are run along much more smaller lines than their industrialized counterparts, partly as a way of avoiding too much impact on the environment around them, partly as a way of ensuring that there is unity in decision making, and that a separate political bureaucracy is not required.

Cite this page as: Dunn, Michael. Defining indigenous knowledge (26th September 2014). theoryofknowledge.net. http://www.theoryofknowledge.net/areas-of-knowledge/indigenous-knowledge-systems/defining-indigenous-knowledge/ Last accessed: 13th April 2015


http://www.theoryofknowledge.net/areas-of-knowledge/indigenous-knowledge-systems/key-thinkers-and-ideas-on-indigenous-knowledge-systems/

http://www.theoryofknowledge.net/areas-of-knowledge/indigenous-knowledge-systems/defining-indigenous-knowledge/

Indigenous knowledge comes from “Great Mystery”

Somethings can not be explained or proven according to what is

considered science or hard science


Great Mystery

Indigenous knowledge we know

Western Knowledge exist which makes our lives have more comforts :

*plumbing*air conditioning*ice cream*health care*transportation*public schools*communication*iphones*cameras*technology*Starbucks*medicine DS BigFoot, 2016© 28

Great Mystery

There are ideas, understandings, information, concepts, techniques, common practices that are not unique to western knowledge

Indigenous knowledge we know

RelaxationThought StoppageBreathing Select IgnoringPraiseIdentity FormationSocializationBonding & Attachment


Evidence Based Principles

• Cognitive - Behavioral principles• Attachment – Relational• Humanist – We are all related• Developmental – Naming• Neurobiology – we knew the earth was

round• Empowerment – non interference

non-directive


There is the eternal belief among the Indigenous Peoples of this Great Turtle Island that each walks a sacred path occupied by both spirit and reasoning. That there is a purpose for the journey from the First World into the Second World and into the Third World followed by a Fourth World. That there is order and structure to the beginning of human beings, and a need for understanding where we come from, why we are here, and where we are going. We also recognize that we do not walk this path alone and that we have many relatives who walk with us. Families are an essential feature of this sacred path.

Honoring Children in the Circle Way

31DS BigFoot, 2016©

This existence is not without opposition, therefore the need for connection to that Creator and the holy ways are given to make the journey filled with knowledge and wisdom pass to each generation and also with inspiration for guidance and direction. There was never the belief that this journey would be one of aloneness or singularity of purpose, however one can feel alone and think that little could come from being born into this Third World. Helpers and Healers in many forms attend to the petitions and sacred pledges uttered in gratitude or in compassion. The circle and connection between earth, sky, the above and the under, all are petitioned, not as the creator of things but as beings at the hands of the Creator.



Children are believed to be the center of the circle, surrounded by many relatives both in the present and those that came before them and those that will come after them. The Circle is a protection as well as a teacher, an understanding, an way of being connected, a way of knowing relatives, a way of belonging, a way of having an identity, a way of having purpose, a way of recognizing boundaries and responsibilities, a way of knowing actions and learning, a way of thinking about expectations and disappointments, a means of testing and safety, a generosity of exchanges both inwardly and outwardly.



Honoring Children SeriesMending the Circle

Trauma Focused Cognitive Behavior Therapy

Making RelativesParent Child Interaction Therapy

Respectfully WaysTreatment of Children and Adolescents with

Inappropriate/Illegal Sexual Behavior Problems


Trauma-Focused Cognitive-Behavioral Therapy

A hybrid treatment model that integrates: Trauma sensitive interventions Cognitive-behavioral principles Attachment theory Developmental neurobiology Family therapy Empowerment therapy Humanistic therapy

WHAT?


Core Values of TF-CBTCRAFTS Components-Based

Respectful of Cultural Values

Adaptable and Flexible

Family Focused

Therapeutic Relationship is Central

Self-Efficacy is emphasizedDS BigFoot, 2016© 36

Honoring ChildrenMending the Circle


Cultural Enhancement of Trauma focused Cognitive Behavior Therapy


Indigenous PathwayPractice Based Evidence

• Identification of Indigenous practices that are Healing

• Identification of Indigenous ways of explaining the world

• Identification of Indigenous ways of explaining how things happen

• Identification of Indigenous ways of explaining when things do not go well


• Teach that wellness is spiritual, emotional, mental, physical, and relational balance and that these are all interconnected aspects of ourselves

• Help the individual to draw upon traditional healing practices to assist moving forward toward spiritual balance

• Help instill an enthusiasm for life, a sense of hope, and a willingness to meet new challenges

• Increase sense of self-identity, self-worth, self knowledge

Practices that teach SacrednessPractice Based Evidence

RELATIONAL

MENTALPHYSICAL

EMOTIONAL

SPIRITUAL

Honoring Children – Mending the Circle

Well-Being Model FrameworkDS BigFoot, 2016© 40

Trauma is a part of the circle of life. There is a long history of trauma in Native American families, communities, and Nations.

Trauma is like a roadblock or burden in our path. Healing is the way to make the roadblock or burden more manageable or to make it go away completely.

Healing means that the circle is whole again. One must know how to change one’s thinking, feelings, and beliefs about a traumatic experience in order to regain balance or harmony.


Personal imbalance is disharmony inone or more personal dimensions -

spiritual, relational, mental, emotional or physical.

When an individual experiences disharmony, it may manifest through

unhealthy behaviors and attitudes.

Trauma Exposure May Create Personal Imbalance



Well-being is considered balance in the spiritual, emotional, mental, physical, and relational dimensions of a person. The goal is to achieve and maintain balance.

AI/AN Orientation to Well-Being


Physical

MentalEmotional

Relational

Spiritual

Model of Well-Being

•Balance

•Harmony

•Respect

•Connectedness

•Wellness

Example of a HC-MC Family Component Worksheet Using Circle


• Degree of affiliation of American Indian and Alaska Native with their culture or strength of cultural ties

• Symbolic representation of the Circle and its applications

• Use of culturally based analogies (Grand Entry, Beading)

• Incorporation of tribal creation stories or similar telling of meaningful events

••

Considerations for Using Cultural Adaptations in Individual Cases



• Teach that wellness is spiritual, emotional, mental, physical, and relational balance and that these are all interconnected aspects of ourselves

• Help the individual to draw upon traditional healing practices to assist moving forward toward spiritual balance

• Help instill an enthusiasm for life, a sense of hope, and a willingness to meet new challenges

• Increase sense of self-identity, self-worth, self knowledge

Practices that teach SacrednessEvidenced Based Cross Walk

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Honoring Children –Mending the Circle

Trauma-Focused Cognitive Behavior Therapy

Spiritual

Mental Psychoeducation, Cognitive Coping, In Vivo Desensitization

Physical Relaxation

Emotional Affect Regulation

Relational Psychoeducation, Parenting Skills, Safety Skills, Social Skills

Mending the Circle Trauma Narrative, Cognitive Processing, Conjoint Parent-Child Sessions

Treatment Components

DS BigFoot, 2016©

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Physical Aspects of HealingHC-MC Methods

– Sweatlodge– Drumming– Meditation– Singing/Chanting– Prayer– Smudging– Active Outdoor

Games & Sports– Healing

Ceremonies

TF-CBT Methods– Progressive

Muscle Relaxation

– Controlled Breathing

– Visualization– Identifying

Enjoyable Activities

DS BigFoot, 2016©

StorytellingCreation stories are the history and tradition of the tribes; they tell how the world began in what manner. They explain how the world, people, animals, and plants are related. Through creation stories, people can understand the natural order of life and in what direction they came and in what direction they are going. They give reason to the overall scheme of things. It is therefore important to understand the creation of things because it provides the framework within which wise decisions can be made.Storytelling was the form of transmittal for how things were and why things happened. There were winter stories and summer stories, stories for days that the rains fell, and stories for early mornings. Creation stories were retold and retold many times in the growing years.

BigFoot, 1989


Stories

• Buffalo and the Storm• Eagle Strength• Cheyenne Creation Story• Beading• Pottery Making• Horizon Story• Talking Stick Story



Buffalo and the StormAs is known, millions of buffalo roamed the Great Plains areas in years pasted, as was common then and still common today is the tumult lighting and thunderstorms that cover the landscape from early spring into the summer months. We are familiar today with those raging, darkening storms that typically form in the west and move toward the east, especially those that grown quite menacing with tornadoes, strong forceful winds, pounding hail, and/or icy rain. Out in open prairie, the buffalo were intensely aware of approaching storms. The question the elders would ask when someone was hesitant about the next move or question undertaking a difficult task, was did the millions of buffalo gather into a single mass for protection, did they run into the menacing storm force or did they run away from the approaching storm? When watching buffalo out on the plains, the people saw that the buffalo ran into the storm because the buffalo instinctively knew that there was calm, brightness, sunshine, and peaceful grazing behind the retreating storm. (Retold by Dolores Subia BigFoot, PhD, 2011)

What did the buffalo do? Did they huddle together (freeze)? Did they run away from the storm (flight)? Or did the turn toward the storm and run into it (fight)?

By facing the storm, they find themselves quickly passing through it. We have a choice in life with all the storms that we encounter: we can spend our time and energy running from our trials, or we can be like the buffalo, facing life's trials, and passing quickly through them.

Example of a HC-MC Crosswalk with Psycho-Ed for Exposure Using Traditional

Teachings


Honoring ChildrenMaking Relatives

Cultural Enhancement

of Parent Child Interaction

Therapy


American Indian Parents

•Familiar Understandings•Culturally based•Storytelling skills•Circle Theory•Honoring the Child


BeadingBeadwork is a common but highly personalized skill among many American Indian and Alaska Native artists with exquisite variety in design and application. However certain features remain the same with the necessary and required needle, thread, backing, colored beads, cutting implements, wax, desired design, required measurements, and buckskin or similar material for shape and form. The creativity and beauty of the beadwork piece is at the heart and hands of the gifted artist; however the structure, form and function comes from the common elements which the artist uses to bring forth the exquisite piece. The therapeutic process of Parent-Child Interaction Therapy is much similar. The skilled clinician uses the common components of PCIT of explaining/educating, skill building, modeling, praise, enthusiasm, etc., to produce the structure of PCIT while deciding what complimentary features they wish to add in personalizing or making the structure more of their own.


As the mother described how to bead, I used the scenario that PCIT was the string that would help to guide the beads along the way but she as the parent was one who was actually creating the pattern i.e. relationship and how it was necessary to follow the string (PCIT protocol) in order to reach the goal. I was amazed. I talked about how in American Indian and African American cultures we learn though visuals and story telling and tied it in with the PCIT protocol and how her role was to tell her daughter's story in the moment. The Mom expressed her struggles in not relating to her daughter in the way that I had been asking her to do with straight PCIT and that PCIT was not like other parenting classes she had taken. I talked with her about finding her natural voice and even though I might tell her a statement to repeat, she should take a deep breath and turn my statement around and put it in words that felt right to her. She can tell the stories of what her daughter’s hands were doing.

DS BigFoot, 2016©

Photo by DS BigFootBeadwork by Cleo Wilson Sipes

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Understanding Protocol

With this treatment, we know what to expect when we follow the protocol or engage in each of the components. It is built with little tiny pieces, common words like "You drew a big blue bus,” “You are very gentle with the crayons as your draw your bus," Each element is unexceptional until it is all put together just like in beadwork, very tiny beads one at a time create a beautiful piece of art.

DS BigFoot, 2016©

Photo by DS BigFootBeadwork by Cleo Willson Sipes

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Honoring Children

In implementing PCIT with American Indian parents, the parent comes to understand that they will continue to use their understanding of what is familiar to them to improve their parenting skills and their ability to interact positively with their children.

DS BigFoot, 2016©

Photo by DS BigFootBeadwork by Rufus Spear

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By honoring your child with storytelling, listening, watching, and doing, you are doing one bead at a time

DS BigFoot, 2016©Photo by DS BigFootNorthern Cheyenne Healing Camp, Lame Deer, Montana

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