NWX-SAMHSA

Moderator: Jane Tobler
March 30‚ 2011
2:00 pm CT

Coordinator: Welcome and thank you for standing by.

At this time‚ all participants are in a listen-only mode until the question and answer session. Today’s conference is being recorded. If you have any objections‚ you may disconnect at this time.

The PowerPoint presentation‚ PDF version‚ the audio recording of the teleconference and a written transcript will be posted to the SAMHSA 10×10 Campaign web site at http://www.10×10.samhsa.gov.

Our presentation today will take place during the first hour and will be followed by a 30 minute question-and-answer session at which time you may press “star 1” to ask a question.

I would now like to turn the call over to Jane Tobler. Thank you. You may begin.

Jane Tobler: Hello‚ and welcome to The Impact of Trauma on Wellness: Implications for Comprehensive Systems Change. Today’s teleconference is sponsored by the Substance Abuse and Mental Services Administration 10×10 Wellness Campaign.

SAMHSA is the lead Federal agency on mental health and substance abuse and is located in the U.S. Department of Health and Human Services. Through an interagency agreement‚ SAMHSA is privileged to partner in this effort with the U.S. Food and Drug Administration Office of Women’s Health. We encourage you to join the 10×10 Wellness Campaign Listserv at www.10×10.samhsa.gov.

The views expressed in this teleconference event do not necessarily represent the views‚ policies‚ and positions of the Center for Mental Health Services‚ the Substance Abuse and Mental Health Services Administration‚ the U.S. Food and Drug Administration‚ or the U.S. Department of Health and Human Services.

Today we are joined by three people with extensive experience and knowledge about the impact of trauma on wellness. Our first presenter is Ann Jennings. Her personal experience of trauma fuels her passion to reduce human tragedy and create compassionate and effective human services.

She is the founder and executive director of The Anna Institute‚ a non-profit organization dedicated to providing trauma informed resources for professional‚ community and survivor use. Please note that citations for Ann’s slides are at the very end of the PowerPoint presentation.

Ann will give us an overview of the adverse childhood experience for ACE study and the consequences of unaddressed childhood trauma. Thanks for joining us‚ Ann.

Ann Jennings: And thank you for the opportunity to speak with everybody online today about the adverse childhood experiences study. The findings of this study are crucially important to health and human service systems as well as individuals‚ families‚ and communities across our country.

The implications for all of our health and well being over the lifespan are profound. ACE study findings have the potential to increase our understanding of what it is to be human. And with that understanding may come more compassion for one another and less of the “we-they” type of thinking that seems so prevalent in our society today.

I’m going to start by briefly telling you a story‚ the story of my daughter Anna. The picture on this slide is of Anna in her early 20s. Slide 5. The picture at the top of this slide is Anna at age one and a half. The next picture is Anna years later in a mental institution. What happened to her? Slide 6.

Anna‚ at the age of 3 years old‚ was sexually abused. The abuse was at the hands of a trusted caregiver and continued for four years. This was in the early 1960s. We were unaware that it was happening and Anna did not have the language to tell us.

She was seen by numerous health and human service providers but no one recognized the signs. No one asked or looked into what might have happened to her. Instead they focused on what was wrong. Was she learning disabled? Did she have a mental illness?

When she broke at the age of 13‚ she was misdiagnosed as schizophrenic. For 17 years she was in the mental health system‚ 11 of those years in mental institutions. For 17 years no treatment helped and some made her worse.

When she was 23‚ she learned from other patients that she was not the only one in the world to have been sexually abused as a child. She diagnosed herself with PTSD. Still‚ no one listened‚ understood or helped her.

At that time no one had trauma training. Anna took her life at the age of 32 in the back ward of a mental hospital. The emotional cost to her family was devastating. The lifetime financial cost of her care was almost five million dollars.

Her story‚ unfortunately‚ is not unique. The majority of people in our mental health‚ substance abuse‚ correctional‚ and other human service systems can tell similar stories about their own childhood experiences. The information I will present today helps us to understand why this is the case. Slide 7.

The adverse childhood experiences‚ or ACE‚ study is a 14-year collaboration between the Center for Disease Control and Kaiser Permanente’s Department of Preventative Medicine in San Diego. The largest study of this kind ever done‚ it reveals the relationship between traumatic stress in childhood and leading causes of morbidity‚ mortality and disability in the United States.

Over 17‚000 middle class Americans‚ average age of 57‚ with Kaiser health insurance‚ responded to questions about adverse experiences in their childhoods from birth to age 18. The extent to which these experiences related to adult well-being‚ social function‚ health risk‚ disease‚ and life expectancy was then examined by thorough reviews of their medical records.

About 70 articles on ACE study findings have been published since 1998. PDFs of many of these articles and of all the resources referred to in my presentation can be found on the Anna Institute Web site. The address of this Web site is in your slides under speaker contact information. Next slide.

In 2009‚ CDC‚ with the health departments of Arkansas‚ Louisiana‚ New Mexico‚ Tennessee‚ and Washington‚ conducted a problem study to determine the extent of ACEs in the lives of over 26‚000 adults in the five states. This study found overall prevalence rates to be similar to those found by the Kaiser ACE study. Next slide.

What both studies reveal is that adverse experiences in childhood are exceedingly common. Two-thirds of the more than 43‚000 adults involved had at least one type of traumatic experience in childhood. One in nine had five or more.

The Kaiser ACE study also reveals irrefutable evidence that an accumulation of different types of potentially traumatic experiences in childhood have a significant graded relationship to the development of many of the most troublesome health behavioral health and social problems of today. This has important implications for the Wellness Campaign‚ which will become clear as we review the following slides. Next slide please.

This slide shows the three columns of a one-page chart available on the Anna Web site giving a comprehensive overview of the ACE study. What the chart shows is adverse childhood experiences leading to neurobiological and health risk impacts‚ which in turn lead to long-term health and social problems.

The more types‚ or categories‚ of ACEs‚ the greater the neurobiological impacts and health risks and the more serious the lifelong consequences. Next slide please.

Participants in the ACE study were asked questions about ten categories of adverse childhood experiences. Emotional abuse; physical abuse; contact sexual abuse; emotional neglect; and physical neglect; and in the child’s household‚ alcohol‚ drug use; depressed‚ emotionally disturbed or suicidal household member; mother treated violently; imprisoned household members; and the loss of a parent.

Note to the right of each category the percentage of adults reporting each of these types of ACEs. For example‚ sexual abuse was reported by 22 percent of the people interviewed; physical abuse 25; drug use in the household 27 percent. A person’s ACE score is based on the number of categories of adverse childhood experiences they identify in their childhood.

So if as a child you were physically abused‚ that counts as one ACE no matter how many times the physical abuse occurred. Each type of adverse childhood experience gets a score of one. The ACE questionnaire can also be found on the Ann Web site so that you can tabulate your own ACE score. Out of ten ACEs‚ Anna had a score of seven. My score is five. Next slide please.

The higher the ACE score or the more types of trauma experienced as a child‚ the greater the impacts on the brain and nervous systems and the more numerous the possible health risks. Neurobiologic affects of trauma include disrupted neuro development‚ difficulty controlling anger‚ hallucinations‚ depression‚ panic‚ anxiety‚ somatic problems‚ sleep problems‚ impaired memory‚ flashbacks‚ and disassociation.

Health risks are viewed by the ACE study as attempts to cope with‚ get release from‚ or lessen the pain caused by childhood trauma. These behaviors include smoking‚ obesity‚ physical inactivity‚ suicide attempts‚ alcoholism‚ drug abuse‚ multiple sex partners‚ and repetition of original trauma‚ self-injury‚ eating disorders‚ and perpetration of violence. Next slide please.

The ACE study found graded relationships between the adverse experiences and childhood and chronic health conditions. The higher the ACE score‚ the greater the possibility of ischemic heart disease‚ autoimmune disease‚ lung cancer‚ chronic obstructive pulmonary disease‚ asthma‚ liver disease‚ skeletal fractures‚ and sexually transmitted disease.

Multiple traumatic childhood experiences also increased the possibility of experiencing such serious social problems as homelessness‚ prostitution‚ delinquency‚ criminal behavior‚ inability to sustain employment‚ re-victimization by rape or domestic violence‚ compromised ability to parent‚ negative alterations of self perception and relationships with others‚ alterations in what gives life meaning‚ intergenerational transmission of abuse‚ and long-term use of health‚ behavioral health‚ correctional and social services.

So we see early childhood trauma impacts on all eight dimensions of wellness identified by the Wellness Campaign; social‚ physical‚ emotional‚ spiritual‚ occupational‚ intellectual‚ environmental and financial. Next slide. Next slide please.

This is another way of viewing the various connecting aspects of ACE study’s findings. ACEs at the bottom of the pyramid underline disruptive neuro-development and social‚ emotional‚ and cognitive impairments causing the adoption of health risk behaviors‚ which are often precursors to disease‚ disability‚ or social problems and can lead to early death. Next slide please.

Now that you have an overview of this incredibly important study and the multiplicity of ways in which childhood trauma can manifest‚ we’ll look at just a few of the many examples.

Please note in the following slides the consistently graded relationships are dose-response relationships‚ in which it is clear that the higher the ACE score shown at the bottom of the graph‚ the more the likelihood is of developing problems across the lifespan. Next slide please.

Childhood experiences underlie chronic depression. The study found that adult women and men with an ACE score of four or more were 460 percent more likely to be suffering from chronic depression‚ with women twice as likely as men to experience episodes of major depression over their lifespan. Next slide please.

With an ACE score of seven or more‚ the likelihood of adult suicide attempts is shown to increase 30-fold or 3000 percent when compared to an ACE score of zero. ACE study analysis finds a startling 80 percent of child adolescent suicide attempts to be attributable to cumulative childhood traumas. Next slide please.

Traumatic experiences in childhood underlies several serious and persistent mental health problems. This is demonstrated by ACE study analysis of the use of anti-psychotic‚ anti-anxiety and anti-depressant prescription drugs. Note the graded relationship between the more the ACE score‚ the more the use of these psychiatric medications later in life. Next slide please.

Adverse childhood experiences underlie addictions of all kinds. With this slide‚ we see the graded relationship of numbers of ACEs to the rate of adult alcoholism. This picture is characteristic of all the addictions.

The ACE study finds that two-thirds of alcoholism is attributable to childhood traumatic experiences and that people with an ACE score of four or more are over five times more likely to struggle with alcoholism than people with an ACE score of zero.

Similar graphs not included here show the same relationship of ACE scores to addictions such as smoking and illicit drug use. A child with an ACE score of six or more‚ for example‚ is 250 percent more likely to become an adult smoker. With an ACE score of four‚ that child is 14 times more likely to inject street drugs.

The study found a male child with an ACE score of six compared to a male child with an ACE score of zero has a 46 fold or 4600 percent increase in the likelihood that he will become an IV drug user later in life. Next slide please.

This slide demonstrates how children exposed to violence often grow up to become victims of violence. Some may also inflict violence on others. Women with an ACE score of four or more‚ for example‚ are almost 900 percent more likely than a woman with an ACE score of zero to be victimized by rape during their life and 500 percent more likely to become victims of domestic violence. Both men and women with higher ACE scores are also more likely to be perpetrators of domestic violence. Next slide please.

One of the most tragic consequences of unaddressed childhood trauma is the significant rise in chronic health conditions associated with high ACE scores. These findings are particularly relevant to integrated care and wellness programs and practices. They reveal the need to address trauma as central to the health and well-being of people across a very wide spectrum of problems. Next slide please.

And finally‚ poor life expectancy. On average people with an ACE score of zero live to age 79 whereas those exposed to six or more ACEs die at the age of 60‚ a 20-year difference.

In conclusion‚ it is clear that the most crucial challenge faced by SAMHSA’s Wellness Campaign is to recognize and address the impacts of cumulative childhood traumas that lay hidden at the root of so much human suffering and premature death.

The findings of this groundbreaking study also underscore the need for taking a trauma-informed public health approach to prevention‚ early intervention‚ and treatment within a context of safe and supportive healing relationships and organizational cultures‚ which is what my colleagues Roger Fallot and Cathy Cave will be talking about in their presentations to follow.

Thank you again for the opportunity to speak with so many of you today.

Jane Tobler: Thank you Ann for that important overview of the ACE study and the societal impacts of childhood trauma. Just to share with everyone‚ there’s also an ACE Study Web site that aggregates many links and resources on this study at http://www.aceresponse.org.

Our next presenter is Roger Fallot‚ a clinical psychologist and Director of Research and Evaluation at Community Connections‚ a private human services delivery agency in the District of Columbia. He is author of numerous publications and he has a special interest in the effectiveness of integrated services for both male and female trauma survivors and the relationships between spirituality‚ recovery and well being.

Today‚ Roger joins us to talk about creating cultures of trauma informed care in behavioral health settings. Welcome‚ Roger.

Roger Fallot: Thank you for that gracious introduction and thank you to Ann for laying out so clearly the connections between early experiences of trauma and a whole host of later difficulties.

When we talk about achieving goals related to wellness‚ then it should be not surprising to any of you that I want to talk today about creating cultures of trauma-informed care.

In order for people to become engaged in services of any kind to maximize their wellness and get the most benefit from the programs offering those services‚ whether these services are primarily identified as physical health care‚ mental health or substance organizations‚ the cultures of the programs need to be trauma informed.

The first thing we emphasize is the difference between trauma specific services and trauma-informed care. Trauma specific services refer to those interventions and therapies that are explicitly designed to address the impact of trauma in a person’s life and to facilitate trauma recovery.

So‚ most of you have heard of groups like the Trauma Recovery and Empowerment Model or TREM groups or seeking safety. You may be familiar with trauma-focused cognitive behavioral therapy for children or cognitive processing therapy for adults. These are all examples of trauma-specific services.

What I want to focus on today‚ by contrast‚ is the context of the organizational culture that may hopefully characterize any human service‚ mental health and substance abuse to be sure‚ but also physical health care‚ homelessness‚ criminal justice‚ children’s welfare‚ education in schools among many others.

Trauma-informed cultures take seriously what we know about trauma‚ about its prevalence‚ its broad and profound impacts‚ and the very diverse way in which people cope with and recover from traumatic events. And this information gets into the bones of the service system into the way that people think and act.

Services become more welcoming and hospitable‚ more caring and collaborative. Providers stop asking what is your problem or what is wrong with you and start asking what has happened to you and how have you dealt with it. They stop saying‚ “Here’s what I can do to fix you‚” and start asking‚ “How can you and I work together to achieve your goals of recovery and healing?”

In fact‚ this brings me to a violation of nearly every pedagogical principle I know of. I’m going to spill the beans right upfront and tell you this slide is the most important one I’m going to present today. Realize this may be an open invitation to tune out everything I say afterwards but it is a chance worth taking to really emphasize the importance of these key elements.

Safety‚ trustworthiness‚ choice‚ collaboration‚ and empowerment are the core values of a trauma informed culture. They tell us what matters most in the day-to-day life of an organization. When we say culture‚ we’re talking about every activity‚ every practice‚ every physical setting‚ and every relationship in a program.

These core values stand as antidotes for the toxic affects of abuse and violence in people’s lives. People growing up fearful‚ uncertain about the dangers of abuse or violence‚ and safety becomes a top priority. If people who were supposed to care for you betrayed your reliance on them‚ trustworthiness becomes the top priority. If you’ve had little control and your voice has been silenced‚ then choice becomes a top priority.

If your world has been arrayed in one-up‚ one-down ways with you perpetually in a one-down position‚ the realistic offer to share power and decision making and collaboration becomes a top priority. If you felt helpless to do anything to counter these painful realities‚ then empowerment becomes a top priority.

That is why‚ if a program can truly say that it expresses these five values in every practice‚ activity‚ physical setting and relationship‚ it’s indeed enacting a trauma-informed culture.

Now let me turn to some of the ways in which this can be expressed in day-to-day practice changes. We’ve developed a protocol for organizations that want to establish trauma-informed cultures of care. For most settings‚ this model entails changes at both the surfaces level and the systems or administrative level.

Though all of these changes are important‚ I want to focus on the first of them today‚ the thorough review of a program’s procedures in the settings in which they are likely to be enacted.

What we do is ask agencies to think through and identify the specific concrete context a person might experience within services. As my mother and countless others‚ I’m sure‚ said so (rightly)‚ “Remember‚ you only get one chance to make a good first impression‚” so be clear and concrete about the first thing a person sees and hears and smells and touches when they come into contact with your program; and the second thing and the third right up until they are fully engaged with your agency services and through to their very last visit.

After the list is well developed‚ we then ask key questions about each activity and setting. Now‚ the key questions are not‚ surprisingly‚ how fully each of the core values are currently expressed in the program practices‚ and ways in which the services might be modified to reflect that core value more clearly.

For example‚ in looking at safety‚ we ask about consumers’ experiences of both physical and emotional safety. We brainstorm ideas for ensuring people’s safety as consistently and thoroughly as possible. Not only do we talk about the first contact and where it occurs on the street‚ in an office‚ in a shelter‚ in a coffee shop‚ et cetera‚ but we focus on how it occurs.

The average workers or receptionists or even the answering machine’s tone of voice‚ staff’s body language‚ their offers of assistance all need to convey a deep respect for the consumers’ needs for safety.

As we move into the physical setting‚ signs and other visual cues become especially important. For instance‚ in one substance abuse setting that serves abuse in adults‚ a sign appeared over the program entrance; it’s a large sign. It said‚ “Denial stops here.” I don’t know what your reaction is‚ but when I first walked in‚ I almost turned around and walked back out. To say I felt unwelcome is an understatement.

It seems as if they were asking to give up my most prized way of coping with things without offering anything in its place. So I suggested they replace that sign with one that said‚ “Recovery starts here.” Though they did not do that‚ they did put up one that said‚ “Welcome.” And I felt that I had earned my fee that day.

On TV the other night I was watching a “60 Minutes” story about an inner-city school in New Jersey. The entrance to the school is a sign that said‚ “You are entering a special and safe place‚ and the street stops here.”

I was reminded of a comment made by a local politician in Connecticut who was describing the need for enhanced security at the local shopping mall. “If people don’t feel safe here‚” she said‚ “nothing else is going to happen.” Well‚ it’s true of the mall and it’s true in most places in our society. If people don’t feel safe‚ then nothing else does happen.

In another state we were touring a juvenile justice facility and saw this sign‚ “Optimism lives here. We believe in kids.” The signs do not always point to the rest of reality. This one did. The culture of optimism was palpable on this place. And kids coming into this site for the first time must have felt warmly welcomed and safe. So‚ safety is the first and most important value of a trauma informed culture.

Trustworthiness‚ though‚ is a close second. In terms of communicating a program’s trustworthiness‚ issues are primarily those of honesty‚ transparency and consistency. We’ve learned a lot from other businesses in our line of work. A kitchen remodeling business placed an ad in the Connecticut newspaper that captured very well what human services should be aiming for.

They said‚ “We guarantee our estimates and we guarantee our work. We arrive on time. We return messages within 24 hours. We tell you what we are going to do before we do it.” That’s a real key in trauma-informed care. I can’t tell you how many times in the past few years I’ve been told by a healthcare professional that this might hurt a little right after it hurt a whole lot.

And finally‚ they said‚ “We listen carefully‚ we tell it straight and we keep our promises.” In virtually all human services‚ these are guidelines to live by. And there was such an understandable pull to guarantee things that can’t really be guaranteed like good housing or a job or medications that will work without major side affects. Offering only those things we can be sure of and really following through is a first step to earning people’s trust.

When we think of maximizing consumers’ choices and their sense of control‚ we might also start right at the beginning‚ to providers who respect the choice not to engage with them and to providers (unclear) to consumers or ultimately not to engage at all. Providers offer choices about apparently simple routine things like where and when to meet but what they might offer the consumer is most responsive to consumers’ needs or about even simpler things.

When I was trained as a psychotherapist for instance‚ we were taught that the first thing that had to happen when a new client came into our office was the door had to be closed. If people don’t feel their privacy is protected‚ then nothing’s going to happen‚ was the apparent lesson.

And that worked pretty well for me until one day a young woman screamed at me after I closed the door at the beginning of her first session. “What makes you think I’m going to stay in this office alone with you with that door closed?” Took her nearly six months to explain the childhood sexual abuse that had led to her reaction. But her point had been well made. And I made a small move but significant shift in my usual practice.

Now when a new person comes into my office‚ I ask them if they prefer to have the door open or closed. This takes perhaps five seconds of the session but communicates clearly that this is a place where I will be listening for what the person chooses in his or her life. Sounds seemingly superficial or minor choice that’s going to have huge consequences.

And enhancing a sense of collaboration is important to remind ourselves that all abuse is the abuse of power. And shifting from something – and shifting from doing something to or for someone‚ to doing it with them‚ providers need to be aware of the potential skepticism that is likely to meet these efforts.

Real offers to share power‚ or be a motivational interviewing‚ or person center planning‚ are still relatively new in our field. And those who have been burned by earlier relationships with providers may not be responsive at first. Nonetheless‚ let me give you an example of a simple but important trauma-informed shift in this area.

One provider I had talked with had always entered and taken interviews the traditional way. She said that she sat at her desk with the forms laid out in front of her‚ asked questions of the perspective consumer listening across the room and then she filled in the answers.

After thinking about alternatives‚ she came up with this: she invited the consumer to join her on a shared side of the desk and basically said‚ “These are some forms the agency needs to have completed in order to offer you services. Let’s read through these questions together then we can decide how to fill out the forms. Does that sound okay to you?”

The provider reported that no other single change in her first contact with someone had led to such a significant shift in the second one. When the person came back in for their second interview she said‚ the consumer expected to do something together with her; not to have her do something to or for them.

Finally‚ let’s talk about maximizing consumers’ experiences of empowerment. Here is a gold standard. If in every contact and every relationship in your program a consumer feels that either‚ one: they had been validated and affirmed as person who has strength‚ deserves to have those strengths acknowledged or‚ two: they have learned a skill that will help their recovery‚ then your program has met this empowerment criterion.

Again‚ some corporate folks may have a good handle on this. A few months ago I was at Starbucks and I received a long printed receipt that invited me to complete a customer satisfaction survey and told me that if I did I might win $1000 in a drawing. I didn’t win the drawing but I got a good story out of it. So here it is.

The survey started in a straightforward way with questions like was your drink prepared properly. “Yes‚ thank you‚ it was‚” I said. Then it asked whether anyone had greeted me by name. “No‚” I said‚ “but that’s not a problem because my caffeine addition is free floating among many different coffee shops.”

Then came the final question. “Was you visit to Starbucks today (blank)?” I generally ask people to fill in the blank and I get such responses: “satisfactory‚” “pleasant‚” or “enjoyable.” But the Starbucks people had set their sights a bit higher.

They wanted to know if my visit to Starbucks had been “uplifting.” I responded that though the caffeine had had the kick I expected‚ it was not truly uplifting‚ because that’s a term I associated with an almost spiritual experience. But if Starbucks was overreaching to aspire to be uplifting in each visit‚ many of our programs may learn from this goal.

What an idea. If every contact with a service provider left the feeling of feeling—left the person feeling uplifted‚ it might indeed be more interesting in engaging in services.

Now we’re shifting to the second or perhaps even a co-leader in the “most important slide contest.” Revisiting the core values for the staff. To be honest‚ when we first started doing this work on trauma-informed care‚ we underestimated the importance of the attending side of these experiences in these domains.

Then one day‚ a consumer advocate who had been out talking to providers about this approach came in and vetted her frustration. “Every time I try to talk with staff about consumer safety‚ all they want to talk about is their own safety‚” she said. A long-delayed light bulb went off and we saw the wisdom of this basic lesson.

Staff members – that is‚ all staff members‚ can create a setting of and offer relationships that are characterized by safety‚ trustworthiness‚ choice‚ collaboration and empowerment only when they experience these same factors in the program as a whole.

So in a parallel way‚ we asked programs to review the same procedures and settings with an eye towards enhancing staff member safety physically and emotionally. All staff — staff members had adequate support for their safety. Trustworthiness. Can staff trust each other and the program supervisors and administrators?

Choice. Does staff exert some control over how they accomplish their task? Is creativity valued? Collaboration. Do administrators’ activities – do administrators actively seek out and take seriously staff ideas about the program and empowerment? Do staff feel valued? Do they have resources to do their jobs well?

A colleague of mine once told me that no matter how brief or how long my talks are‚ and believe me this is a very brief one for me‚ people are only going to remember three things I say anyway. So here are the three things you might want to remember today‚ especially the last one was the school of collaboration for all participants in the human service system.

That’s one we hear more of than any of the others about what trauma informed changes might bring about for people that really feel like they’re working well together across these supposed boundaries between administrators‚ clinicians‚ support staff and consumers.

For those of you who are interested‚ here’s information about how to obtain some of our materials. These are resources that we’ve developed in Community Connections primarily. And my contact information is listed later on in the document.

So I want to thank you for your attention. I realize that there were about 689 people when I started and there are now 704 online so that means nobody left while I was talking. That’s good news. Take care.

Jane Tobler: Thank you Roger for those insights into the many dynamics of creating comprehensive and holistic trauma informed care cultures.

Today‚ our final presenter is Cathy Cave. Cathy has extensive experience in program management across broad and diverse communities informed by her lived experience with service systems. She’s a Senior Program Associate for Advocates for Human Potential. Cathy will provide a spotlight on engaging community and the development of trauma informed support. Welcome Cathy.

Cathy Cave: Thank you for that warm introduction. And I guess I would start by saying that this – we could really call this portion of this conversation engaging community in their own wellness.

A lot of what we’ve talked about in terms of creating – understanding trauma and creating cultures of trauma - better trauma-informed organizations really does need to translate to the community and engage folks in their own – in their own healing and in the own wellness. Next slide please.

On the Federal level there’s been a lot of attention around trauma and how do we spread the word about creating trauma-informed services and supports. And these are a few of the initiatives that we’ve been involved in at Human Potential and throughout the country.

There are people who are very interested in creating trauma informed services and support. So I won’t go over the list but it’s there. There is a National Center for Trauma-Informed Care and a national center to promote trauma-informed practices and alternatives to restraint and seclusion.

And a lot of people have been involved. And people who are trauma survivors‚ people who are supportive of survivors and really changing the face and changing the focus of trauma informed care. Next slide please.

We know that disparities exist in access to services and support. And one of the challenges around that is that people who are most in need of services for trauma and healing‚ who are most impacted by trauma‚ have no idea that trauma is at the center of their distress.

The national study on morbidity and mortality showed that people who have a diagnosis of mental illness die – have a – their lifespan is shortened by 25 years. And when you consider that disparities exist‚ we can only imagine that – for – people of color and for people who don’t have access to all of the things that we know can be supportive and healing‚ are dying at much greater rates.

So when we think about what do we need to do to reach people around trauma‚ we have to do – have a different approach. We have to be able to respond to people where they live and where they work and where they function‚ you know‚ in their day-to-day. So if trauma has a broad reach then the resources and supports to heal trauma need to have just as broad a reach. Next slide please.

So‚ some of the contributing factors to disparities: they have inadequate access to care whether it’s based on economics or language‚ healthcare‚ financing and‚ you know‚ at the heart of so much of this is our cultural beliefs‚ values and practices.

So when we think about how people are getting a substandard quality of care and what might be contributing to that‚ we need to think then about in our outreach around trauma how do we reach populations that are again experiencing this distress. People who are‚ you know‚ just on the margins.

And how do we also consider what kinds of educational strategies and support strategies have to be in place because we know stereotyping and prejudice and discrimination are factors that influence health care.

So if we want people to get assistance and get support‚ we really again have to think about how do we change some of these other pieces and also take on the topic of stigma. And‚ you know‚ that that has to happen – individually it has to happen with families. It has to happen with communities and where people are and where they work and where they‚ you know‚ breathe and live every day. Next slide please.

When trauma is not considered as part of‚ you know‚ what might be happening for a person‚ people tend to be looked upon by their behaviors alone. And sometimes see themselves in light of their behavior alone. So again‚ if we’re missing these opportunities to really connect hope and healing and talk with people about that trauma happens‚ that healing happens in relationship.

And that we in the way that we work to inform people about trauma really does demonstrate that we are recognizing connections‚ recognizing collaborations and moving forward in a way that engages whole populations around how do we address trauma and what do we do about that. Next slide please.

This slide speaks to the broad ways that we think about culture and cultural considerations. And that the circle in the center really speaks to different kinds of cultural considerations that have to do with how people self-identify. So who I am in my heart and my soul at my core is influenced by‚ you know‚ some of these factors.

Race‚ ethnicity‚ age‚ gender‚ sexual orientation; these are things that are solid that are from – that are in me‚ in the core of me. And for each and every one of us who’s a survivor if we’re going to be effective‚ you know‚ working together‚ we have to have those core identities recognized.

There are some cultural considerations that are around the outside circle. And those are – signify how people participate in their communities. So when we think about outreach‚ when we think about engaging people and trauma-informed care and developing practices‚ we have to think about how do we reach people where they participate.

We have to pay attention to our reading levels. We have to pay attention to whether or not there’s a military experience‚ where people live‚ are they in rural communities or urban communities. So whatever strategies we develop around sharing information about wellness and healing really has to take into account both how people identify and how people participate.

And you may notice that some of the cultural considerations straddle both circles. And‚ you know‚ one of the experiences I’ve had that just stays with me is there was a woman that – a trauma survivor and we were talking and she‚ you know‚ "When I think about myself at my core‚ I’m a Christian woman." And so before her own name‚ she sees herself as a Christian woman.

And so it’s important to recognize that what may be important culturally for one person may shift for that same person‚ that we need to be flexible around how fluid and understand how fluid culture is. And we also need to understand that for different people there are different cultural considerations that matter.

So how I think about this with trauma is that‚ you know‚ my mother was someone who was involved in her church. And if there was a way that‚ you know‚ in her prime and when she was so connected to her church that someone said at her church‚ you know‚ trauma is something we really need to pay attention to. And this is how it impacts us. It impacts our health and impacts our wellness and impacts our relationships. Then that would have been an environment where she could have heard and understood.

While hearing maybe a message at a physician’s office or maybe a therapist office if she would ever have gotten that far. And I don’t‚ you know‚ don’t believe that she would have. I don’t believe that mental health was something for her that you explore‚ help‚ and support to manage.

But to hear those messages outside where she lived‚ worked and participated may have been helpful to her and may have been much more helpful to our family. Next slide please.

Trauma cuts across all of those cultural considerations. It becomes something that impacts both how we experience our lives‚ how we see ourselves‚ where we feel able to participate. So if we’re not mindful of those considerations‚ we will again – we’ll continue to miss opportunities to engage people with messages that make sense to them. Next slide please.

So‚ trauma impacts wellness in all of the areas that the 10×10 Wellness Campaign has been thinking about. And we know that unaddressed trauma impacts wellness in pervasive ways. And that the flip side of that is that wellness can be a unifying way of engaging communities.

So rather than starting with what’s the problem‚ it’s starting with how do we talk about wellness and then let’s talk about what impacts wellness. I have the great privilege of being involved with a group of women in Albany‚ New York. And we meet‚ you know‚ every couple of weeks. And there’s – it’s all peer support. There isn’t a leader per se.

But one of the things that happened with this group is that these were women who the terms “trauma” and “trauma-informed care” were new to them and didn’t really resonate with them. But when we talked about‚ you know‚ what helps you stay strong and then what impacts you so you don’t feel so strong‚ all of the things they talked about had to do with the trauma in their lives.

And within two meetings they were already beginning to talk about well‚ what if we get together and have a health fair. And if at our health fair we could talk about‚ you know‚ all of the things that are – have been challenging to our wellness and to our health. We could talk about trauma.

And if we talk about it‚ then people in our neighborhoods will listen because it’s coming from us. And these are women who had very little formal education‚ had very little exposure if any to the language around trauma and trauma informed care and they were already thinking about what they could do to educate their community and to support their community.

So I think there’s a real – an opportunity here to engage communities in conversations where they’re making change for themselves. Next slide please.

And this brings me to this conversation around the power of peer support because again‚ this was language that was new to this group of women. And yet‚ all of the principles of peer support were active and relevant‚ and they were seeing it as‚ you know‚ this is what makes us strong. This is what makes me feel like I can go home and go home to my family and do what I have to do and maintain.

And so much of what they were concerned about was making sure that whatever we talked about in this group did not make them feel sorry for one another or sad for one another. And they talked about how much shame is inherent in the conversations around trauma. So they recognized that on their own.

So‚ when trauma causes shame and devalues people‚ then what they were able to see with this focus on peer support and around wellness that they are clear about describing their own lived experience. They were clear about how they could help each other‚ support each other and make sure that there’s a place where there’s an absolute transparency or honesty in their lives every day.

So I think these are the kinds of conversations that we need to really bring to all kinds of environments and to consider trauma‚ to consider what can counter the impact of trauma and to establish relationships based by choice and focus on education and focus on wellness. Next slide please.

Lila Watson says‚ “If you’re coming here – if you’ve come here to help me‚ then you’re wasting your time. But if you’ve come here because your liberation is bound up with mine‚ then let us work together.” And this so speaks very clearly to the power of peer support and the power of people helping each other in a place where the benefit is to their community and the liberation occurs within their community. Next slide please.

So in terms of community involvement‚ taking peer support to scale really does take some strategizing. But it certainly has to begin with the people who are present in the community.

We had – I had the great pleasure last year of working with the Leadership Council on African American Behavioral Health and we hosted a series of focus groups in five cities and really talked with African Americans around‚ you know‚ what is it that would be helpful to sustain peer support and family support. And how can communities be enhanced?

And one of the things that folks talked about is really recognizing the importance of these factors. That there’s self-determination that‚ you know‚ people in communities need to be able to say for themselves what works and what’s effective. That there’s informed decision-making and reciprocity.

And all of the things that we talked about‚ that community people talked about being important to them in this focus group process were already part of the components of peer support.

So it – peer support makes sense. Collaboration makes sense. It allows us to think about‚ you know‚ what within this community and within each community is already here that’s a strength and a resource and how do we enhance that with new information.

So looking at every opportunity to capitalize and build relationships that promote healing in broad-based ways is a much better way than having‚ you know‚ a select few group of people who already know they need assistance and support‚ who already know trauma impacts their lives. And waiting for folks to line up to say‚ okay‚ I’m going to this provider because this makes sense to me.

Well for every one of those‚ there’s hundreds‚ if not thousands of people who have not had this conversation or exposure to this conversation. So with community collaboration and peer support‚ we have opportunities to make healing possible for everyone. Next slide please.

So there’s a mindset for wellness when we talk about community outreach that says‚ “Who else can we reach‚ where else can we go?” And when it’s –when supports are provider-driven‚ we’re often worried about‚ you know‚ not acting outside of our scope of work or not acting outside of our capacity to treat people who come in.

So if we hang out a big sign that says‚ you know‚ “We do trauma treatment‚” everyone who’s aware can come. Then we have to worry about do we have the capacity to serve them. When we talk about peer support and we talk about wellness and community engagement‚ the mindset is different and it’s much more expansive and there’s a broader reach and it’s much more effective.

So I think we need these two things‚ these two kinds of strategies to develop‚ you know‚ parallel so that people can engage in healing. Next slide please.

So the community‚ what do they need? Communities need information. They need information about trauma. They need information about how trauma impacts people‚ what the service systems and supports would look like.

You know‚ I’m thinking about some of the things that Ann shared with us and that Roger shared with us. And all of that content needs to be shared with the communities so people have information to drive their own decisions around help and healing.

We need to have dialog help at the community level. I mean‚ when we held a series of focus groups‚ there were people who were just appreciative s – most appreciative of a time and a place to have the conversation where it was dedicated and we said this is what we’d like to talk about.

And I think that if that has happened every time where we’ve tried to have some broader conversations around peer support. I happen to be part of a group we were working in a women’s prison yesterday‚ and the women were just so grateful for the opportunity to have the conversation.

The information that we share with everyone when we talk about trauma and its impact has to be easy to understand. It has to be very portable and easy to share. It has to be available in formats where it’s accessible. So much of the information that we’ve been preparing‚ you know‚ and many people are involved in sharing information about trauma and a lot has happened in the last few years.

But so much of the information is either has a clinical slant in terms of how we talk about trauma and its impact. You know‚ a lot of medical jargon‚ a lot of – a lot of shorthand for people who are already on the inside of the conversation.

What we need to do is provide information where it’s accessible for everyone to pick up‚ to understand‚ to share it‚ to ask questions‚ to challenge us on what it is that we’ve missed talking about. And I think that has – that’s what we need to do and where the focus needs to be for communities to be able to engage in their own process. Next slide please.

So I guess the biggest question around some of this is what are we willing to do? Are we really willing to work with culturally diverse communities and can we find the resources to provide information in the way that organizations need to get it and the way that communities and families need to get it‚ that individuals and survivors need to get it?

We need to work with neighborhood associations. You know‚ all of the clubs that exist in a community are great places to begin to talk about‚ you know‚ trauma impacts all of us. What’s the impact here? How do we talk about business – with businesses? Can we engage all of the ethnic and social and religious organizations? And really not be afraid to engage spiritual leaders and providers in this conversation that has mostly been parked in the mental health community.

So how do we let go of our fear of that and really begin to think about all of these folks that need to be part of the conversation? And then how do we promote and support communities in determining what their own needs are? You know‚ we tend to approach these kinds of things with an agenda rather than here’s a topic. You tell us what the agenda should be.

And I think it will really take a willingness to shift the perspective‚ to shift the approach so that decision-making and the financial pieces that go with that really do come from the community and are driven by the community. And providing the information in a way that says‚ you know‚ we have some thoughts about trauma-informed services and support but we also need to hear what your support – what you thoughts and ideas are around this. Next slide please.

So here’s some resources for folks who are interested in contacting the different centers and gathering some more information about both trauma and around cultural competence. And I thank you for you time and your attention with this topic.

Jane Tobler: Thank you‚ Cathy for sharing that information and enlightenment of community engagement when developing trauma informed support.

One of the things we have done is ask today’s presenters to share their vision. So Ann‚ could you please share what your vision is?

Ann Jennings: Sure. My vision‚ pardon me‚ at this time centers on primary prevention although I’m certainly concerned about many other things including the creation of trauma informed services and cultures and what Cathy’s talked about trauma informed communities is a huge interest of mine.

But when we’re looking at this‚ I think this is at the root. If we can do something about childhood‚ then we’re ahead of the game. So I’m focusing on primary prevention here.

I envision‚ I hope that someday we will live and raise our children in a society that holds as a sacred trust and duty that the rights of all children are respected‚ their welfare protected and their lives are free from fear and want and that they grow up in peace. That’s a statement of Kofi Annan who was the head of the United Nations. And I’ve always loved it.

The other vision I have is a little bit of an exaggeration but I think there’s a lot of kernels of truth to it. I envision that when this happens‚ when we really focus on what Kofi Annan talks about for children‚ child abuse and neglect will become so rare that the DSM4 or 5 shrinks to the size of a pamphlet in two generations and the prisons empty. So that’s part of my vision.

The last part is that I hope that we will come to recognize childhood trauma as the major public health crisis that is underlying many of our most pressing and costly problems. And that the necessary fiscal and policy structures will be put in place to support trauma-informed nurturing‚ especially non-stressed parenting.

Just to end with‚ I think that there’s really a lot of wisdom doing this and since we’re so concerned about budgetary items these days‚ the annual cost of not paying attention to trying to eliminate childhood adverse experiences. From a 2007 economic impact study by Prevent Child Abuse America‚ the cost was estimated to be nearly $104 billion a year of the impacts of childhood abuse and neglect; $104 billion a year. So that’s my vision. Thank you.

Jane Tobler: Thank you Ann. Roger‚ what is your vision? Roger‚ you’re still on mute if you’re speaking. Roger? Okay. I’m going to assume he had technical difficulties and Cathy‚ let’s go on to your vision.

Cathy Cave: Sure. My visions really are very simple. That communities are equally engaged as partners to address health disparities. And have both the agency and the resources to facilitate healing. I think too much has been parked in organizations or agencies within communities and leaving the communities out of the conversation. So my vision is that they’re front and center and have the authority to do what they need to do and know what needs to be done.

And the other is implementation of trauma-informed services and supports as a commonplace prevention strategy. You know‚ just to echo some of what Ann was saying. And truly when we stop thinking about trauma-informed as an add-on to things where it becomes much more central to the way anyone does business‚ that in our engaged in helping and healing people.

Jane Tobler: Thank you Cathy. On Slide 59 we’ve shared the presenters’ contact information. On Slides 60‚ 61‚ and 62 we have longer biographies of today’s presenters.

And on Slide 63‚ we have your instructions for the questions and answers. And we are now taking questions from callers. So please dial “star 1” on your telephone keypad to be placed in the queue and give the operator your name. If you do not wish your full name to be announced‚ please only state your first name. Because time is limited‚ please limit yourself to just one question so our presenters can get to more questions.

And after the conference operator announces your name‚ go ahead and ask your question. And once you’ve asked‚ we’ll have the presenters answer. Thank you. Operator‚ can we go to our first caller?

Coordinator: Gwendolyn‚ you may ask your question.

Gwendolyn: Hello. Are you able to hear me?

Jane Tobler: Yes Gwendolyn.

Gwendolyn: Thank you very much. This is not going to be a question. It’s a comment. This is one of the most – best programs that I’ve ever experienced in my entire life. This is well developed and you’ve crossed all the sectors. I had a question for a person like Cathy‚ didn’t realize you were going to cover that. I will get in contact with the way that you say that‚ it’s easy to do. Thank you kindly for the contributions you are making to our community.

Jane Tobler: Gwendolyn‚ thank you so much. We really appreciate the feedback. Operator‚ next question please.

Coordinator: Cathy Taylor‚ you may ask your question.

Cathy Taylor: Yes. Thank you. And thank you to all the contributors. I wanted to see if each person could please address the fact that there are so many of us who have endured childhood trauma that have not been able to endure. But there are many who have been able to endure and have gone on to thrive in spite of this trauma. What are some of the studies that examine this phenomenon and what are your comments?

Jane Tobler: So Cathy‚ your question is what are the – what are the research studies that show children who go on to thrive. Is that correct?

Cathy Taylor: Yes. Who have indeed endured significant childhood trauma. In other words‚ the—what people are writing about as the resiliency gene.

Jane Tobler: Great. Thank you Cathy. Ann‚ can you address that please?

Ann Jennings: Well‚ I can take a stab at it. Actually it’s something – it’s a question I’ve been asking myself‚ Cathy. It’s one of those – I haven’t been able to find a whole lot in the research about it. But what I have found seems to indicate something very simple.

Often people say‚ “It’s just one relationship that I had. It’s one person that I was able to reach out to and believe me. It’s one individual who supported me in what my dreams were.” It’s‚ you know‚ it seems to – when people talk with me who’ve had these horrendous backgrounds‚ Tonier Cain comes to mind and I’m sure that Cathy Cave can talk about her even more than I can.

But Tonier Cain spent years under a bridge homeless. She was raped countless times. She was in jail and prison something over 40 times. She had children that were taken away. But she had just an unbelievable history of child adverse experiences as well as ongoing trauma all through her life.

And she is now one of the most outstanding speakers in the area. She’s turned—she’s turned her pain into blessings for other people. She’s taken what happened to her and is using it to help others. And that’s the second thing that I hear from people who have endured so much and yet have thrived and have become strong at the broken places‚ which would be another way of putting it.

And they often are advocates for other people who have had the same kinds of difficulties. And their example is just – it’s a shining example. So I don’t know if that helps or not. I’m sorry I can’t think of a whole bunch of research articles. If you find any‚ I would love to hear.

Jane Tobler: Great Ann. Thank you so much. And we have this email‚ thanks to Philip. He wants to point out that this year many local and national organizations will recognize in the impact of trauma on May 3‚ 2011 through SAMHSA’s National Children’s Mental Health Awareness Day. To learn more about this national initiative‚ please visit http://www.samhsa.gov/children. That’s http://www.samhsa.gov/children. Operator‚ please go to the next question.

Cathy Cove: Actually‚ this is Cathy‚ can I just respond?

Jane Tobler: Sure.

Cathy Cove: Just a quick thing. I wanted to mention that – thanks Ann‚ for mentioning Tonier. Tonier Cain does work with the National Center on Trauma Informed Care and you can get in touch with her through our office if you’d like.

The other thing I would say is that as a trauma survivor‚ I would echo what Ann was saying in terms of having people who believe that you have‚ first of all‚ experienced something – that you’ve experienced trauma. That the violence did happen and people who have acknowledged that healing has also happened.

And to be able to be in a community of where survivors are saying‚ “We’re here and we support each other.” And that has been significant in my healing and recovery.

Jane Tobler: Great. Cathy‚ thank you so much for sharing that.

Coordinator: Roberta‚ you may ask you question.

Roberta: I wanted to say thank you to the presenters. I really enjoyed the information. One of the questions that I have is regarding is there any information available on historical trauma of the effect on Native people?

And one of the reasons I’m saying that is because I believe some of the things we have as Native people the spiritual‚ emotional and the mental and the well-being that we have within our own Native communities within our own belief system. So I just wanted to see if there’s any data out there. And I do appreciate this. I think that trauma is one of the underlying factors that is affecting us in Indian country.

((Crosstalk))

Ann Jennings: Can I respond to that? Hello.

Jane Tobler: Hi.

Woman: Hello.

Ann Jennings: Could I respond to that just quickly?

Jane Tobler: Sure.

Ann Jennings: This is Ann Jennings. And Roberta there is – there are numerous articles and documents and I would be happy to forward you what I have if you could get in touch with me. Use my contact information. There’s wonderful information out there about Americans—Native Americans and Alaskan natives in trauma.

Cathy Cove: Hi. And this is Cathy. I also wanted to add that we recently as part of a collaborative project at the National Center of Trauma Informed Care put together a document called the Peer Engagement Guide for Trauma-Informed Peer Support with Women.

And in that document‚ we’ve quoted quite a few personal stories and several of them have—were from like a woman who’s wonderful‚ Maria Yellow Horse Brave Heart‚ around trauma and the Native communities and she just really does shine a light on so much on that experience.

So I would just‚ one: recommend the peer engagement guide as a document for folks to think about. And to definitely‚ you know‚ email or‚ you know‚ with questions and we can certainly connect you with some other resources.

Ann Jennings: I have one more resource to mention. Am I on?

Cathy Cove: Go ahead.

Ann Jennings: Oh okay. There’s a Listserv called the state public system on trauma listserv where it’s been in existence since 2001. And it’s – information about it is on the resource slide that followed my presentation.

It’s a way communicate with over 300 people across the country. And many of the people involved are researchers and policymakers‚ lots of consumers and survivors‚ many people who are advocates.

So with a question like you just asked you would get – if you posted that question on the Listserv‚ you would get a lot of resources that you might not otherwise be able to get. So I would encourage you just to email and get yourself involved in that.

Roberta: Thank you.

Ann Jennings: You’re welcome.

Woman: And we can also make sure to get that information and list it on the wellness site‚ which is the 10x10.samhsa.gov site. So if you all want to follow up later we will be sure and list those resources as well.

Jane Tobler: Here is a question that came in. Roger‚ this is for you if you were able to get back on‚ which I think you are...

Roger Fallot: I think I am.

Jane Tobler: Yay. Yay. That confirms it.

Woman: Good.

Jane Tobler: Are there trauma-informed care training modules for the following three groups: psychiatrists‚ non therapists such as nurses‚ psychiatric technicians and the third one – administration or human resources? So the question is‚ “Are there trauma-informed care training modules for those various groups of people?” Roger.

Roger Fallot: I’m sure there are. I think the way we have approached it is to create a culture of trauma-informed care‚ though‚ is to get everybody involved in the process so that the trainings are actually simultaneous trainings for administrators‚ clinicians‚ consumers‚ support staff; especially administrators and support staff are so frequently left out of this sort of process because they’re thought to be irrelevant to the clinical contacts that go on in a program.

But as everybody knows‚ they’re very important to it and it’s important to get everybody involved in planning the sorts of changes we make in the trauma-informed approaches.

So that although specialized training modules are available‚ the way we’ve done these trainings primarily is by having them simultaneously involve everybody in the process. It’s a smaller version of what Cathy is talking about in terms of communities. That the community is an organization in this case but everybody needs to be engaged in the process of change.

Jane Tobler: Excellent.

Wilma Townsend: Jane?

Jane Tobler: Yes.

Wilma Townsend: This is Wilma Townsend. I also would like to answer that.

Jane Tobler: Yes‚ please do‚ Wilma.

Wilma Townsend: We also have another project here at SAMSHA called Recovery to Practice‚ and it’s a project in which we have contracted with a group that subcontracts with all sides of the major national professional organizations.

The American Psychiatric‚ American Psychological‚ the American Psychiatric Nurses‚ National Association of Peer Specialists and Council of Social Work Education. What they are developing are curriculums around recovery that they’re going to use to go out and train either students in the university and in the field within their profession.

But within that‚ all of those trainings are inclusive of the sections on trauma. So each one of those professional groups will be doing some very specific training around recovery but also is being inclusive of trauma.

Jane Tobler: Excellent‚ Wilma‚ as always. We appreciate that information.

Cathy Cove: And this is Cathy. I have another resource as well

Jane Tobler: Sure.

Ann Jennings: You know‚ I’d like to make a comment here about trauma-informed‚ if I may. I’m thinking of something I thought about a little bit earlier when somebody asked the question about resiliency and so on and how important it was with my daughter’s history that she was in environments that were quite toxic. And sometimes she would have a good psychologist or she’d have a good psychiatrist or‚ you know‚ the administrator might be a really great gal.

But the environment itself was toxic. There were so many things that went on a daily basis‚ from the people in the cafeteria to the grounds keepers to the aids to everybody involved. And I think that’s what we’re talking about.

When we talk about trauma-informed‚ it’s engaging all of those people. Everybody that interacts with somebody in whatever way they interact. Because you can get the best therapy in the world and‚ bing‚ bang‚ if you get out there and somebody’s cruel‚ or insensitive‚ or triggers you in ways that are not trauma-informed – triggers your past trauma‚ you lose. So I just wanted to make that point.

Jane Tobler: Thank you Ann. Thank you for sharing that. You’re absolutely right. Roger.

Roger Fallot: No‚ I would agree with Ann entirely. I think the point is that in fact when we do these consultations and trainings‚ it’s always amazing to me that the most recently if we had a large number of people and the person who made perhaps the most insightful comments of the day was the bus driver.

He was able to shed light on what was going on in the project in ways that not the senior administrators or the clinicians or even the other consumers could even bring to bear. So it’s important to get everybody involved because everybody has unique perspective and their perspectives are all worthwhile.

Jane Tobler: Great point. Thank you‚ Roger. Operator‚ next call please?

Coordinator: Linda Woods‚ you may ask your question.

Linda Woods: Linda Woods. That’s me. I’d like to thank all of you for putting this on. This seems to be a wonderful concept of reaching the core of our issues. I am a recovered alcoholic. I’m also Native American and I want to say that Roberta’s questions was particularly important to me. I am putting together a sexual assault presentation right now. So this whole thing has been very helpful for me.

And I guess what I’d like to say is‚ “How can I help? And how can I get involved?” And I’m really happy that we’re finally dealing with some of the core stuff rather than the outward behavior. Thank you so much.

Jane Tobler: Thank you very much for sharing. I do want to remind everyone on Slide 59 is the speaker contact information. Cathy‚ I didn’t know if you wanted to add anything to that?

Cathy Cove: Just that I think it’s – I appreciate the question and I heard it a lot yesterday. As I shared‚ we were involved in doing some education and training and technical assistance in a women’s prison and after the conversation how many woman said‚ I want to be involved. How do I get – how do I get involved?

How do I do – how do I stay connected‚ because something gets sparked where you feel listened to. You feel appreciated. You really feel like‚ if I can share what I know‚ that will help somebody else.

So‚ this whole notion of peer support and building peer support can happen right where you are‚ wherever you are. So really thinking about reaching out to other organizations whether it’s sexual assault programs or whether it’s domestic violence programs or whether it’s mental health consumer/survivor programs and really get involved locally in shaping the conversation and bringing peer support to the community level and focusing on trauma.

I think we all have the capacity to do that where we live and nothing would excite me more than being able to support some of that local community development of‚ “Let’s get this conversation going.”

Ann Jennings: I’d like to add one more thing to that. And that is‚ that I have seen the most effective people I’ve ever seen be people with lived experience‚ such as you have‚ go in front of our human service committee‚ of our legislator‚ legislature in Maine. And they had more impact than anybody else just really putting out there their own experience and demanding that there be some services‚ that there be some whatever was needed.

Legislators really sat up in their seats and really paid attention. We had Center for the Deaf in Maine‚ in which a lot of abuse was going on‚ and it went on for years. And then when one person came forward‚ a man that had been abused there as a child‚ and accounted his experience to the state legislators‚ it was changed. So advocacy is another really great way to get involved.

Linda Woods: Thank you.

Roger Fallot: Okay. Let me add one thing also. That is‚ that there are so many different levels of involvement that are important in this process that ranging from the advocacy and the broad scale sort of interventions that Ann and Cathy have just described‚ to just thinking‚ each of us‚ about the ways we can create safety and trustworthiness and choice and collaboration and empowerment in relationships in the places that we work‚ the relationships in the places where we live. Those are important values and that’s why we emphasize them so heavily.

Linda Woods: Thank you.

Jane Tobler: Okay. Operator‚ this is our last question. So we just have like a minute or two left‚ if you could go to the next one.

Coordinator: Wendy Wood‚ you may ask you question.

Wendy Wood: Yes. Can you hear me?

Jane Tobler: Yes‚ Wendy.

Wendy Wood: Okay. My question is this. We’ve talked about a lot of things with trauma but it seems we avoided one issue‚ and I think it’s a really important issue. A lot of the trauma victims that I worked with over the years were thwarted in their recovery by the use of medications and overuse of medications. And I think it’s a critical issue.

And when you were talking earlier about the use – mental health consumers and others losing 25 years of their life‚ a lot of that‚ by some of the research that’s out there‚ can be contributed to the use of medications and the inappropriate diagnoses that trauma victims get. And I wish you’d speak a little bit about that.

Jane Tobler: Roger‚ could you address that please?

Roger Fallot: Sure. I think you’re absolutely right that there are misdiagnoses that are rampant in this field. And so many of them are beginning quite early these days‚ around ADHD in kids and bipolar disorder being diagnosed in children who are really responding to the traumatic events in their lives. And if they were responded to more appropriately‚ their diagnosis would just simply disappear.

So‚ I think we need to be aware of these things‚ first of all. And there needs to be a great deal of education around this for psychiatrists and other physicians who are prescribing medications. There’s lot’s to be said for it‚ but you’re absolutely right and I just want to thank you for raising this important question.

Ann Jennings: Yeah. I want to thank you too. I think it – this is one of my biggest concerns in the field today‚ the medication‚ particularly‚ of small children. It’s just – I think we’ll look back on it in history and consider it one of the scandals of our age‚ basically. So thank you very much for bringing up the issue.

Wendy Wood: You’re welcome and thank you.

Jane Tobler: Thank you and thank you to our presenters. And I would just like to briefly say that if you enjoyed this training teleconference please‚ please sign up for the 10×10 Wellness Listserv. You will get lots of information on different things happening‚ especially new resources with SAMHSA’s new public awareness tool for expectant mothers who have endured trauma‚ and this will be available in August.

Also‚ you will be able to know when information and educational material to help promote National Wellness Week will be available‚ and the National Wellness Week will happen in September. We encourage you to sign the Pledge for Wellness to promote wellness for people with mental health problems by taking action to prevent and reduce early mortality by 10 years over the next 10 years.

And you can also contact us‚ the SAMSHA 10×10 Wellness Campaign‚ at 10×10@samhsa.hhs.gov and you may send us any burning questions that you still may have or that you’d like us to address.

We also encourage you to join the ADS Center Listserv and receive information on recovery and social inclusion activities and resources including information about future teleconferences.

So we thank everyone for their time today. We remind you that the contact speaker information is on Slide 59. And Ann‚ Roger‚ Cathy‚ thank you so much for your work on this vitally important subject and thank you for taking the time to share your insights today. Thanks also to everyone all of the callers for caring about this topic and taking time out of your afternoon to learn more today.

This conference has been recorded and the audio recording and the transcription will be available in mid April on the SAMSHA 10×10 Campaign Web site.

Later this week you will receive an email request to participate in a short anonymous online survey about today’s training. It will take about five minutes to complete. Please take the survey and share your feedback with us. Survey information will be used to determine what resources and topic areas need to be addressed by future training events.

Thanks to everyone once again for joining us today and working on this important topic. And thanks in advance for signing the Pledge‚ signing up for Listserv and taking our survey. Have a good day.

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