Trauma Informed Practice Kay McCarthy People come to attorneys because something in their lives has changed, generally for the worse. Realizing that many clients have some level of trauma, and understanding how to deal with that, makes you a more effective attorney. Because we deal with the legal system and enjoy some level of comfort with it, we sometimes have difficulty realizing the trauma it creates for our clients. This compounds the trauma they already have when they come to us. Whether the clients are families, juveniles, defendants in criminal matters or people involved in business controversies, this may be their only exposure to our justice system. We can provide a higher level of service by learning these practices. In this seminar you will: • Recognize the impact trauma (physical, emotional, psychological, violent) has on your client and others involved • Understand how the trauma impacts and complicates your client’s interaction with you and the legal system, both now and in the future • Learn how to collaborate with other professionals to improve how your client deals with the current legal situation, and to set them up for success when litigation is complete • Identify ways you can reduce and address the trauma from client intake to appearance in court. • Care for you and your staff who must deal with client trauma daily 1 I. What is Trauma Informed Practice A. History of Defining Trauma “Historically, symptoms of traumatic stress have been recorded in both military and civilian populations (Lasiuk & Hegadoren, 2006). Early accounts described the effect of battle conditions on soldiers; “soldier’s heart” and “nostalgia” were the terms for traumatic stress reactions used during the American Civil War. As warfare techniques and strategies changed, so did the depiction of soldiers’ traumatic stress reactions. The advent of heavy explosives in World War I led to the attribution of symptoms to “shell shock,” giving a more physiological description of the effects from explosions (Benedek & Ursano, 2009). On the civilian side, the industrial revolution gave rise to larger and more dramatic catastrophes, including industrial and railway accidents. These, as well as other disasters, are noted in occupational health histories, newspapers, and contemporary literature. Even with a more physical explanation of traumatic stress (i.e., shell shock), a prevailing attitude remained that the traumatic stress response was due to a character flaw. For instance, a soldier’s pain at that time was often seen as a symptom of homesickness. In spite of the efforts of Charcot, Janet, and Freud, who described the psychogenic origin of symptoms as a response to psychological trauma (Lasiuk & Hegadoren, 2006), World War II military recruits were screened in attempt to identify those “who were afflicted with moral weakness,” which would prevent them from entering military service. At the same time, there were new treatment innovations for war-related trauma during World War II. One approach treated soldiers in the field for what was then called “battle fatigue” by allowing some time for rest before returning to battle. During the Korean and Vietnam wars, approaches began to focus more on the use of talk therapy. It was not until the post-Vietnam era that interest in developing treatment alternatives started to take hold. During this time, the U.S. Department of Veterans Affairs (then called the Veterans Administration) developed group therapy for posttraumatic stress disorder (PTSD). Beyond being cost-effective, the technique was well suited to the symptoms of the veterans and fostered socialization and reintegration (Greene et al., 2004). The publication of the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), in 1980 marked the introduction of PTSD as a diagnosis, inspired by symptoms presented by veterans of the Vietnam War (Benedek & Ursano, 2009). The diagnosis in this iteration required the identification of a specific stressor—a catastrophic stressor that was outside the range of usual human experience (APA, 1980)—and classified PTSD as an anxiety disorder (Lasiuk & Hegadoren, 2006). Beginning with this definition, the body of research grew, and the scope of application began to broaden, but not without considerable debate on what constituted a trauma.” Treatment Improvement Protocol (TIP) Series, No. 57. Center for Substance Abuse Treatment (US).Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. 2 B. What is the current paradigm for handling clients with trauma? 1. Move from “What is wrong with you?” to “What Happened to You” 2. Empower the survivors 3. Provide resources C. What is Trauma? (SAMHSA Substance Abuse and Mental Health Services ) defines trauma as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that have lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual well-being.” (See attachment 1: SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach June 2014) D. Three E’s of Trauma: 1. Event(s): actual or extreme threat of physical or psychological harm, or severe life-threatening neglect for a child that imperils healthy development. 2. Experience: may be traumatic for one person but not another. How an individual labels, assigns meaning to and is disrupted physically and psychologically by an event will contribute to how it is experienced. 3. Effects (Adverse): may occur immediately or have delayed onset. Duration varies. II. Why is Trauma Informed Practice Important for Attorneys (See attachment 2: The Pedagogy of Trauma-Informed Lawyering, 22 Clinical L. Rev. 359 (2016) Temple University Legal Studies Research Paper No. 2016-29) A. We are providing a service B. Impact on Outcomes (Case and Life) III. What can attorneys do? 3 A. Recommendations from the National Center on Domestic Violence, Trauma & Mental Health (See attachment 3: Trauma-Informed Legal Advocacy: Practice Scenario Series March 2015) 1. Understand how overwhelming nature of trauma 2. Minimize re-traumatization 3. Prepare for the initial and follow up interviews with your client. The National Immigrant Women’s Advocacy Project created a great list of questions. Not all will apply, but it’s a great starting point. (See attachment 4: National Immigrant Women’s Advocacy Project (NIWAP) Structured Interview Questions American University, Washington College of Law Updated April 18, 2018) B. Minimize their triggers in advance 1. Physical space 2. Use open body language 3. Explain things in advance 4. Offer breaks 5. Support self-soothing behaviors 6. Be thoughtful about note taking 7. Tour of court 8. Enlist supporters 9. Ask about emotional needs 10. Safety planning 11. Involve them in the process 4 C. Challenges 1. Interactions that are humiliating, harsh, impersonal, disrespectful, critical, demanding, and judgmental. a. SHOW RESPECT. Interactions that express respect, kindness, patience, reassurance, and acceptance. 2. Difficulty Listening and Following Their Story a. Use active listening 3. Thinking and Asking “What’s Wrong With You?” a. Think and ask “What has happened to you?” Ask for their story 4. Reacting to their aggression or hostility a. Remain Calm. Use a quiet tone of voice and a slow pace of speaking that encourages stability and physiological regulation. 5. Know your own personal biases a. Be vigilant in your awareness of your own personal biases as it can alter your perception of the impact of trauma. D. Dealing with children (Works for anyone representing kids, whether GAL, Juvenile or CINC and recognizing issues in divorce 1. Adverse Childhood Experiences (ACE) a. Original study by CDC-Kaiser Permanente from 1995 to 1997. The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors. More detailed information about the study can 5 be found in the links below or in “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults External,” published in the American Journal of Preventive Medicine in 1998, Volume 14, pages 245–258. b. What are ACEs- Adverse Childhood Experiences (See attachment 5: The Truth About ACES, Centers for Disease Control) (1) Abuse-physical, emotional or social (2) Neglect-physical or emotional (3) Household dysfunction-mental illness, violence, incarceration, substance abuse or divorce c. Frequency of ACEs (See attachment 6: Understanding Child Trauma from the National Child Traumatic Stress Network) (1) 2/3 of children reported at least one event by age 16 (2) Each year number of youth requiring hospital treatment for assault related injuries would fill 9 stadiums (3) 1 in 6 have suffered cyber bullying d. Impact of ACEs (1) Substance Abuse (2) Behavioral Problems 2. Establish a solid attorney-client relationship (See attachment 7: ABA Child Law Practice, Establishing a Trauma-Informed Lawyer-Client Relationship, Vo. 33 No. 10, October 2014) a. Need client trust and engagement 6 b. Client emotional control 3. Determine if trauma services are needed- (See attachment 8: National Child Traumatic Stress Network Bench Card for the Trauma-Informed Judge) a. Trauma Exposure b. Multiple or Prolonged Exposures c. Outcomes of Previous Sanctions or Interventions d. Caregivers Roles e. Safety Issues for the Child f. Trauma Triggers in Current Placement g. Unusual Courtroom Behaviors 4. What information is needed about the child a. Completeness of Data for Decisions b. Inter-professional Cooperation c. Unusual Behaviors in the Community d. Development e. Previous Court Contacts f. Out -of-Home Placement History g. Behavioral Health History E. Set up your referral network and update it regularly 1. Therapist for the individual 2. Therapist for the children 3. Co-Parent therapy where appropriate and safe 4.