TIS 101 2.1 09.28.17...*Disinvestment Place *Unsafe public spaces *Deteriorated environments...

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San Francisco Department of Public Health, Trauma Informed System Initiative. 1

TransformingStressandTrauma:Fostering Wellness and Resilience

HealingOrganiza6ons:TraumaTransformed

10/11/17

AdaptedfromUCSFHealthyEnvironmentsandResponsetoTraumainSchools(HEARTS)Curriculumby

JoyceDorado,Ph.D.Director,UCSFHEARTS

ChildandAdolescentServicesUCSF-SanFranciscoGeneralHospital

LynnDolce,MFT

Director,FosterCareMentalHealthChildrenYouthandFamiliesSystemofCare

TransformingStress&Traumawasadaptedfrom:

UCSFHealthyEnvironmentsandResponsetoTraumainSchools(HEARTScurriculum;JoyceDorado&LynnDolce)

bytheTISfoundingworkgroupmembers:KenEpstein,LynnDolce,JoyceDorado,BrianaLoomis,Norman

Aleman,Kay6eSpeziale,andMichaelMarcin.

Pleaseciteas:

SanFranciscoDepartmentofPublicHealth,TraumaInformedSystemIni6a6ve.(2014).Transformingstressandtrauma.[organiza6onaltrainingcurriculum]SanFrancisco,CA:Author.

Directcorrespondenceto:

KenEpstein,PhD,LCSWatkenneth.epstein@sfdph.orgor415-255-3439

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San Francisco Department of Public Health, Trauma Informed System Initiative. 2

GoalsforTodayTodevelopasharedunderstandingandlanguageaboutstressandtrauma

Toprovideguidingprinciplesandprac6caltoolstosupportyouatwork

GoalsofTrauma-InformedSystemsIni6a6ve

Tocreateatrauma-informedpublichealthsystemthatfosterswellnessandresilienceforeveryoneinthesystem

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OutlineforToday•  Overview•  UnderstandingStressandTrauma•  CulturalHumility•  Break•  SafetyandStability•  CompassionandDependability•  Collabora6onandEmpowerment•  Break•  ResilienceandRecovery•  CommitmenttoChangeAc6vity

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Resources

Wecanberesilientandhealfromchronicstressandtrauma.

WesupportTrauma-InformedCare.

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WhyIsaTrauma-InformedApproachImportanttoMe?

Becausestressandtraumaimpactallofus

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ThesePeopleMadeitThroughandChangedtheWorld

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Reflec6onCommunityMee6ngStructure

– Whatisyourname?

– Howareyoufeeling?(Onewordinyourbubble)

– Whatisonegoalyouhaveforthistraining?

– Nameonesuccessyouhavehadthisweek

– Reflectonyourownreac6ontothevideo

(fromSanctuaryModel,Bloometal.,2013)10/11/17

Let’sTalkAboutStress

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HowStressAffectsOurJobPerformance:TheYerkes-DodsonLaw

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StressandTraumaArePublicHealthIssues

•  Stresslinkedto6leadingcausesofdeath– Heartdisease,cancer,lungailments,accidents,cirrhosisoftheliver,andsuicide

•  Traumaimpactsmorethanjusttheindividual– Rippleeffecttoothers

•  Somecommuni6esdispropor6onatelyaffected:– Bigotry+UrbanPoverty+Trauma=Toxic

•  Intergenera6onaltransmissionoftrauma•  Systemic,preventa6veapproachneeded

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Vignele

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WhatiswrongwithAnthony?

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WhatiswrongwithVanessa?

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ShimYourPerspec6vefrom

"Whatiswrongwithyou?"to

"Whathashappenedtoyou?"

(fromWisconsinDept.ofHealthServiceswww.dhs.wisconsin.gov/6c)

Providescontext,fosterscompassion,helpsustoseestrengthsinfaceofadversity

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

System&Service

FormalPolicies&Administra6ve

Supports

Accountability

Inter-agencyStructures&Prac6ces

ServiceDelivery&

Prac6ce

Perspec6ves

Clients

Family

Community

Staff

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Trauma-InformedSystem:CoreGuidingPrinciple

UnderstandingTraumaandStress

“Learningaboutthepsychobiologyofstress,toxicstress,andtraumaislibera6ngforpeople.Itgivesusexplanatoryreasonsforsomeofthepuzzlingbehaviorsweengageinandthefeelingsthatcancometodominateus.”(Bloom,2013,p.48)

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WhathashappenedtoAnthony?

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WhathashappenedtoVanessa?

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Trauma=Event,Experience,&Effect

Overwhelmsbrainandbody

Helplesstoescape

Dis-integra8on

(Herman, 1997; Van der Kolk, 2005; DSM-5; SAMHSA; Siegel, 2012; Bloom, 2013)

Actualorextremethreatofharm

“Fight,flightorfreeze”

Las6ngadverseeffects

Dysregula8on

Event

Experience

Effect

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ComplexTrauma

Repe66veharm,neglect,orabandonmentbypeoplewedependuponcancompromisedevelopment

(CourtoisandFord,2009)

BuildingaTrauma-Informed,HealingSystemStructure:

•  Safety&Stability•  Compassion&

Dependability•  Collabora6on&

Empowerment•  Resilience&Recovery

Furniture:Trauma-InformedPrac6ces

Founda8on:•  Trauma

Understanding•  CulturalHumility&

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Stretch

Adapta6onstoComplexTrauma

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WeSharetheSameNeurobiology

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Accelerator BrakesSympathetic Parasympathetic

dilates pupils

relaxes bronchi

accelerates heart beat

inhibits digestion

contracts vessels

contracts pupils

constricts bronchi

slows heart beat

stimulates digestion

dilates vessels

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Challenge Threat

Perceivedresources

Perceivedresources

Perceivedstressor

Perceivedstressor

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HPAAxisAc6vatedinResponsetoThreat

Pituitary

Hypothalamus

ImmuneSystem

AdrenalCortex Cor8sol

Cor8sol

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ChronicStressCauses“WearandTear”ontheBody

•  Medicalillnesses•  Immunesystemsuppression•  Inflammatorydiseases• Obesity

•  Adverseeffectsonbrainandcogni6vefunc6oning

•  Fromstressorsthatarechronic,uncontrollable,experiencedwithoutsupportfromcaringothers

•  Canresultfromstressorslikebigotry,poverty,chronichunger

(Bloom,2013;McEwen,2000);10/11/17

Neuronsthatfiretogetherwiretogether

(Hebb’sRule)

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Trauma“WearsaGroove”intheBrain

“TheFearSong”10/11/17

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SurvivalMode:Fight/Flight/FreezeFrontallobe(prefrontalcortex)goesoffline

Limbicsystem/midandlowerbrainfunc6onstakeover

ThinkingBrain(PrefrontalCortex) Survival/

Emo8on Brain(LimbicSystem)

(Ford, 2009, Van der Kolk)

ThinkingBrainandSurvivalBrain•  ThinkingBrain=RiderMakesinformed,ra6onaldecisions

•  SurvivalBrain=HorseProtec6veins6nctsbasedonfeelings

•  Whentriggered,theriderfallsoffthehorse

(VanderKolk)(Ford,2009)

Dysregula6on•  Dysregula6onisdifficultycontrollingtheinfluenceofstressarousalonhowwethink,feel,behaveandinteractwithothers

•  Thiscanhappenwhenweare“triggered”intoSurvivalBrain

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KeyTool:GetYourRideronYourHorse

•  Aggrava6ngbehavioris“acauseforapause”•  Pauseandtakeabreath•  Askyourself

– “Whathashappenedtoyou?”– “Whatishappeninghere?”– “Whatistheneedbehindthisbehavior?”– “HowcanIrespondtothisneed?”

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Heisbull

ying

me

Whatishappeninghere?Mysonisgoingtodie

Sheis

abando

ningu

s

I’mnever

goingto

catchupHe’s

dangero

usNomaler

whatIdoit

’s

notenough

Anthony Vanessa

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SystemicLevel:ChronicStressandTraumaCanLeadtoDis-organiza6on

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ATrauma-InformedSystemTakesCareofthe

Caregivers

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Transforming Our Organizations

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

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Trauma-InformedSystem:CoreGuidingPrinciple

CulturalHumilityandResponsivenessWecomefromdiversesocial

andculturalgroupsthatmayexperienceandreacttotraumadifferently.Whenweareopentounderstandingthesedifferencesandrespondtothemsensi6velywemakeeachotherfeelunderstoodandwellnessisenhanced.

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CulturalHumility

•  Lifelonglearningandcri6calself-reflec6on•  Recognizingandchangingpowerimbalances•  Developingins6tu6onalaccountability

(Tervalon&Murray-Garcia,1998)

“Morethanaconcept,CulturalHumilityisaprocessofcommunalreflec6on

toanalyzetherootcausesofsufferingandcreateabroader,more

inclusiveviewoftheworld.”

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ShimYourPerspec6ve

from"Whatiswrong?"

to

"Whathashappened?"

(fromWisconsinDept.ofHealthServiceswww.dhs.wisconsin.gov/6c)

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What’sWrong:APublicHealthExample

HealthDispari8esandTrauma

Race Place Health

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HealthDispari6es:WhatHappened?

Race Place Health

InsidiousTraumaHistoricalTraumaIns6tu6onalRacism

CommunityViolence

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InsidiousTrauma

“likedropsofacidfallingonastone”

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ContextMaTers

Racism

Oppression

Inequity

Sexism

Classism

Xenophobia

TraumaSynergis8cTrauma

Homophobia

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HistoricalTrauma

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Opportunity*Intergenera6onal

poverty*Disinvestment

Place*Unsafepublic

spaces*Deterioratedenvironments*Unhealthyproducts

People*Fragmented

socialrela6onships*Destruc6vesocial

norms

UnderstandingCommunityLevelTrauma(Pinderhughes et al.

Prevention Institute Report, 2015)

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Opportunity*Economic

empowerment*Qualityeduca6on*Restora6vejus6ce

Place*Saferpublic

spaces*Investinparks,

housing,transporta6on

*Availablehealthyproducts

People*Rebuild

rela6onships*Strengthenhealthysocial

norms

Promo6ngCommunityResilience(Pinderhughes et al.

Prevention Institute Report, 2015)

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Star6ngwiththeSelf

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AnneFadiman,2008

CreateaSharedCulture

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StressOmenInterfereswithCrea6ngSharedCulture

(adaptedfrompresenta6onbyGhosh-Ippen,2012)

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CulturalHumilityExercise•  Race•  Religion•  Ethnicity•  Na6onality•  Appearance•  Bodystructure•  Physicalability

•  Gender•  Age•  Occupa6on•  Sexualorienta6on•  Educa6on•  Class

•  Primarylanguage•  Family

constella6on•  Immigra6on

status

AdaptedbyMelanieTervalonfrom:PinderhughesEB:UnderstandingEthnicity,RaceandPower:TheKeytoEfficacyinClinicalPrac6ce.NewYork:TheFreePress,1989,p.25

AwarenessandAccountabilityWeallhaveimplicitbiasesTakethetest:Implicit.com

MustbecomeawareofourbiasesNeedtopreventourbiasesfromharmingothers

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

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Trauma-InformedSystem:CoreGuidingPrincipleSafetyandStability

Traumaunpredictablyviolatesourphysical,social,andemo6onalsafetyresul6nginasenseofthreatandneedtomanagerisks.Increasingstabilityinourdailylivesandhavingthesecoresafetyneedsmetcanminimizeourstressreac6onsandallowustofocusourresourcesonwellness.10/11/17

KeyTool:EstablishSafety

PhysicalsafetyProtec6onfromharmReduc6onofunnecessarytriggers

SocialsafetyBuildposi6veworkingrela6onshipsthatcanprovidesupportandcalmingin6mesofstress

Emo6onalsafetyBuildskillsinmanagingemo6ons

StabilityRou6nes,predictabilityandconsistency

Emo6onalSafety:Emo6onRegula6on

Capacityto:• Iden6fyemo6ons

• Expressemo6ons

• Modulateemo6ons(NCTSN,2003)

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AvoidRe-escala6on:WhereAreYouintheCycle?

Client’s Cycle

(AdaptedfromSFGHSafetyManagementandResponseTechniques(SMART)Training)10/11/17

ToolsforStressReliefatWork•  Physicalmovement

– Stretching– Goingforawalk

•  Tac6legrounding– Lo6on– Stressballs

•  Drinkwater•  Breathingexercises(bellybreathing)

•  Sleepwell,eathealthily,exercise

Keystowellnessbreak:•  Onethingata6me•  Enjoyable•  Physicalac6vity•  Breathedeeply

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BellyBreathingSlowbreathoutthroughmouth

Emptychest,thenbelly(emptybellyairallthewayout)

SlowbreathinthroughnoseFillbelly,thenchestwithair

•  Exhaleac6vates“brakes”inbody•  Re-setsbrainandbody•  Allowsbodytometabolizestressarousal

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Re-visi6ngtheVignele

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Vignele:ApplyingTrauma-InformedPrinciples

UnderstandingTrauma&StressCulturalHumility&Responsiveness

SafetyandStabilityApplyyourknowledge

aboutstress,trauma,andtrauma-informedprinciplestothevigneletoimprovetheoutcome.

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

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Trauma-InformedSystem:CoreGuidingPrinciple

CompassionandDependabilityTraumaisoverwhelmingandcanleaveusfeelingisolatedorbetrayed,whichmaymakeitdifficulttotrustothersandreceivesupport.However,whenweexperiencecompassionateanddependablerela6onships,wereestablishtrus6ngconnec6onswithothersthatfostermutualwellness. 10/11/17

Rela6onshipsAreCentraltoHealing

•  Needconnec6onasmuchasfood(Harlow,1958)

•  Healthyrela6onshipsinvolvealunement–  Beingsensi6ve,responsive,andinharmonywiththefeelingsandneedsofourselvesandofothers

•  Alunedinterac6onshelpustofeelsafeandcalmdownwhenwearestressedout

HumansAreHard-wiredforConnec6on

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Co-Regula6on

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Co-Regula6on

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ComplexTraumaInterfereswithCo-Regula6on

•  Ifchild’scaregiverissourceoftraumaorunavailabletoprovideco-regula6on,canderaildevelopmentofhealthyemo6onregula6onskills

•  Thisaffectsrela6onshipsinadulthood

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ReframingRiskBehaviorsTensionreduc8onbehaviors– Drugsandalcohol– Risk-takingbehavior– Self-injuriousbehavior– Compulsivestealing– Aggression– Problema6csexualbehaviors(whereanyconnec6onfeelsbelerthanabandonmentandisola6on)

(fromtrainingonIntegratedTreatmentforComplexTraumabyJohnBriere,2009)

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Rela6onshipDifficul6es

Whenhumanshaveexperiencedcomplextrauma:•  Overlyclingy/dependent•  Pushothersaway•  Don’tknowhowtomakeuseofhelpful

others(includingproviders)Workingwithtraumacanpullforintenseemo6onsinstaff:

•  Vicarious/Secondarytrauma

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Whatpushesyourbulons?

Outofpropor6onreac6ons

Confusionbetween“thereandthen”and“hereandnow”

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Rela6onshipBuildingTool:Connect,thenRe-Direct(Siegel)

•  Partnership“Let’sworktogether”•  Empathy“Thatsoundsfrustra6ng”•  Apology“I’msorrythathappened”•  Respect“Youhavegonethroughalot”•  Legi6ma6on“Itmakessensethatyoufeelthisway”

•  Support“Let’sseewhatwecando”(AmericanAcademyonCommunica6oninHealth)

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YouCanMakeaDifference“BigI”=Interven6ons“Lillei”=interac6ons

(Ghosh-Ippen,2013)

CAPPD

calm,aluned,present,predictable&don’tescalate(fromMulEpleConnecEons,Philadelphiatraining)

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

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Trauma-InformedSystem:CoreGuidingPrinciple

Collabora6onandEmpowermentTraumainvolvesalossofpowerandcontrolthatmakesusfeelhelpless.However,whenwearepreparedforandgivenrealopportuni6estomakechoicesforourselvesandourcare,wefeelempoweredandcanpromoteourownwellnessandthewellnessofothers. 10/11/17

TraumaHelplessness

Disempowerment

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MovingThroughTrauma

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Empowerment:Promo6ngaSenseofAgency

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Collabora6onTool:FosterVoiceandChoice

ARCC– Ask– Respond– Clarify– Confirm

• “Doesthisworkforyou?”

(AdaptedfromAmericanAcademyonCommunica6oninHealth)

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

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Trauma-InformedSystem:CoreGuidingPrincipleResilienceandRecovery

Traumacanhavealong-las6ngandbroadimpactonourlivesthatmaycreateafeelingofhopelessness.Yet,whenwefocusonourstrengthsandclearstepswecantaketowardwellnesswearemorelikelytoberesilientandrecover.

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Science-BasedHabitsofHappinessPeoplewhoprac6ce

mindfulnesshavestrongerimmunesystems,aremorelikelytobehappyandenjoygreaterlifesa6sfac6on,andarelesslikelytofeelanxious

orhos6le.Beingkindtoothersmakesusfeelgood.

Altruis6cactslightupthesamepleasurecentersinthebrainasfoodandsex.

(greatergood.berkeley.edu/ar6cle/item/how_to_be_happy_fine_print)

Regularexerciseincreasesself-esteem,reducesanxietyandstress,andmaywellbethemost

effec6veinstanthappinessboosterofall.10/11/17

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ResilienceTool:Cul6va6ngGra6tude

•  KeepaGra6tudeJournal•  List5thingsthatyouaregratefulforonceperweek

•  Countyourblessingsonceaday(Emmons,2010)

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Prac6cingGra6tudeIncreasesWell-Being

•  Physical•Strongerimmunesystems•Lowerbloodpressure

•  Psychological•Morealert,alive,andawake•Moreop6mismandhappiness

•  Social•Morehelpful,generous,andcompassionate•Lesslonelyandisolated

(Emmons,2010)

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TheGoodnessofGra6tude

•  Gra6tudeallowsustocelebratethepresent•  Gra6tudeblockstoxic,nega6veemo6ons•  Gratefulpeoplearemorestressresistant

(Emmons,2010)

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Whatareyougratefulfor?

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ApplyingTrauma-InformedPrinciplesResilienceandRecovery

•  Whatstepswillyoutaketotake

careofyourself?•  Whataresomethingsyoucandofor/witheachother?

•  Whatdoyouneedfromyourworkplacetoenhancewell-beingforall?

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Resilience&Recovery

Collabora6on&Empowerment

CulturalHumility&Responsiveness

Safety&Stability

Compassion&Dependability

UnderstandingTrauma&Stress

System&Service

Perspec6ves

Neurobiology&

Development

Trauma-InformedPrinciplesforPromo8ngWellnessandResilience

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CommitmenttoChange

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ATrauma-InformedSystemisn’tatraining,oranidea,orabuzzword–it’s

anexperience.

It’syourexperience.

Applyingtheprinciplesinourworklivesisgoodforus,goodforourcolleagues,andgoodforthe

peopleweserve.

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Howcanwemakeadifferenceinyourworklife?

Big,policylevelsystemchangesarenecessarybutnotsufficient…

Smallindividualchangesthatyouimplementhaveabig

impactonyou

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Whataboutyou?Whatareyoursmallsteps?

•  Ideasfromtodaythatinspiredyou•  Principlesthatareimportanttoyou•  Examplesthatresonatedwithyourlife“Iwillmeetwithmysupervisortodiscussasafetyconcernandgetsupportresolvingit.”

Inthenextmonth,let’salltakeonesmallsteptowardexperiencingatraumainformedworklife.

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Over6,000SFDPHemployeeshavecommiledtoaC2Cproject!

“It was difficult at first. But as I put it into

practice, I felt a sense of relief because it became easier to

incorporate it in my attitude and thinking.”

“It makes coming to work worthwhile.”

70%aresuccessful

74%willcon6nue

thechange

“one of the best things to ever

happen to me”“empowering”

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YourCommitment2ChangeProject

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Share&Inspire

Ifyoufeelcomfortable,shareyourideaswithyourgroup.

Helpinspire,plan,andsupporteachother’sC2Cprojects.

ThenturninyourC2CPlan!

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Inordertowrapuptoday,weneedyouto:

1.  Completetheconfiden6alC2Chandoutduetoday•  TherewillbeagiXcarddrawingforcomple8ngafollow-upsurvey!

2.  Keepthe sheet,turninthewhitesheet

3.  CompleteandturnintheblueTrainingEvalua6onform

Thanks!Ourtrainerwillcloseusout…

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TransformingTrauma

Atrauma-informedsystemunderstandshowchronicstressandtraumaaffectshumanbeings

ANDcreatessafeandsuppor6vecareenvironmentsthatfosterstrengthand

resiliency,sothateveryoneinthesystemcandevelop,growandthrive10/11/17

Closing:SoupBowlBreathing

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