WRAP® WELLNESS RECOVERY ACTION PLANNING ®

A DO IT YOURSELF POWER TOOL TO HEAL TRAUMA!

Cheryl S. Sharp, MSW, ALWF Special Advisor for Trauma-Informed Services National Council for Community Behavioral Healthcare

PREVIEW • WRAP as a Dynamic Self Help Power Tool to Heal from Trauma in All of Its Forms • Context of WRAP within a Trauma-Informed Paradigm • WRAP in the context as an Alternative to Seclusion & Restraint

LET’S BE PERFECTLY CLEAR – WRAP® - A TOOL FOR PEOPLE WHO WANT TO GET WELL AND STAY WELL (wellness and recovery is self defined) – A PLAN FOR MOVING TOWARD WHAT WE WANT IN LIFE – SELF-DIRECTED, SELF EMPOWERING AND SELF-DETERMINING – NOT A CLINICAL PRACTICE, THOUGH IT IS AN EVIDENCE BASED BEST PRACTICE _ IN TIMES WE DON’T FEEL IN CONTROL WRAP CAN PROVIDE TREMENDOUS OPPORTUNITY TO DRIVE OUR OWN CARE AND TREATMENT

“NOTHING ABOUT US WITHOUT US” IT WAS DEVELOPED BY PEOPLE WHO WERE STRUGGLING WITH MENTAL HEALTH AND EMOTIONAL ISSUES, HOWEVER, ANYONE CAN USE A WRAP PLAN FOR JUST ABOUT ANYTHING … Mental Health Substance Abuse Diabetes Smoking Cessation

Moving Finding and Keeping a Job Relationships Fibromyalgia

Weight Loss

Trauma

Arthritis Loneliness

Grief & Loss

WHY CONSIDER WRAP® AS A TOOL TO ADDRESS HEALING FROM TRAUMA • Knowing what our triggers are and being able to communicate those to our supporters can stop what has often lead to seclusion and restraint • When we know and express what helps and what hurts we are personally empowered to do something different than what we have traditionally experienced. • WRAP as a prevention tool – developing new coping strategies • Offering what we know supports our supporters and provides better outcomes for everyone • Every person, as soon as possible, should have the opportunity to develop a WRAP®

TRADITIONAL HUMAN SERVICES PARADIGM Understanding of Services – The primary goals of services are stability and the absence of symptoms – Services are often crisis driven – Service time limits are economically and administratively driven – Services are chosen in order to minimize risk and provider liability Roger Fallot “Trauma – Informed Services”, Long Beach 2008

TRAUMA-INFORMED HUMAN SERVICES PARADIGM • Understanding of Services – Primary goals are empowerment and recovery – Survivors are survivors; their strengths need to be recognized – Service priorities are prevention driven – Service time limits are determined by survivor, self-assessment, and recovery/healing needs – Risk to the consumer is considered along with risk to the system and the provider Roger Fallot “Trauma – Informed Services”, Long Beach 2008

TRADITIONAL HUMAN SERVICES PARADIGM • Understanding of the Service Relationship – Hierarchical provider/consumer relationship – Provider is presumed to have a superior knowledge base – The consumer is seen as a passive recipient of services – The consumer’s safety and trust are taken for granted Roger Fallot “Trauma – Informed Services”, Long Beach 2008

TRAUMA-INFORMED HUMAN SERVICES PARADIGM • Understanding of the Service Relationship – A collaborative relationship between the consumer and the provider of her or his choice – Both the consumer and the provider are assumed to have valid and valuable knowledge bases – The consumer is an active planner and participant in services – The consumer’s safety must be guaranteed and trust must be developed over time Roger Fallot “Trauma – Informed Services”, Long Beach 2008

HOW DOES WRAP FIT INTO A TRAUMA-INFORMED PARADIGM • Primary goal is to move toward healing, empowerment and recovery • Self-directed • Self-authored and designed • Completely voluntary • Done at a person’s own pace and in their own time • Healing and recovery is self-defined • Is a collaboration between the person and theirre supporters of choice and trust level with those supporters • The person writing their WRAP is the expert on themselves

HOW DOES WRAP FIT INTO A TRAUMA-INFORMED PARADIGM • A celebration of what we can do rather than what others’ perceptions or what our abilities might or might not be • Is wellness driven rather than “crisis driven” • Allows for learning from our experiences rather than discounting them • Supports our desire to make meaning of those experiences if we decide to • Offers alternatives to traditional modalities of treatment as we educate ourselves • Can become a way of life, addressing many areas rather than only focusing on what happened to us

A BRIEF HISTORICAL CONTEXT OF TRAUMA & PSYCHIATRIC “CARE”: Traditionally People have been: • Called hysterical, bad, liars, manipulative, etc. • Treatment beliefs had been to: – Contain it – Control it – Medicate it – Tell people to get over it/told they were exaggerating (not believed) – Tell people they were sick/attention seeking – Seclude and Restrain – Put people into institutionally abusive situations

Why might this have been done?...

4 PARTS TO THE STUDY OF MENTAL HEALTH RECOVERY: 1. 2. 3. 4.

Key Concepts Wellness toolbox Wellness Recovery Action Plan® (WRAP®) Recovery Topics • • • •

Trauma Recovery Building Self Esteem Peer Support Work related issues

FIVE KEY CONCEPTS OF RECOVERY WRAP® is based on 5 Key Concepts of Recovery HOPE PERSONAL RESPONSIBILITY EDUCATION SELF-ADVOCACY SUPPORT

HOPE

Hope is the elevating feeling we experience when we see--in the mind’s eye--a path to a better future. Jerome Groopman, Harvard School of Medicine (2004)

PERSONAL RESPONSIBILITY “In the long run, we shape our lives, and we shape ourselves. The process never ends until we die; and the choices we make are ultimately our own responsibility.” – Eleanor Roosevelt • We are the expert on ourselves • We know what we need and want • Whether we recognize it or not, we are powerful survivors and we possess tremendous courage and strength and wisdom • We have it within ourselves to take on personal responsibility for our own wellness and recovery

EDUCATION • We can learn from our experiences; turning them into lessons rather than viewing them as mistakes, so you don’t have to repeat them – CRISIS as a learning opportunity • Paying attention to what Life has taught us about what works and what doesn’t work • Engaging the support of trusted peers to do deep reflection about our true selves • We learn from the experiences of others • We seek out opportunities to explore things we may not have been encouraged to explore in the past • We draw on our innate curiosity of the world that we may have lost due to lack of trust in the world

EDUCATION & SELF-AWARENESS • How do I know what I know - worldview? • What is truly important to me – owning my personhood? (as opposed to what others want me to value) • What are my dreams – who knows them better than me? • What are my true goals in Life? • What is keeping me from realizing my dreams and goals?

“I want to be treated Like a woman.” Rosa Parks

SELF ADVOCACY

"You are powerful. Sorry. Hate to be the bearer of bad news. You are. You can continue arm wrestling with yourself, or you can use both arms, your whole heart, and all your strength to wrestle with greatness. The choice is yours." - Peter McWilliams, DO IT! • Speaking up and speaking out for yourself • “Going for it” with courage, persistence and unwavering determination • Expressing yourself clearly and calmly until you get what you need for yourself

SUPPORT • Developing and maintaining a strong system of informal and formal supporters • Natural supports from family, friends • Formal supports from providers as needed • Having multiple supporters to call on in times of crisis who have agreed to follow your plan • Community in all its varied meanings

WELLNESS RECOVERY ACTION PLANNING® WRAP® INCLUDES

• • • • •

Wellness Toolbox Daily Maintenance Plan Triggers and Action Plan Early Warning Signs and Action Plan When Things are Breaking Down and Action Plan • Crisis Planning • Post Crisis Planning

THE WELLNESS TOOLBOX This is a list of things you do that help you feel well and/or help you feel better when struggling.

Play with my dog and cats

Spend time with my boys Listening to music that fits my mood Gardening

Prepare a nice meal

Relaxation techniques Read a good book

Spend time on the water

THE DAILY MAINTENANCE PLAN The daily maintenance plan has three parts: 1. What you ‘look’ like when well 2. Things you need to do everyday to keep yourself as well as possible 3. Things you may choose to do or need to do on occasion to keep yourself as well as possible.

TRIGGERS AND ACTION PLANS • We then discuss those external events that may cause a person to feel ‘big’ feelings and develop action plans to reduce the intensity of one’s feelings caused by these events.

EARLY WARNING SIGNS & ACTION PLAN • These are internal indicators that things are not going as well as we want them to. • We identify some of these internal indicators and develop action plans for taking personal responsibility for overcoming these early warning signs and getting back to wellness.

IDENTIFYING EARLY WARNING SIGNS • Because Early Warning Signs are so subtle, they are very easy to miss or ignore • It may be helpful to ask friends or family about early warning signs they may have noticed • Make a detailed list of all the Early Warning Signs you can identify and review it regularly • As you pay more attention to keeping yourself well, you will begin to notice even subtler warning signs and you will be able to take even earlier action to keep yourself well 28

WHEN THINGS BREAK DOWN • Despite our best efforts sometimes things get worse. • At this point it is important that a person take immediate and assertive action steps. • We develop action plans to take care of our safety and health during these times.

CRISIS PLAN • The Crisis Plan of WRAP® is similar to a Psychiatric Advanced Directive or Mental Health Advanced Directive. In spite of your best planning and assertive action, you may find yourself in a crisis situation where others will need to take over responsibility for your care. You may feel as though you are totally out of control. • Write your crisis plan when you are well. Your plan will instruct others about how to care for you when you are not well. It keeps you in control even when it seems like things are out of control.

A CRISIS PLAN LETS YOU RETAIN CONTROL • It’s difficult to plan for a “crisis,” especially if you associate it with losing control, so it’s helpful to remember that crisis planning is about staying in charge • By carefully developing a Crisis Plan through negotiation and collaboration with your supporters, you can create a plan that keeps you in control even when decision-making is temporarily turned over to supporters • Your supporters will be following your plan

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CRISIS PLANNING • • • • • • • • •

What I’m like when I’m well Indicators other need to take over Supporters Medications Treatments Home, community or respite care Hospitals or treatment facilities Support from others Indicators that I can resume responsibility

CRISIS PLANS APPLY TO ANY “CRISIS” • Although Crisis Plans are often written with past psychiatric crises in mind, they are equally applicable to any situation where we would recognize the need to turn decision-making over (temporarily) to supporters whom we trust to follow our plans • Considering other circumstances that might overwhelm you; medical, financial, or relationship crises, may help you to recognize “crisis” and crisis planning as opportunities to learn, grow and face life more confidently

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POST CRISIS PLAN

• This is a time for addressing certain issues that may have played a part in your crisis and creating a Timetable for Resuming Responsibilities

TRAUMA INFORMED WELLNESS RECOVERY

An approach to healing relationships

WHAT MAKES SOMETHING A TRAUMATIC EVENT?

WHAT IS TRAUMA?

•

•

Definition (NASMHPD, 2006) – The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters DSM IV-TR (APA, 2000) – Person’s response involves intense fear, horror and helplessness – Extreme stress that overwhelms the person’s capacity to cope 37

WHAT DO WE MEAN BY PSYCHOLOGICAL TRAUMA? Those events which leave someone feeling emotionally, spiritually, cognitively, and physically overwhelmed. The circumstances of the event commonly include abuse of power, betrayal of trust, entrapment, moral conflict, helplessness, pain, confusion and/or loss. People’s reactions to traumatic events may be quite different based on their past experiences.

WHAT KINDS OF EVENTS CAN BE TRAUMATIC? • • • •

War Disaster Physical/sexual assault Childhood abuse (physical sexual, emotional • Loss • Witnessing violence

• • • •

Death Torture Childhood neglect Compounded and cumulative loss • Medical trauma • Bullying

TRAUMA CAN AFFECT… • • • • • • •

Physical (seemingly unrelated illness) Emotional (extreme or no emotions, fear of feelings) Cognitive (our beliefs and assumptions) Spiritual (Sense of meaning) Our relationships Development Current life: We repeat what we know because that’s how things make sense

THE AFFECTS OF TRAUMA CAN BE • • • • •

Personal Relational Organizational Cultural/Political Historical

WE MIGHT OBSERVE OR EXPERIENCE Personally: • Difficulty with physicality • Self Injury • Lack of self worth • Feeling constantly suicidal • Abuse of alcohol and drugs • Numbness/confusion • Disorientation • Intense fear, sadness, guilt, shame • Moodiness • Avoiding people places or things that serve as reminders • Startle reactions

Relationally: • People in current abusive situations • Anger • Hurting before I get hurt • Mistrust • Secrecy/dishonesty • Boundary issues Organizationally/Politically: • Mistrust • Over-generalizing • Secrecy • Blaming • Taking power over

PREVALENCE OF TRAUMA CHILD MENTAL HEALTH/YOUTH DETENTION POPULATION - U.S. • American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD • 70-90% incarcerated girls – sexual, physical, emotional abuse (DOC, 1998, Chesney & Sheldon, 1991)

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PREVALENCE OF TRAUMA MENTAL HEALTH POPULATION – UNITED STATES • 90% of public mental health clients have been exposed to trauma (Mueser et al., 2004, Mueser et al., 1998) • 51-98% of public mental health clients have been exposed to trauma (Goodman et al., 1997, Mueser et al., 1998) • Most have multiple experiences of trauma (Mueser et al., 2004, Mueser et al., 1998) • 97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood. (Goodman et al., 1997) 44

Prevalence of Trauma Substance Abuse Population – U.S. • Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000)

• Study of male veterans in SA inpatient unit – 77% exposed to severe childhood trauma – 58% history of lifetime PTSD (Triffleman et al., 1995)

• 50% of women in SA treatment have history of rape or incest (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006)

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CRITICAL TRAUMA CORRELATES: THE RELATIONSHIP OF CHILDHOOD TRAUMA TO ADULT HEALTH • Adverse Childhood Events (ACEs) have serious health consequences • Adoption of health risk behaviors as coping mechanisms – eating disorders, smoking, substance abuse, self harm, sexual promiscuity • Severe medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancer • Early Death (Felitti et al., 1998)

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CHILDHOOD EXPERIENCES UNDERLIE CHRONIC DEPRESSION

Adverse Childhood Experiences and Current Smoking

%

ACE Score

ACE Study • Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk? • Significant implications for medical practice and treatment programs • Are those behavioral adaptations many of us develop, a desperate attempt to cope with the effects of traumatic histories? (Felitti, et al, 1998)

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WHAT DOES TRAUMA DO? • Trauma shapes a child’s basic beliefs about identity, world view, and spirituality. • Using a trauma framework, the effects of trauma can be addressed and a person can go on to lead a “normal” life. • Symptoms are ADAPTATIONS

HOW TRAUMA INFLUENCE OUR LIFE AND COMMUNITIES:

• What are some of the rituals, beliefs, that can form out of a life of trauma?

SOME BELIEFS STEMMING FROM TRAUMA • Crisis is safer than calm • My body is dangerous/bad • I only have control over living and dying • Living means pain • No one could understand/love me given what I’ve experienced

• There is no safety in the world • People with power are out to get me • I’ll hurt you before you hurt me • People aren’t who they say they are

Given these beliefs what are our choices?

DEFINITION OF TRAUMA INFORMED CARE •

Mental Health Treatment that incorporates: – An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services – A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual (Jennings, 2004) What about things that we can do that are not considered treatment such as WRAP?

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FOCUSING ON WELLNESS Avoidance of deficits • Pain • Shame • Fear • Self Hate • Lack of trust

Focus on wellness • Feeling good • Self esteem/pride/hope • Confidence • Trying new things • Fun • Trust

WHEN OUR OWN STUFF GETS TRIGGERED • • • •

Grounding techniques Talking to someone you trust Take a break Be honest about what you need, not blaming • YOUR WRAP!

FOUR STEPS TO HEALING THE TRAUMA OF ABUSE

• Empowerment • Trauma Recovery • Creating Life Changes • Closing Rituals

EMPOWERMENT Taking stock: This might not be the right time for you if: 1. Your are trying to get out of an abusive relationship 2. There are other big changes going on in your life, such as divorce or close to a person with a terminal illness. 3. You are in an addiction-rehabilitation program. (Research has shown a correlation between relapse and unaddressed trauma). If you feel you are ready then Go For It! Any part of the activities in the workbook are suggestions and you do what works for you

EMPOWERMENT 1. Who Am I: Gender, Family and Societal Issues 2. Knowing and Feeling your body 3. Physical Boundaries 4. Emotional Boundaries 5. Self Esteem and Self Soothing 6. Intimacy and trust 7. Sexuality (female) 8. Sex with a Partner

PART TWO: TRAUMA RECOVERY Understanding Trauma • The Body Remembers What the Mind Forgets • What Is Physical Abuse? • What Is Sexual Abuse? • Physical Safety • What Is Emotional Abuse? • Institutional Abuse • Psychological or Emotional Symptoms • Addictive or Compulsive Behaviors • Abuse and Relationships

CREATING LIFE CHANGES • • • • • • • • •

Family Myths and Distortions Current Family Life Decision Making: Trusting Your Judgment Communication: Making Yourself Understood Self-Destructive Behaviors Blame, Acceptance, and Forgiveness Feeling Out of Control Relationships Goal Assessment

CLOSING RITUALS

• Developing Rituals to celebrate yourself. • Very personal and unique process • Practice when ever you reach an important milestone

REFERENCES • Wellness Recovery Action Planning® (WRAP®) www.mentalhealthrecovery.com • Healing the Trauma of Abuse: A Women’s Guidebook. Copeland & Harris, 2000. www.mentalhealthrecovery.com • Using Trauma Theory to Design Service Systems. Harris & Fallot. 2001.

REFERENCEs: www.wrapandrecoverybooks.com

• This workbook is based on an approach to trauma recovery developed by Maxine Harris and clinicians at Community Connections, a private not-for-profit mental health agency in Washington D.C. • The community of women who developed the model included some who had experienced trauma themselves. • This workbook is based on a model from an instruction manual for clinicians, Trauma Recovery and Empowerment: A Clinician's Guide for Working with Women in Groups (New York: free Press, 1998),

PEACE: It does not mean to be in a place where there is no noise, trouble, or hard work. It means to be in the midst of these things and still be calm in your heart.

CONTACT INFO Cheryl S. Sharp, MSW, ALWF, CPSST [email protected] 202/684-7457 252/670-0178