Paula Buege’s life has been defined by trauma.
She grew up in a “chaotic” household with a mentally ill mother. She survived sexual abuse. She left home at age 16 and by her mid-20s was addicted to heroin.
Buege says her struggles were “outward manifestations” of the toxic stress she endured as a child — traumas that went unaddressed and unacknowledged until a caseworker at ARC House, an alcohol and drug abuse treatment center in Madison, became the first person to ask Buege an all-important question: “What happened to you?”
“Everyone else always asked, ‘what’s wrong with you?’” says Buege, now 52. “That was the first correlation that [my mental health issues] had something to do with what had happened to me growing up.”
Buege’s experience at ARC House goes back more than two decades, before the concepts of trauma sensitivity and trauma-informed care became buzzwords within the mental health community. But in the last few years, the approach has gained momentum as agencies and organizations in Wisconsin and throughout the nation have shifted to embrace a treatment and recovery model that focuses on empathy and empowerment for trauma survivors.
Trauma-informed care rose to national prominence after the 1998 publication of the groundbreaking Adverse Childhood Experience (ACE) Study by the Centers for Disease Control and health care giant Kaiser Permanente, says Sharyl Kato, director of The Rainbow Project Inc., a child and family counseling and resource clinic on Madison’s east side.
The study links instances of childhood traumas, like abuse and neglect, to significantly increased risks for an array of health, social and emotional problems later in life.
A point is assigned to each traumatic event, so the more trauma a person has experienced, the higher his or her ACE score. It’s common to have some childhood trauma — nearly two-thirds of adults in the study had at least one instance. But as the ACE score increases, so does the likelihood of things like chronic illness, suicide, smoking, alcoholism, multiple marriages and obesity. Individuals with an ACE score of six or higher are expected to live 20 fewer years than those without trauma.
“When many things start piling up, it’s very scary,” Kato says. “It actually impacts brain development and neurobiology.”
But early interventions rooted in trauma-informed care provide hope for ACE survivors, experts say.
In Wisconsin, the state Department of Health Services hired its first part-time trauma-informed care consultant in 2008 and later assembled an advisory committee that works to educate professionals who work with mental health clients on trauma-informed care and implement trauma-sensitive practices across systems.
“Trauma-informed care runs counter to the traditional medical model,” says Scott Webb, who was hired by DHS 11 months ago as a full-time trauma-informed care coordinator.
Instead of assessing symptoms, reaching a diagnosis and implementing a treatment plan developed and dictated by “experts,” the trauma-informed approach views the client as the expert in his or her life, Webb says. The strength-based approach empowers them to collaborate on their own treatment and wellness plan.
“We want to provide safety and permission to share their story and bear witness to their pain,” Webb says. “It really is a complete paradigm shift.”
Making the switch requires a total reevaluation of the way agencies deliver services, Webb says, from the mission and vision of the organization to the human resources policy to the design and physical layout of its office.
It takes organizations two to five years to make the shift to adopt the trauma-informed model, but they “never truly arrive,” Webb says. “They’re always making improvements, finding metrics, constantly monitoring.”
Webb envisions building statewide “systems of care” that allow clients receiving mental health treatment to move seamlessly from one provider to another. This would avoid “re-traumatization” and improve recovery outcomes as clients navigate the web of available support systems.
“The state of Wisconsin is really pushing [trauma-informed care] into all the agencies,” says Webb, who travels throughout the state training and educating key stakeholders.
There have been numerous early adopters in the state: the Department of Children and Families, the Department of Corrections and the Department of Public Instruction have all taken steps to become trauma-informed, as have numerous county-level agencies, Native American tribes, schools, nonprofit organizations and hospitals.
First Lady Tonette Walker has recently become an advocate as well, partnering with DCF to form a committee to expand trauma-informed care and establish Wisconsin as a “national leader” in the area.
“I think the trauma-informed approach is a good approach for any individual, whether they have a history of childhood trauma or not,” says Sue Janty, behavioral services director at Meriter-UnityPoint Health. “It’s a more validating approach as opposed to a more punitive one.”
In the past 20 years, Janty has seen hospitals shift from using practices like leather restraints and seclusion rooms to a more soothing approach that helps patients identify and express their feelings and enhance self-coping mechanisms. Her department uses tools like soft lighting and weighted blankets to create a sense of calm and security.
Trauma-informed care is already the basis of new staff orientation at Meriter, and in 2016 the hospital will expand the focus to include its emergency services department, Janty says.
The Department of Public Instruction is also expanding trauma training for Wisconsin educators, rolling out a multi-year professional development program for schools to become more trauma-informed, says Nic Dibble, an education consultant in school social work services. The program builds on the current model of “positive behavioral interventions and supports,” an evidence-based approach to reducing disciplinary incidents.
“In Wisconsin schools, we’re seeing more kids presenting at younger ages with bigger behavioral challenges,” Dibble says. “Behavior is how they communicate, and rather than trying to correct that behavior, we really need to understand what’s behind that behavior.”
The court system is making a shift as well. Dane County Circuit Court Judge Shelley Gaylord is one of a few local judges who have been trained in ACE scores and trauma-informed practices, but she says there’s “momentum” among those involved with the criminal justice system to embrace the concept. Nationally, between 75% and 93% of youth entering the juvenile justice system have experienced trauma, according to the Justice Policy Institute.
“It starts with a physical observation of what it’s like to come into the courthouse,” Gaylord says. In family and child welfare cases, the social worker on the case generally sits at the same table as the prosecution, whether it be the district attorney or a corporate counsel — a positioning Gaylord says can send the wrong message to the family.
“That makes it seem like the social worker is on [the prosecution’s] side,” Gaylord says. “Many clients and parents would voice that concern.” As an alternative, Gaylord pushes the tables together, putting the social worker in the middle.
Many proponents of trauma-informed care describe “bubbles” or “pockets” of awareness growing throughout Wisconsin as service providers receive training.
The most recent push has been to expand resources and training beyond child and family services to include more adult-centric service providers, such as drug and alcohol counselors, Webb says. Advocates are also exploring the role of cultural competency in trauma-informed care and looking at the impact of trauma that has been passed down through generations of a family.
“What I’m envisioning is that more and more counties will get it, embrace it, make the transformation and become part of a statewide conversation,” Webb says. “I don’t want this to be a best-kept secret.”
For Buege, facing the struggles of her past was the first step on a long journey to recovery. The road was difficult. After beating her heroin addiction, she nearly died when she overdosed on psychotropic medication twice within the same week. Worse, it happened when her three small children were in the house.
Buege knows she could have lost custody of her children. But her social worker, instead of taking a punitive approach, acknowledged Buege’s history of trauma and chose a trauma-informed approach, directing the family toward more supportive services and therapy.
“We kept working,” Buege says.
But trauma is often passed down through generations. Buege’s youngest son, Donovan, began to manifest behavior problems at an early age, getting kicked out of his first daycare program at 18 months and attempting suicide at age 4. He was later diagnosed with autism and bipolar disorder.
When he was an elementary student, his teachers attempted to control his behavior using seclusion and restraint. Buege says these punishments added to Donovan’s trauma. A daylong seclusion launched the 7-year-old into psychosis; doctors said he would never recover.
But instead of heeding recommendations to institutionalize her son, Buege urged Donovan’s doctors and teachers to acknowledge his trauma. Together, they developed a treatment plan that taught him self-regulation and interpersonal skills. “As we did that, his behaviors that were due to anxiety and dysregulation diminished really fast,” Buege says. Now 21, Donovan works as a peer mentor for troubled youth.
Buege’s experience advocating for her son launched her into a larger role lobbying for statewide education and mental health policy reform, and since 2008 she has done statewide trainings in trauma-informed care. Now, she works as a family and consumer advocate at Community Partnerships, a local agency that provides mental health services.
“We’ve come a long way from the conversation starting 10 years ago,” Buege says. “But as far as a statewide movement, we still have a long way to go.”