4: Supporting MDT Clients
Developing Guiding Principles
Now that you have identified the needs of your community, determined the purpose of your MDT, understand which gaps your MDT intends to fill, and recruited core team members, it is important to begin thinking about how your team can best serve older adults who have experienced elder abuse. This goal is most achievable when teams adopt trauma-informed and person-centered practices.
Understanding Trauma and Trauma-Informed Practices
Individual trauma results from 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 has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.
A history of trauma may increase vulnerability to elder abuse, elder abuse may be subjectively experienced as a traumatic event, or elder abuse may result in traumatic responses.
Three Elements of Trauma
Trauma can be best understood by looking at the three elements: event, experience, and effect.
Event. Trauma results from an event. Traumatic events can include natural disasters, violence, the threat of physical or psychological harm, or actual harm. It may be random and impersonal (e.g., natural disasters) or intentional and interpersonal (e.g., child abuse or elder abuse). Trauma events can occur at any age, but older adults are more likely to experience certain types of trauma:
- Loss of spouse/partner, peers, and family members
- Chronic and life-threatening diagnoses
- Physical injury
- Physiological changes, limitations and disability
- Cognitive and memory loss
- Loss of roles and responsibilities
- Increased dependence on others
- Elder abuse, neglect and exploitation
Experience. A person’s experience of trauma is subjective. That is, two people can experience the same event, but it may have different effects on each individual. There are many factors, positive and negative, that can contribute to a person experiencing an event as traumatic. Some negative factors include: a personal or family history of mental illness or substance use; a previous exposure to traumatic experiences; ongoing stress or trauma (such as abuse); and lack support from friends and family. Some protective factors include: social connections; internal locus of control; and supportive childhood family.
Effect. The effect of trauma refers to the impact traumatic exposure has on a person. Responses may range from no response to a normative response, or to the development of psychopathology (e.g., a substance abuse disorder, anxiety disorder, depressive disorders, and/or PTSD). Trauma can impact many aspects of a person’s life Including:
- Emotional (e.g., emotional dysregulation, numbing)
- Physical (e.g., somatization, biological trauma, hyperarousal and sleep disturbances)
- Health (e.g., heart disease, diabetes, chronic pain)
- Cognition (e.g., intrusive thoughts and memories, cognitive errors, idealization, feeling different, triggers, flashbacks, dissociation)
- Behavioral (e.g., reenactments, self-harm and self-destructive behaviors, substance use, avoidance)
- Social/Interpersonal (e.g., dysfunctional relationships, avoiding relationships, rebuffing supportive relationships)
- Spiritual (e.g., loss of faith, feeling abandoned by God, experiencing existential dread or crisis, feeling disconnected from nature or a higher power)
The effect experienced by an individual may be immediate, or it may occur months, years, or decades later. For example, a person who experiences trauma may be able to manage the trauma symptoms while they are working in a job they love, and they have a family and other support persons, but in later life upon retirement or losing a loved one, their ability to manage the trauma falls away and the person experiences sudden onset PTSD or similar symptoms.
The 4 Rs of Trauma: Realize, Recognize, Respond, and Resist
To best serve MDT clients, it is important to adopt trauma-informed practices. Trauma-informed practices represent a paradigm shift away from asking “What is wrong with you?” to asking, “What has happened to you?” This shift changes how you interact with and respond to older adults who have experienced abuse. It involves a recognition of the impact that trauma can have on an individual's physical, mental, and emotional well-being, and an understanding that trauma can be triggered by events or experiences that are related to abuse or neglect, engaging with the criminal justice system and other proposed interventions, and your interactions with the MDT client. The 4 Rs of trauma-informed care are described below.
Realize the widespread prevalence and impact of trauma and understand that there are multiple pathways to recovery.
Trauma is ubiquitous. In the general population, over 70% of adults reported experiencing a traumatic event in their lifetime; and among older adults, 90% reported experiencing a traumatic event in their lifetime. Because there are multiple factors that contribute to the experience of trauma (described earlier), there are necessarily multiple pathways to recovery.
Recognize the signs and symptoms of trauma in clients, families, staff and others. Signs and symptoms may include:
- Emotional (e.g., sadness, shame, emotional dysregulation, numbing (feeling too much (overwhelmed) or too little (numbing))
- Physical (somatization, biological trauma, hyperarousal, sleep disturbances)
- Cognitive (intrusive thoughts and memories, cognitive errors, idealization, feeling different from others, flashbacks, dissociation)
- Behavioral (e.g., reenactments, self-harm, self-destructive behaviors, substance use, avoidance)
- Social/Interpersonal (e.g., social withdrawal, feeling betrayed)
Trauma changes people. It impacts their beliefs, emotions, sense of self, social relationships, spirituality, and neurobiology. It is easy to misinterpret the behavior and emotions of trauma survivors (e.g., difficulty making decisions, hypervigilance, difficulty regulating behavior or emotions, the need for control). That is why it is important to recognize that the behaviors and emotions you encounter from trauma survivors result from their experience of trauma rather than something inherent in the person. Viewing these behaviors and emotions through a trauma-informed lens changes how members respond and that lens can facilitate a more compassionate and appropriate response.
Respond by fully integrating the principles of trauma-informed care into policies, procedures and practices. The principles of trauma-informed care include:
- Safety (e.g., avoid touching without permission; build psychological trust to enable the client to raise sensitive issues; ensure the environment feels protective)
- Trustworthiness & Transparency (e.g., keep your word; ensure policies are transparent and easily accessible to MDT clients)
- Peer Support (e.g., refer MDT clients to peer support groups; encourage MDT clients to provide peer support if they are ready to do so)
- Collaboration & Mutuality (e.g., reduce the power differential between yourself and the MDT client by recognizing and honoring that your clients are experts in their own needs; think of yourself as “doing with” rather than “doing for” MDT clients)
- Empowerment, Voice & Choice (e.g., return power to trauma survivors by honoring their voice and their choices; meaningfully ask MDT clients about their treatment preferences; prioritize their goals; collaborate with them on planning to achieve that goal)
Resist revictimization of older adults. Both your interactions with older adults, as well as your organization’s policies and practices, can trigger a trauma survivor. Therefore,
- ensure that your organization’s policies and practices are trauma-informed, and
- ensure that your staff and team members are well trained in the six trauma-informed practices listed above.
The Relevance of Trauma-Informed Practices for Elder Abuse MDTs
When working with older adults who have experienced elder abuse, it is important for MDTs to adopt trauma-informed practices to support the recovery and well-being of their older clients. These practices may include:
- Recognizing the prevalence and impact of trauma: Elder abuse MDTs should recognize that many of their clients have experienced trauma or multiple traumas throughout their lifetime. Trauma may explain behavior and may affect their ability to cope with and recover from the abusive event that resulted in their case being referred to the team.
- Providing a safe and supportive environment: MDT members should create a safe and supportive environment for their clients, free from any additional trauma or stress. This may include providing their clients with a private space to discuss their experiences and feelings and by interacting with them in a respectful and non-judgmental way, that demonstrates genuine concern and empathy.
- Focusing on the client's strengths: MDT members should focus on the client’s strengths and resiliency rather than their perceived deficits in order to determine the best course of action and help them feel supported throughout their interactions with the MDT.
- Being aware of the potential for re-traumatization: MDT members should be aware of the potential for re-traumatization, especially when working with clients who have experienced multiple or repeated instances of abuse. They should take steps to minimize the risk of re-traumatization by adopting the six principles of trauma-informed care and ensuring compassionate responses while providing support and resources to help the client cope with any additional stress or trauma.
- Supporting self-advocacy: Empowerment, voice, and choice is a central tenant of a trauma-informed approach. When trauma robs a person of a sense of control over their life, engaging with older adults in ways that help them gain and maintain a sense of control over their lives through voice and choice is an important part of their recovery process. This approach means asking MDT client’s what they want and honoring their choices. It also might involve helping them to understand their options and make informed decisions as well as connecting them with appropriate resources and support systems.
- Encouraging professional education: The MDT can be a place for members to access educational resources related to trauma-informed practices for their profession. There are a number of resources and educational opportunities available that focus on trauma-informed practices for lawyers, law enforcement, APS, physicians, prosecutors, and other disciplines. Circulating information about upcoming training opportunities, subject matter related resources, or sharing notes from conference sessions are simple but effective ways to facilitate learning among MDT members.
Understanding the Person-Centered Approach
A person-centered approach is defined as the systematic focus on the needs, concerns and rights of a person to ensure the compassionate and sensitive delivery of services in a nonjudgmental manner. It means explicitly eliciting the preferences and values of the older adults, and thereafter those preferences and values guide all aspects of communication and care.
Elements of a Person-Centered Approach
A person-centered approach seeks to minimize re-traumatization associated with the criminal justice process by providing the support of advocates and service providers, empowering older adults who have experienced abuse to be engaged participants in the process, and ensuring they play a significant role in their recovery.
A person-centered approach is necessarily trauma-informed insofar as it takes into consideration the needs, wishes, and past experiences of trauma survivors. For example, asking the client to choose the time of day for a visit and whether she would prefer a male or female service provider gives the client increased feelings of control and potentially avoids triggers. A person-centered approach places the relationship between service providers and the older adult at the center of this work.
Relevance of Person-Centered Approaches for Elder Abuse MDTs
Adopting a person-centered approach as a key principle of your MDT will permeate all aspects of the MDT, including policies and procedures and interactions with clients. Some person-centered practices on an elder abuse MDT are described below.
- Develop procedures and policies that include understanding the MDT client’s values, wishes, and life experiences.
- When working with clients and during case consultation meetings, acknowledge and respect the client’s subjective experience of trauma and work to ensure that the team understands the client’s unique needs so as to avoid practices that might trigger the client’s past experiences of trauma.
In both official and unofficial communications and interactions, avoid stigmatization of all kinds including:
- Labeling a client’s behavior as disruptive, uncooperative, resistant, defiant, etc.
- Judging a client’s living environment, etc.
- Minimizing the client’s stated needs, experiences or expressed desires/hopes for the outcome/conclusion of their case.
Rather, MDTs should seek to understand and be respectful of the underlying issues, including trauma responses described above, that might be contributing to a client’s behavior, life choices, or hopes for how their case will be resolved.
- Advocate for the client’s wishes as their cases proceeds across multiple agencies and service providers.
- Secure access to trained forensic interviewers (where warranted; see SAFE Training).
- Institutionalize practices for ensuring a client’s communication needs are met, which could include supporting vision, hearing, or mobility needs as the client seeks to tell their story.
- Secure access to quality decision-making capacity evaluations (where warranted) that include strength-based recommendations.
It is important for elder abuse MDTs to put the needs of clients first. By adopting person-centered and trauma-informed practices, elder abuse MDTs can better understand and support their client’s needs and prevent unintentional re-traumatization. Being thoughtful about these practices at the earliest stages of team formation can help to align the policies, procedures, and potential interventions with the needs of each individual to create better client outcomes.