TRAUMA 101

TRAUMA INFORMED PRACTICE

Feb. 11, 2013

Kathy Savicki, LCSW,

Mid-Valley Behavioral Care Network

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WHAT DO WE MEAN BY TRAUMA?.

“Traumatization occurs when both internal and external resources are inadequate to cope with the external threat.” Van der Kolk

Critical role of environmental support Link with abuse and neglect – toxic stress

for children Fear + disrupted attachment

Limitations of the Diagnostic System

Acute Stress Disorder – 1st month after event PTSD

1st described Vietnam vets and rape victims Poor fit for children and youth DSM V will change criteria

Proposed but rejected by APA: Developmental Trauma Disorder Complex Trauma/Disorders of Extreme Stress

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Generational TraumaParental trauma responses affect their children Parental problems and crises impact kids Parental coping tools and relational styles

are passed down Children can learn a ‘trauma response’ to

life

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Trauma in Our Lives Up to 70% of American adults experience

at least one traumatic event At any time 5% of Americans have active PTSD 8% of us will experience PTSD in our lifetime

Approx. 25% experience multiple traumas

Prevalence in women is 2x that in men

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Ability to Cope with TraumaDepends on:

Single vs. repeated trauma Age when trauma occurred or began Agent – natural vs. human Nature of the trauma – accidental vs.

purposeful Innate resilience

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Select Traumatic Events and Risk for PTSD

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31.9

23.7

16.8 15.4 14.310.4

7.33.8

05

10152025303540455055

Risk of PTSD (%)

Source: Breslau, 1996 Detroit Area Survey of Trauma

Neurobiology of Trauma

What happens in our brains?

These slides are available on the BCN website at

http://www.mvbcn.org/home/mv1/smartlist_176/trauma-sensitive_services.html

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Trauma and the Brain Thalamus (temporal lobe) receives sensory

signals Amygdala sorts for immediate danger

- Shuts down ‘thinking brain’

- Diverts energy to physical response Hippocampus stores episodic long term

memory Reactivation of this pathway strengthens it

In the Traumatized BrainIn the Traumatized Brain

In the Traumatized BrainIn the Traumatized Brain

Intervention StrategiesIntervention Strategies

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Memory & Perception

Narrative, verbal

Visual imagery

Sensory, somatic

Affective, feeling

Interpersonal, behavioral

A memory includes:

Traumatic memories are encoded or “remembered” in a different way from

normal, everyday events.

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Traumatic Memory Sensory Linked with intense arousal Fragmented ‘Body’ rather than verbal memory

Role of psychotherapy is to develop the use of the frontal cortex to make sense of and manage reactivity

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PTSD Symptom Clusters (DSM IV)RRee--LLiivviinngg tthhee

EEvveennttAAvvooiiddiinngg

RReemmiinnddeerrssHHyyppeerr--AArroouussaall

Recurringnightmares,flashbacks

Intrusive images“pop” into head

Extreme emotional orphysical reactions toreminders (shaking,chills, panic, racingheartbeat)

Avoid places, people,thoughts or otherassociated activities

Emotional numbing,Loss of interest ineveryday activities

Withdrawal fromfamily, friends

“Avoid awareness”that trauma occurred

Overly alert, easilystartled, “on guard” atall times

Irritability or suddenanger

Difficulty sleeping,Lack of concentration

1 + symptoms present 3 + symptoms present 2 + symptoms present

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Developmental Trauma DisorderExposed to over a year of interpersonal violence, with significant disruptions of protective caregivingAffective and Physiological DysregulationAttentional and Behavioral DysregulationSelf and Relational DysregulationPTSD SymptomsFunctional Impairment

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Complex PTSD, also called Disorders of Extreme Stress

Proposed for DSM-IVR by trauma treatment experts, but not adopted

Superb clinical description of adults who experienced on-going child abuse and neglect and multiple or pro-longed trauma

Better way of understanding many people otherwise labeled with personality disorders

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Generational TraumaParental trauma responses affect their children Parental problems and crises impact kids Parental coping tools and relational styles

are passed down Children can learn a ‘trauma response’ to

life

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Systems Trauma Simply put, systems trauma is the trauma

that people experience or re-experience as a direct result of their interaction with a powerful system

Although it may be connected to a single trauma, more often it is part of complex trauma

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Systems Trauma The experience of powerlessness is key to

retraumatization, especially when people have experienced authority figures as cruel.

People are often retraumatized when they experience being treated in a way that is similar to past traumas.

The more trauma a person has experienced, the more vulnerable they are to retraumatization

If you have a negative sense of self, feeling judged can be powerfully retraumatizing

When Under Stress………. We all tend to use our more primitive defensive

brain Use of that part of the brain curtails the use of the

more-highly organized, intelligent part of the brain

We become more tuned in to immediate survival, and less tuned in to the abstract future

We opt for simple and swift as opposed to complex and thoughtful reactions

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Retraumatization: Feeling States

Being retraumatized often invokes intense feelings Hopelessness Helplessness Extreme vulnerability Intense desires to die, disappear or run Pervasive shame Anger or rage Terror Self-hatred/condemnation

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Retraumatization: Common responses Strong negative emotions that may be difficult for

the person to explain, and expressed in ways that we might not understand (or appreciate)

Defensive or angry verbalizations/avoidance Withdrawing emotionally/shutting down/self-

sabotage Telling people “in authority” what they think the

person wants to hear/overly “compliant” Disengaging from services/leaving

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SYSTEMS WHICH FREQUENTLY

RE-TRAUMATIZE Law Enforcement Criminal Justice Child Welfare Hospitals and related medical systems Mental Health Substance Abuse Treatment

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Many Parents Encountering Child Welfare Have experienced abuse as children Have experienced multiple life traumas and

developmental interruptions Have not had the natural and therapeutic

supports needed to initiate their own recovery Have had little or no experience, training or

support in being a parent Have multiple life stressors and limited

resources

CHILD WELFARE Parents experience Child Welfare staff as

extremely powerful Parents who encountered the Child Welfare

System as children know that power What’s at stake is the primary attachment to

one’s child Actual and perceived negative experiences

create difficulties in building a relationship

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CHILD WELFARE The Child Protective Services System

works with a legal system that can feel adversarial

Fact-based reports can feel accusatory, triggering intense feelings of guilt

Parents often experience this process as frightening, unfair, humiliating and painful

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Potentially traumatizing experiences

Not being informed of or understanding the plan for the children when they have been taken into custody, not knowing the process

Having – or feeling that - important decisions are made about them or their children without their knowledge, participation or consent

Multiple conflicting priorities without the resources or support to accomplish them

Negative evaluations of their character or value as parents

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Potentially traumatizing experiences Judgments and stereotypes related to the

parent’s addiction, mental health, or family history

Being treated as hopeless or as if their past history dooms them to failure

Fear of their children having negative experiences (big or little) in foster care

Loss of contact with child or termination of rights

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Basic Skills: Trust and Respect Kindness, courtesy, politeness Reliability Attentive listening – open ended questions Emphasize choice Owning our mistakes Assume symptoms (including lies) have a

positive intent and an adaptive function

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Reconsidering Our Words Frequent flyer

Perjorative label reflecting our helplessness/frustration Manipulation

An indirect method of achieving a goal when being direct isn’t see as an option or likely to succeed

Secondary Gain Reflects a primary need not met in other ways

Attention Seeking Why do people have to work so hard to get our attention?

Borderline Person with an attachment disorder

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We Have to Believe in RecoveryStay strengths-based and respectful Remember that change is terrifying Know that the person is doing their best to

survive in the moment If they rage at you, assume you’ve reactivated

previous traumatic relationships and don’t over-react yourself

Peer supports are invaluable to help people feel truly understood and hopeful about change

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We Have to Believe in RecoveryStay grounded in Recovery Principles Recovery is not linear, but marked by growth,

setbacks and learning from experience Honoring attempts that don’t work

Moving from destructive to healthy coping involves daily choices for health and safety The process can be laborious Small steps need to be recognized and valued Beware when you feel “Here we go again” Holding on to hope