Understanding Traumatic Stress

A Brief Overview

What’s In Store? Part 1: Recognizing Trauma

Definitions of Trauma Three Types of Trauma Short-term and long term impact Principles of Trauma Treatment

Part 2: Responding to Traumatized People ARC (Attachment, self-Regulation, &

Competency) Building safety, attachment, and attunement

Recognizing Trauma

Part 1

What Is “Trauma”?American Psychological Association

“ an emotional response to a terrible event like an accident, rape or natural

disaster ” Merriam-Webster Dictionary

“ a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury. an

emotional upset ”

Australian Psychological Society

“ The word ‘trauma' is derived from the Greek term for ‘wound'. Very frightening or distressing events may result in a psychological wound or injury - a difficulty in coping or functioning normally following a

particular event or experience. “

SAMHSA DefinitionIndividual trauma results from an event, series of

events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being...

In short, trauma is the sum of the event, the experience, and the effect.

Three Types of TraumaAcute

(isolated event) Trauma

Chronic (repeated or prolonged)

Trauma

Complex (developmental)

Trauma

An isolated event such as being the victim of a crime, surviving a natural disaster, or a serious accident

Living through an ongoing situation such as experiencing domestic violence, or a war

Experiencing multi-layered traumatic circumstances such as caregiver abuse or neglect, or a combination of multiple trauma events, particularly in childhood.

PrevalenceAdverse Childhood Experiences (ACE)

reported by adults: 28% physical abuse, 21% sexual abuse,

15% emotional neglect 10% physical neglect, 13% domestic

violence, 27% substance abuse in home

The Impact of Trauma About 80% of 21 year olds who were

abused as children met criteria for at least one psychological disorder (e.g. Depression, Anxiety)

ACE in any category increased the risk of attempted suicide 2- to 5-fold

Persons who have experienced 5 or more ACE events had a nearly threefold increase in rates use of psychotropic prescriptions.

The Brain

Mid-Brain – Motor regulation, arousal, appetite, sleep

Brain Stem – blood pressure, heart rate, body temperature

Cortex – Abstract thought, concrete thought, language

Limbic System – Attachment, sexual behavior, emotional reactivity

About The Human Brain Develops in a use-

dependent fashion Repeated activation of

specific nerve connections develops those connections and the areas required to sustain those connections

Areas that do not get consistent, repeated stimulation may not develop at all HHS Child Welfare Information

Gateway

Acute Response To Trauma In the reptilian and animal brain:

Hyper or Hypo-arousal: Fight, Flight, Freeze, Submit.

Information is processed directly for survival purposes.

In the cortex: New information is not processed or retained. Rational thought is avoided in favor of survival-

related activities.

About “Fight or Flight”Fight

When a threat can be

conquered

FlightWhen a

threat can be avoided

SubmitWhen a threat

can be mitigated

FreezeWhen there is

no way to avoid harm

PosturingVerbal outbursts or threatsConfrontationPhysical aggression

Physically moving awayDissociationHiding“shrinking” in posture, tone of voice

“if you can’t beat them, join them”Self-harmInstigatingDefending the attacker

Complete helplessnessPhysical freezingStuporCatatonia

Lasting Effects of Trauma Attachment and attunement:

Struggles to empathize with others Difficulty identifying others’ feelings through

verbal or visual cues OR extreme sensitivity to others’ feelings perceived through these cues

Isolation, or trouble developing safe, trusting relationships

Unhealthy physical boundaries (touch aversion, sexual or social permissiveness)

Lasting Effects of Trauma Physical challenges:

Problems with balance (e.g. uneven gait) Movement coordination problems Lack of hand/eye coordination Delays in growth and development (e.g.

“failure to thrive”) Unexplained physical pain Sleep disturbances, night terrors, or altered

sleep pattern

Effects of Trauma Emotion and Mood:

Difficulty describing feelings Feelings are experienced as overwhelming,

with limited ability to modulate Depression, anxiety, and numbness are

common Lack of affect

Effects of Trauma Arousal modulation:

Dissociative states (black outs, out-of-body experiences, a “blank stare”)

Abrupt outbursts of anger and/or aggression Hyperactivity or “mania”-like presentation

Behavioral control: Difficulties in impulse control Self-destructive behavior

Lasting Effects of Trauma Cognition:

Problems with attention and concentration Difficulty retaining new information Short term memory problems Limited autobiographical memory Poor self-image and self-esteem Persistent intrusive thoughts and images,

sometimes resembling hallucinations “Arrested development”

Trauma Treatment & Recovery

In order to foster change, people’s reparative experiences must be

Predictable Consistent Repetitive Appropriate for developmental stage of the

person in the specific area of activity, rather than their chronological age or the usual performance of non-traumatized peers

Inclusive of any and all unoffending caregivers

Trauma Treatment & Recovery The case of Robert and Mama P. (Excerpt

From the book, “The boy who was raised as a dog”, by Dr. Bruce Perry)

Questions for discussion: What themes are common to the case of

Robert and the people with whom we work? What feelings/thoughts arise as we consider

these common themes? What can we learn from this case?

Responding to Traumatized People

Part 2

ARC Framework ARC: Attachment, Self-Regulation,

Competency In order to be effective, treatment of

complex trauma must be responsive to the specific developmental needs of the person, recognizing and addressing factors that have derailed normative development.

ARC Building Blocks

CaregiverAffect Mgmt

AttunementConsistent Response

Routines&

Rituals

Affect Identifi-cation

Affect Modulation

AffectExpression

Executivefunctions

Self-Dev’t& Identity

Dev’tal tasks

Attachment Attachment is a relational (two-way)

process, without which people do not develop the capacity to regulate their own emotions.

People with complex trauma histories often have problematic attachment styles due to repeated disruptions in attachment

The Still Face Experiment

Attachment StylesAttachment

StyleBehavior

Underlying beliefs

Previous caregiver’s behavior

AvoidantEmotionally distant, does not connect with others

“I can’t rely on others to meet my needs.”

Never emotionally or physically available

Ambivalent

“push/pull”: fluctuates between connecting and rejecting

“There is no way to predict whether my needs would be met.”

Inconsistent in availability or response

Disorganized

No pattern: sometimes Avoidant, other times Ambivalent. Often dissociative.

“Those who meet my needs are also likely to hurt me.”

Intermittently aggressive and/or abusive

Level 1: Attachment Goal: work with caregiver system to crate a safe

environment to support the client in meeting own needs

Who is considered a caregiver? Anyone who has regular and consistent responsibility to

support the client. Four tasks:

Build caregiver capacity to manage affect Build caregiver-client attunement Build consistency in caregiver response to client

behavior Build routines and rituals

Caregiver Affect Management Caregivers can support clients in developing

healthy self-regulation skills through modeling the response they’d like the client to develop. E.g. child falls down. Mother’s response determines

whether the child will cry. Challenges to caregiver affect management

Client vigilance to caregiver cues Intensity of client affect Caregiver’s own history and situation Relational reenactments

Addressing The Challenges

Encouraging self-awareness and self-monitoring Building capacity for self-care Developing a built-in support system Practicing teamwork Recognizing and addressing Secondary Traumatic

Stress (STS), compassion fatigue, and burnout. Supporting knowledge sharing activities Identifying successes and failures and using them

as teaching moments

Integrating Who You Are Into Your Work Your personality, communication style, and

background will inevitably find their way into your interactions with clients. Past hurts, traumas, and fears are bound to influence

these interactions- sometimes in unpredictable ways. YOU can be a powerful catalyst for client growth

and change: Identify what you bring into different interactions Recognize the impact of your life experiences on your

work Consciously choose which parts of YOU enter the

interaction with the client

Attunement Traumatized clients often have difficulty

communicating effectively. Behavior is an attempt to communicate

Unmet needs Unregulated affect

These difficulties may be global, or situation-specific

Caregivers often respond to the most distressing symptom or behavior, rather than the underlying emotion or need.

Value of Attunement Helps clients develop trust in caregiver

system Clients experience being understood Demonstrates true compassion, caring Allows clients to learn that their needs and

feelings will be addressed Facilitates prevention and rapid de-

escalation of high-intensity situations Increases client engagement Supports client behavior change

How Attunement Happens Become a “feelings detective”

When the client acts, consider what he/she might need or feel

Consider basic needs: hot, cold, tired, hungry, thirsty...

Consider the fight/flight response Consider the client’s attachment style and possible

triggers

Use reflective listening skills Practice responding to feelings/needs and

not to behavior

Consistent Response Predictability in caregiver response helps

clients feel safe, and reduces their need to exert control

Limit-setting and praise are common triggers: they are often associated with powerlessness and vulnerability. Where possible, reduce the need for limits Adapt response to the individual needs of the

client Build on successes

Routines and Rituals Trauma is often associated with chaos and

unpredictability Routines enable clients to feel safe,

anticipate and evaluate their experience, and learn reliability

It is important to be selective in developing routines/rituals, build-in flexibility

Routines/rituals are often subtle

Core Principles Safety

How do we know whether a situation is safe? How do we know if a person is safe? How does our personal definition of safety

impact our interactions with clients? Does our idea of safety translate into our work

environment? Why? Why not? What are the challenges in creating /

maintaining safety in our environment and interactions? How do we overcome them?

Core Principles Consistency

What are some challenges to consistency that we encounter in our day-to-day?

What can you do to create consistency? What support do you need, and from whom?

Repetition Why is repetition important? Why is it good? How much is too much repetition? How much is not

enough? How do we feel about repetition? How do we manage

any potentially negative feelings?

Thank You!

Questions, Comments, and Feedback welcome!