from maltreatment to well being 1st

From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for

People with Disabilities

• Ice-Breaker

• Trauma Defined

• Trauma Effects to People with Disabilities

• How Trauma Develops

Workshop Outline 9 am – 10:30 am



• Critical Incident Stress– Defusing– Debriefing

• Immediate Steps that can be Taken to reduce the progression to Post-Traumatic Stress and related Disorders

Workshop Outline 11 am – 12:00 am



• Group Case Exercise 1:00 pm–2:00 pm

• Feedback and Questions 2:00-2:45

Workshop Outline 1 pm – 2:45 pm



• Intermediate-Term Steps to reduce and eliminate the effects of Post-Traumatic Stress and related Disorders

• Long-Term Steps to reduce and eliminate the effects of Post-Traumatic Stress and related Disorders

• Final Questions and Answers Discussion and Next Steps

Workshop Outline 3:00 pm – 4:00 pm



• A Trauma, or Critical Incident, is “an extraordinary event or series of events which is sudden, overwhelming, and often dangerous, either to one’s self or to one’s significant other(s).”

• (Hillenberg and Wolf, 1988)

Trauma Defined (The Event)



• Premature, distorted and traumatic sexualization;

• Betrayal of trust; • Reinforcement of a sense of powerlessness

and helplessness; • Irrational stigmatization by self or others:

(disgust, blame, moralizing, a sense of personal "badness", worthlessness).

Trauma Defined (The Wounds)



• "Damaged Goods" syndrome;

• Guilt;

• Fear;

• Depression;

• Low self‑esteem and poor social skills;




• Repressed anger and hostility; Impaired ability to trust;

• Blurred role boundaries and role confusion;

• Pseudomaturity coupled with failure to accomplish developmental tasks;

• Self‑mastery and control [is disturbed]..."




• somatic and psychosomatic disorders– abdominal distress; – physical damage or complaints: – mutilations and self‑mutilations such as

castration, burns or slashes; – permanent and severe urogenital or anal

injuries such as enlargement leading to functional encopresis;




• somatic and psychosomatic disorders– infections; – skin irritations; – child and unwanted pregnancy; – menstrual disorders; – sexually transmitted disease;– brain injury and other life‑threatening

organic damage.




• violence and aggression against the self or others;

• "second‑generation child abuse";• shame, guilt and depression with or

without suicide attempts or thinking;• hostility and anti‑social behaviour;• sexually anomalous behaviour and sex

disorders




• failure to thrive, withdrawal, behavioural regression– bedwetting, – thumb‑ sucking, – toileting problems

• alienation and isolation• incompetence, underachievement, school

failure and truancy;




• delinquency;

• substance abuse;

• Prostitution;

• anxiety, phobic and panic states;

• appetite (induced obesity, anorexia) and sleep disorders




• histrionic, hysterical, multiple or other personality disorders, including "Post Traumatic Stress Disorder" and dissociative mental states;

• other moderate to extreme neurotic or even psychotic states or episodes;

• Death




Often, maltreatment has been an ongoing fact of life for years or even decades for the child or adult, in a

home environment where alcoholism, mental illness, drug

abuse and other family problems may co‑exist



• 1. Predisposition to the abuse experiencea

– a. male socialization experiences (especially sex‑role, authority and violence)a

– b. childhood abuse experiencesa

– c. "second‑generation" damage, history of institutionalization, dehumanizing experiences, severe neglect, physical abuse, damaging upbringing and lack of appropriate experience, trainingb

• a (from Russell, 1987, cited in Senn, 1988)• b (from Wolfensberger, 1972)

Predisposing Factors



• 2. Reduction of internal inhibitionsa

– a. minimization of harm done or lack of consciencea

– b. cultural view of females as commodity and children as propertya

– c. cultural support for predatory male behaviour and violencea

– d. child not related by blood (step‑relations)a

– e. alcohol consumptiona

– f. pornographya

• a (from Russell, 1987, cited in Senn, 1988)




• 2. Reduction of internal inhibitionsa

– g. sexualization of children and portrayal of violence in the mass mediaa

– h. casting of people with disabilities into deviant roles (menace, object of dread, object of pity, sick person, subhumans, etc.)b

• a (from Russell, 1987, cited in Senn, 1988)

• b (from Wolfensberger, 1972)




• 3. Reduction of social inhibitionsa

– a. pornographya

– b. male dominance or authoritarian stancea

– c. power disparity between adults and childrena

– d. power disparity between "non-disabled" and "disabled" peopleb

– e. reduction of child's resistancea

• a (from Russell, 1987, cited in Senn, 1988)• b (from Wolfensberger, 1972)




• 1. "[Person] is emotionally deprived... " • 2. "[Person] is socially isolated... " • 3 & 4 "[Person] knows [caregiver or

authority] and has special fondness for [caregiver or authority]... "

• 5. "[Person] is vulnerable to incentives offered by [caregiver or authority] " (Senn, 1988)




• 6. "[Person] feels helpless and powerless… "

• 7. "[Person] is ignorant of what is happening... "

• 8. "[Person] is sexually repressed and has sexual curiosity... "

• 9. "Coercion..." (Senn, 1988)


Symptoms of Acute Stress

PHYSICAL

EMOTIONAL

MENTAL

BEHAVIORAL

NauseaUpset stomachDiarrheaFeeling uncoordinatedChest pains* Difficulty breathing* Rapid heart beat Muscle aches Headache Chills Profuse sweating Sleep disturbances Dizziness

Anxiety Fear Grief Depression Sadness Feeling lost Feeling abandoned Feeling isolated Worry about others Wanting to hide Limiting contact with others Anger Irritability Startled Shocked

Slowed thinking Difficulty making decisions Difficulty in problem-solving Confusion Disorientation, especially to time and place Difficulty calculating Difficulty naming common objects Seeing event over and over Distressing dreams Poor attention span

Withdrawal Restlessness Emotional outbursts Increased alcohol use Change in speech Change in appetite Increased startle reflex

Physical Reactions• Aches and pains like headaches, backaches,

stomach aches• Sudden sweating and/or heart palpitations

(fluttering)• Changes in sleep patterns, appetite, interest in sex• Constipation or diarrhea• Easily startled by noises or unexpected touch• More susceptible to colds and illnesses• Increased use of alcohol or drugs and/or

overeating

Emotional Reactions

• Shock and disbelief• Fear and/or anxiety• Grief, disorientation, denial• Hyper-alertness or hypervigilance• Irritability, restlessness, outbursts of anger or rage• Emotional swings – like crying and then laughing• Worrying or ruminating – intrusive thoughts of

the trauma• Nightmares

Emotional Reactions - Continued• Flashbacks – feeling like the trauma is happening

now• Feelings of helplessness, panic, feeling out of

control• Increased need to control everyday experiences• Minimizing the experiences• Attempts to avoid anything associated with trauma• Tendency to isolate oneself• Feelings of detachment• Concern over burdening others with problems

Emotional Reactions - Continued• emotional numbing or restricted range of feelings • difficulty trusting and/or feelings of betrayal • difficulty concentrating or remembering • feelings of self-blame and/or survivor guilt • shame • diminished interest in everyday activities or

depression • unpleasant past memories resurfacing • loss of a sense of order or fairness in the world;

expectation of doom and fear of the future

“…it appears that betrayal by someone on whom you depend for survival (as a child on a parent) may produce consequences similar to those from more obviously life-threatening traumas…Experience of betrayal trauma may increase the likelihood of psychogenic amnesia, as compared to fear-based trauma. Forgetting may help maintain necessary attachments (e.g., during childhood), improving chances for survival…Of course, some traumas include elements of betrayal and fear.” (David Baldwin “About Trauma”)



Aristotle: "...let there be a law that no deformed child shall live..."

Plato: "the best of each sex should be united with the best as often, and the inferior with the inferior, as seldom as possible...the offspring of the inferior, or of the better when they chance to

be deformed, will be put away..."

"...those infants who cannot be put to board, the crippled and the infirm,

will be raised in the hospitals" (Napoleonic decree)

Martin Luther: "take this child to the Moldau River which flows near Dessau and drown him"

“...If it is poor health, bad sight, defective hearing, stammering, syphilis, anemia, fatigue, sitting up too late at nights, eating slate pencils,

smoking cigars, drinking beer, wage-earning before the time, tuberculosis, rheumatism, heart

disease, adenoids, enlarged tonsils, repeated infections, or any other removable cause, let

that cause be removed so that the child may not lose his life, health and education, nor the State lose its time, its money, and its citizens.” (Helen

MacMurchy, ca. 1912 Ontario)

“If I take one of these children, and compel him to run the gauntlet of half a dozen specialist examinations, label him with some opprobrious name, exaggerate his imperfections, and advertise him on the housetops as a menace to society, I not only unjustly stigmatize him for life and cause untold suffering to himself and his friends, but I also render all subsequent treatment doubly difficult” (Dr. S. B. Sinclair, ca. 1920’s Ontario)

“Early in 1939, a father from Leipzig Germany who...’loved’ his severely handicapped son, wrote a letter to ask Adolf Hitler asking if it

would not be okay to end the boy’s life. Hitler dispatched his personal physician Karl Brandt to determine if the boy’s life was ‘worth living’.

When Brandt reported back that it was not, Hitler authorized him to give the boy a merciful

death… (Sobsey, 1995)

Brandt was authorized to permit physicians to kill other people with disabilities. Safeguards were put in place. Every case was reviewed by at least two physicians to certify that his or her life was not worth living and that he or she was incurable. No one knows the number of people

who were killed in this program. Some estimates are as ‘low’ as 200,000, others as high as

400,000. Most suggest that the number was about 275,000.

“The methods of killing varied, lethal injections and carbon monoxide were commonly used

because they were painless. Before mass exterminations made carbon monoxide canisters practical, gassings were commonly conducted using the exhaust from trucks. Later custom build (sic) gas chambers were built for the

“euthanasia” program. To prevent the victims from being alarmed, the gas chambers were

disguised as shower rooms…”

“Only much later were the personnel, equipment, and methods learned in the

euthanasia program exported to the ethnic death camps. The holocaust blossomed from the

‘mercy killing’ of one severely handicapped child back in 1939.”

(Dick Sobsey, 1995)

Germany’s Laws against which these Euthanasia programs were justified were based

on US Law from the State of Virginia.

“If we could start afresh, our organization of Mental Health Services would start at the

community level. Up to the present, we have been working backward to bring the mental

hospitals closer to the community and this is the course that, by force of circumstance, we will

have to continue, though hopefully at an increased rate.” Dr. Matthew Dymond, ca.

1960’s Ontario



• Analysis of Placement Failures (Institution to Community, 1985) - in all but a very few cases, behaviour problems of the discharged residents were cited as the reason.

• In fact, further investigation of the phenomenon showed that it was almost inevitably a combination of environmental factors in the placement settings themselves

• Another case of “Blaming the Victim”?



• Analysis of Placement Failures (Institution to Community, 1985)– lack of preparation of staff in the new setting;– a poor match between the competencies of the staff of the

new setting and the challenges of the discharged resident;– poor communication from the referring institution about

needs and sensitivities of the discharged resident;– poor transition planning aided and abetted by lack of

attempts at understanding the discharged residents’ institutional experiences - which often them (especially those who had spent years of their life there) - a kind of “culture shock”.



• Analysis of Placement Failures (Institution to Community, 1985)– poor training in therapeutic approaches applicable to

people with developmental disabilities, especially a lack of orientation and training in mental health and applied behaviour analysis;

– ideology clashes between practitioners which did not respect the unique life experiences of the people with disabilities involved – their “life lived”

– Lack of a consensus about how such differing lifestyles could be reconciled in a comfortable and timely way for those trying to make the transition.



• Delays• Public Exposure

– "...having to recount embarrassing and frightening incidents in a public courtroom at an age [or perhaps ability level] where speaking publicly about oneself is difficult...“

• Facing the Accused– “...Having to face the accused person when on the stand

despite intense fear for personal safety..."

System-Induced Trauma (Testifying)



• Understanding Complex Procedures– "...Being exposed to court procedures that are foreign

and easily misunderstood by children who do not know the legal terminology or the adversarial context...“

• Change of Crown Attorneys– "...Having changes…just prior to or on the day of court

which undermines their sense of security and self‑confidence. The lack of a supportive/comfortable relationship when entering into court with their counsel because insufficient time had been spent together..."




• Cross Examination– "...Being cross‑examined by a defense lawyer, who can

be very aggressive, is challenging….withstanding cross‑examination can be downright harassing, in that it exploits the child's sensitivity and vulnerability...“

• Exclusion of Witnesses– "...Being "alone" in court because the removal of

witnesses results in the child finding himself/herself in court on the stand without significant adult figures in his/her life (i.e. family) present as support..."




• Apprehension and Placement Outside the Home– "...Being removed for safety reasons from one's home

while the accused is allowed to stay: Children are often the ones to leave and are then stripped of their extended family support while the accused remains home...“

• Lack of Preparation for The Role of Witness ‑ – "...Not being aware of the expectations of them because

they are child witnesses. Most children are totally unprepared to give testimony, and do not understand the adversarial system..." (Health and Welfare Canada, Family Violence Initiative Project #4555‑1‑125; p. 9)




• physiological evidence shows that trauma (particularly if it is prolonged and extreme, also involving betrayal by trusted persons), may result in "persistent symptoms of increased arousal" in the Autonomic Nervous System (ANS) (APA 1994)

• See chart next slide

How Trauma Develops

From Maltreatment to Well-Being: Imaginative

Applications from Trauma Intervention for People with Disabilities

• “The limbic system of the brain responds to extreme stress/trauma/threat by releasing hormones that tell the body to prepare for defensive action, activating the sympathetic branch (SNS) of the autonomic nervous system (ANS), preparing the body for fight or flight: increasing respiration and heart rate, sending blood away from the skin and into the muscles, etc. When threat is imminent or prolonged (as with torture, rape, etc.), the brain can also release hormones to heighten the parasympathetic branch (PNS) of the ANS, and tonic immobility - like a mouse going dead (slack) or a frog or bird becoming paralyzed (stiff) - can result (Gallup 1977, Levine 1997).” (Rothschild, 1997).



• “With PTSD the brain continues to respond as if under stress/trauma/threat, continuing to prepare the body for fight/flight, or going dead (sometimes called "freezing") even though the actual traumatic event has ended.

• People with PTSD live with a chronic state of ANS activation - hyperarousal - in their bodies leading to physical symptoms that include: anxiety, panic, muscle stiffness, weakness, exhaustion, concentration problems, sleep disturbance, etc. ....

• During a traumatic event the brain tells the body there is threat. In PTSD, the body persists in telling the brain there is continued threat; the brain continues to stimulate the ANS for defense. It is a vicious circle.



• Objects, sounds, colors, movements, etc., that might otherwise be insignificant, become associated to the trauma and become external triggers that are experienced internally as danger (van der Kolk 1996).

• Confusion can result when recognition of external safety does not coincide with the inner experience of threat. Hyperarousal can become chronic, or can be triggered acutely.

• Breaking this cycle is an important step in the treatment of PTSD.” (Rothschild, 1997)

10 Ways to Recognize Post-Traumatic Stress Disorder

• 1. Re-experiencing the event through vivid memories or flash backs

• 2. Feeling “emotionally numb”• 3. Feeling overwhelmed by what would normally

be considered everyday situations and diminished interest in performing normal tasks or pursuing usual interests

• 4. Crying uncontrollably• 5. Isolating oneself from family and friends and

avoiding social situations

10 Ways to Recognize Post-Traumatic Stress Disorder

• 6. Relying increasingly on alcohol or drugs to get through the day

• 7. Feeling extremely moody, irritable, angry, suspicious or frightened

• 8. Having difficulty falling or staying asleep, sleeping too much and experiencing nightmares

• 9. Feeling guilty about surviving the event or being unable to solve the problem, change the event or prevent the disaster

• 10. Feeling fears and sense of doom about the future (Thanks: American Counselling Association, 2000)

Three main symptom clusters in PTSD

• 1. Intrusions, i.e. “flashbacks” or “nightmares”, where the traumatic event is re-experienced.

• 2. Avoidance, i.e. attempts to reduce exposure to people or things that might bring on intrusive symptoms.

• 3. Hyperarousal, i.e. physiological signs of increased arousal, such as hyper-vigilance, “jumpiness”, increased startle response.

Sources of Angst in Post-Traumatic Stress

• Abandonment• Betrayal• Defeat• Surrender• Grief• Anguish for not having saved others.• Survivor guilt• Shame• Outrage• Shattered values and principles• Severe disruptions of meaning and purpose.

from maltreatment to well being 1st

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