TRAUMA & THE TRAUMA INFORMED CARE INITIATIVE

OCT 23, 2012

CJ DOXTATER, AGING & DISABILITY SPECIALIST

Wisconsin Coalition Against Domestic Violence

TRAUMA & TIC

o Brain Development

o Psychological Trauma

o Brain Effects

o Trauma

o Adverse Childhood Experiences

o Trauma Informed Care (TIC)

o Implementing Value Based Practice

BRAIN DEVELOPMENTMost neural development occurs after birth

A young brain is extremely elastic-realigning neurons at a rate no adult brain can match

Environment determines what neurons are pruned - basic brain architecture

Repetition is the technique used to prune neurons and develop the brain’s architecture

STRESS HORMONESIncreased heart rate & blood pressure

Blood sugar increases

Increased blood clotting

Tunnel vision

Memories come in “HD”

Increased cholesterol

Pain sensation dulled

Increased alertness & focus

Insulin increases

Memory loss from parts of the event

Increased strength, energy & aggression

Hearing may shut down

Time slows down or speeds up

PSYCHOLOGICAL TRAUMA

Trauma refers to extreme stress (i.e. threat to life, bodily integrity or sanity) that overwhelms a person’s ability to cope

The person’s subjective, individual experience determines whether or not an event is traumatic

Traumatic events result in a feeling of vulnerability, helplessness or fearfulness

Traumatic events often interferes with relationships and fundamental beliefs about oneself, others and one’s place in the world

TRAUMA ALTERS THE WAY THE BRAIN WORKS

Hypersensitivity to even minor threats

Extremist thinking

Respond to many things as threats to life- aggression & impulse control

Attention to threat while ignoring less threatening but important information

BRAIN DEVELOPMENT PATTERNS

NeutralStart

BrainHormones, chemicals & cellular systems prepare for a tough life in an evil world

BrainHormones, chemicals & cellular systems prepare for life in a benevolent world

Individual• Edgy• Hot temper• Impulsive• Hyper Vigilant• Brawn over

brains

Individual• Laid back• Relationship

oriented• Thinks things

through • Process over power

Traumatic stress

BRAIN DEVELOPMENT PATTERNS (CONT.)

Outcome

Individuals & Species live peacefully in good timed; vulnerable in poor conditions

OutcomeIndividuals & Species

survive the worst conditions

Dissonance between expectations & social reality fuels psychiatric disorders

BRAIN EFFECTS BY CRITICAL PERIODS

Critical Time Brain Region Function Affected By

First 3 yrs Hippocampus Emotion regulation verbal memory spatial memory

Maltreatment

Ages 3 - 5 W/AmygdalaManages fear, panic, puts the brakes on outbursts and tantrums

Sexual Abuse

Infancy Corpus Callosum

Cross-brain function language & math

Neglect

Age 8 – 10 Social cues Sexual abuse

Age 7 - 9 RT Temporal Gyrus

Spoken language Emotional abuse

BRAIN EFFECTS BY CRITICAL PERIODS (CONT.)

Prior to puberty Cerebellar Vermis

Center for mental health navigation through spaceTrack periphery

All maltreatment

First 2 – 3 years Cortex Thinking and judgment

All Maltreatment

Age 8 - 10 VisionExecutive Function

Witnessing family violence

Ages 15 - 16 Long-term Memory

Sexual Abuse

4 LEVELS OF STRESS REACTIVITYStress Traumatic Stress PTSD Type I Complex PTSD ll

Any demand on the body system

Consequences of exposure to trauma. Generally up to 6 months. Experienced as a single event.

FeelingsFearHelplessnessUrgencyAnxietyAngerSadness

UrgesFight or flightThoughts, memoriesJudgmentsinterpretations

12 months

Exposure to events that are experienced as life-threatening, intolerable or could cause injury or death

Experiences of trauma become more intrusive.Avoidance of cures in the 6 senses (sight, sound, smell, hearing, touch and mind)

Results of multiple events:Age of onset trauma begins in childhood.•Attachment disorder•Implicit memories•Frequency and duration (prolonged, continues through adulthood in absence of resources)

Complexity•Multiple victimization modalities•Interacting effects•Anxiety•Depression•Emotional deregulation•Chronic ptsd•Intrusion•Identify disturbance•Efforts to avoid/numb•Relational disturbance•Hyper-arousal

THE “ONION EFFECT OF TRAUMA”

PTSD

Complex

Inter-generational

Historical

Insidious

Vicarious

ACES Score

ADVERSE CHILDHOOD EXPERIENCES STUDY The ACE Study identifies ”adverse childhood experiences” as growing up in a household with: Recurrent physical abuse

Recurrent emotional abuse

Sexual abuse

A person who abuses alcohol

A household who has a member who is incarcerated

A mother being treated violently

A caregiver who has an untreated mental illness, is chronically suicidal or repeatedly institutionalized

One or no parents

ACES PYRAMID

Early Death

Disease, Disability and social problems

Adoption of high risk behaviors

Social, environmental & cognitive impairments

Adverse Childhood Experiences

TRAUMA-INFORMED CARE: GUIDING VALUES“HEALING HAPPENS IN RELATIONSHIP”

IMPLEMENTING VALUE-BASED PRACTICE

Understand the Prevalence and Impact of TraumaPractice Universal Precautions: presume that every person in a human service

setting has been exposed to abuse, violence, neglect or other highly adverse experiences. Examine all service delivery from this vantage point.

Provide early and thoughtful evaluation with focused consideration of trauma in people with complicated mental health and addiction issues

Learn about ‘triggers’ and coping strategies used by people impacted by trauma

Recognize that the majority of staff are uninformed about trauma and its sequelae, do not recognize it, and do not treat it. Staff receive ongoing training and supervision in how to assess for, support and provide

effective treatment to people with trauma histories (Fallot & Harris, 2002, Cook et al, 2002, Ford, 2003)

IMPLEMENTING VALUE-BASED PRACTICE

Promote Safety Create a service environment that is welcoming and calming

Develop spatial awareness, esp. regarding over-crowding

Provide confidential places to talk

Provide staff and consumer trainings that raise awareness re. re-traumatizing practices

Be open to outside parties, advocacy and clinical consultants

Ask about current abuse and address the current risks to safety

Give advance warning when something out of the ordinary may happen

(Fallot & Harris, 2002, Cook et al, 2002, Ford, 2003)

IMPLEMENTING VALUE-BASED PRACTICE (CONT’D)

Share PowerDo not misuse or overuse displays of power such as

keys, security and general demeanor

Provide opportunities for consumers to have valued roles such as leading initiatives, facilitating groups, training and advocating

Staff provide psychoeducation but do not claim to be experts; consumers are the experts regarding their own lives

IMPLEMENTING VALUE-BASED PRACTICE (CONT’D)

Earn trustAssign one person the role of asking sensitive trauma-related

questions; do not require people to repeat their trauma histories to multiple staff

Provide training to staff on sensitive responses to disclosures of past abuse and trauma

Communicate with compassionRequire all staff use ‘person-first language’

Hold a training in Motivational Interviewing

Sponsor a staff/consumer training in ‘Non violent Communication’

PRACTICE BASED ON VALUES

VALUE: COMMUNICATE WITH COMPASSION

Healing is contingent on the quality of a relationship

Relationships are communicated by the language we use

De-humanizing language creates unhealthy relationships and inhibits healing

Examples of de-humanizing language: target populations, line staff, in the trenches, take downs, high level / low level, unmotivated, cutters, borderlines, non-compliant, manipulative, attention-seeking, case, etc…

IMPLEMENTING VALUE-BASED PRACTICE (CONT’D)

Respect human rights

Learn how to respectfully ask all people about their trauma history (e.g., people who are psychotic and delusional can respond reliably to trauma assessments if questions are asked appropriately)

Participate on community action committees that address issues of social justice

IMPLEMENTING VALUE-BASED PRACTICE (CONT’D)

Pursue the person’s strength, choice and autonomyFocus on ‘what happened to you, and how did you

survive?’ vs. ‘what’s wrong with you?’

Create individualized treatment plans and approaches

Offer opportunities to learn new skills

Recovery goals encompass growth and change not just stabilization of symptoms

5 ESSENTIAL INGREDIENTS FOR HEALING

1. Relationships connecting to a deep set of values that provide a meaningful vision

2. Psycho educational experiences

3. Strength based guidance

4. Safe context

5. Workable realities