Trauma Informed Practice

1. Trauma Informed Practice By Dee Wilson 2019

2. Trauma and Adversities • Trauma is one type of adversity. • Many kinds of difficult experiences are not necessarily traumatic. • Nevertheless, adverse childhood experiences are sometimes used by scholars as a proxy for trauma.

3. Adverse Childhood Experiences Studies of adverse childhood experiences have found a dose related relationship between the number of common adversities in childhood and lifelong health and mental health, i.e., the larger the number of adversities the worse ( on average) a person’s lifelong physical health and mental health.

4. Different Types of Trauma • Acute trauma – a single life threatening or overwhelming event or episode • Chronic trauma- repeated traumatic events • Complex trauma – trauma that is both chronic and inflicted by a caregiver or caregivers

5. Powerlessness and Terror • The combination of powerlessness and terror is what distinguishes trauma from other adversities. • A single potentially traumatic event may be traumatic to one person but not to others. It is the response to events that defines trauma, not the events themselves.

6. Trauma Fragments the Fight or Flight Response • Awareness, affect and action( the Three A’s) may be torn apart during and after a traumatic experience. • The victim of trauma may be aware of a dire threat to life and limb, and yet feel nothing and be unable to act, or experience overwhelming fear for no discernable reason, be unaware of why she/ he is terrified and be paralyzed.

7. Traumatic stress leads to emotion dysregulation • Traumatic stress leads to extreme “survival in the moment” responses. These responses are quick and out of conscious control. • One author has described responses to traumatic stress as “the hostile takeover of consciousness by emotion.”

8. ‘Low road’ vs. ‘high road’ information processing • The ‘low road’ goes through the amygdala, a brain structure that prepares the body for an emergency response to threat. It’s activated by sensory cues and is without context. • The high road is slower, makes use of the prefrontal cortex and the temporal lobe memory system, brain structures which use the hippocampus. • ‘High road’ responses add context, make use of conscious memory and help to regulate emotion.

9. ‘High road’ responses add context • ‘High road’ responses add context, make use of conscious memory and help to regulate emotions.

10. The Four R’s (1) • Regulated – calm, focused, attentive, curious and responsive • Revving – sense of threat, struggle to remain calm, sense of disorientation, escalation of fear/anger • Re- experiencing – flooded with feelings and sensory experiences associated with trauma

11. The Four R’s (2) • Re –experiencing (cont.) – disoriented as to time and place, loss of emotional control, fight, flight or freeze reactions • Reconstituting – transition to a regulated state, may require sleep or extensive comforting, often accompanied by shame.

12. Understanding PTSD- West Wing episode • PTSD – invasive experiences and feelings, for example flashbacks or nightmares • Numbing • Dissociation • Hyper arousal, e.g., startle response, sleep disturbances

13. Flooding of consciousness vs. closing down • The four main symptoms of PTSD divide between the flooding of consciousness with sensory experiences and intrusive memories, or shutting down awareness.

14. Other common PTSD symptoms • Self destructive or reckless behavior • Somatic complaints • Shame, self loathing • Grief • Hopeless/helpless/ loss of efficacy • Feeling permanently damaged, beyond healing

15. Other common PTSD symptoms (2) • Loss of religious faith and belief in the goodness of human beings • Dysfunctional beliefs re the social milieu • Hostility, rage; impaired intimate relationships • Inability to feel “grounded” in body or mind • Impaired sense of physical balance

16. Dissociation • Dissociation is standing apart from oneself as an observer during terrifying experiences. • Deborah Gray, a trauma expert, describes dissociation as a “developmental catastrophe” that undermines the capacity for active responses to threat.

17. Extreme Strategies • Trauma victims sometimes resort to extreme strategies to cope with fear and suffering: • Drug/alcohol abuse • Violence/ revenge • Self mutilation • Apathy/ despair

18. Trauma and depression • The most common mental health condition resulting from trauma is depression. According to Judith Herman, “every aspect of the experience of prolonged trauma works to aggravate depressive symptoms.”

19. Trauma and depression (2) • According to Judith Herman in Trauma and Recovery: “The chronic hyper-arousal and intrusive symptoms of PTSD fuse with the vegetative symptoms of depression, producing .. the survivor triad of insomnia, nightmares and psychosomatic complaints.”

20. Trauma and depression (3) • Herman continues “ the dissociative symptoms of the disorder merge with concentration difficulties of depression. The paralysis of chronic trauma combines with the apathy and helplessness of depression. And “the debased self image of chronic trauma feeds the guilty ruminations of depression.”

21. Disempowerment • PTSD and depression work together to disempower persons with these conditions. • According to Herman, “the core experiences of psychological trauma are dis-empowerment and disconnection from others.”

22. Recovery • Recovery is based on empowerment and the creation of new connections. • According to Herman, “ recovery can only take place within the context of relationships; it cannot occur in isolation.”

23. Mood disorders may be transient • Recovery from mood disorders such as depression is common. Treatment is not always required. • However, some people who experience chronic depression do not recover without treatment.

24. Three Stages of Recovery • Herman views recovery from chronic trauma as having 3 stages: (1) establishing safety • (2) remembrance and mourning • (3) reconnection with others and the community

25. Cognitive Behavioral Trauma Treatment • Common elements of CBT include: • Creating safety • Helping victims self soothe and calm down • Developing a trauma narrative • Strengthening supportive relationships

26. Body Work • Recent innovative thinking regarding therapeutic practices has emphasized physical activities such as dance or massage and mindfulness exercises such as conscious breathing and meditation.

27. Creating inner strength • Calming the mind and finding refuge in bodily states of well being is a pathway to healing. • See Bessel Van der kolk’sThe Body Keeps the Score • Lunch

28. Trauma informed practice • Caseworkers, caregivers and other professionals will be interested in more than managing children’s behavior through praise, other types of rewards and negative reinforcement.

29. Trauma informed practice (2) • Children’s beliefs, expectations, emotion regulation, self awareness and resilience will be major concerns.

30. Quality of caregiving • Following trauma and/or severe neglect, the most important factor in children’s recovery is the quality of caregiving. • Emotionally responsive caregiving helps children use caregivers to calm down.

31. Emotion regulation • According to Saxe, et al, a key job of infants is to attain control over the “switches” between emotional states so that a more desired state is maintained for longer periods of time. • The parent’s role is to help the infant transition from less desired states to a calm regulated state through physical contact, reassurance, concern, redirection, etc.

32. Emotion regulation (2) • After hundreds or thousands of instances of caregivers helping young children to calm down, children learn how to self soothe. • However, “in situations of family trauma, or abuse and neglect, the parent on whom the child depends is either causing the distress or ignoring it.”

33. Trauma and severe neglect • Trauma associated with violence and physical threats and severe chronic neglect have similar consequences. • Story from The Boy Who Was Raised As A Dog

34. Lessons from The Boy Who Was Raised As A Dog • Initially, Perry does something other medical experts in the ER had not done, i.e., takes a careful early history of the child’s caregiving arrangements. Perry discovers that the child had spent much of his early life in a dog cage. • Perry engages the child by “joining to need,” i.e., modeling eating a muffin with pleasure.

35. Lessons (2) • Perry uses structure, which he calls “patterned repetition,” to create a sense of safety for the child. • The child makes rapid developmental progress because he has a vital developmental asset, i.e., nurturing caregiving in the first year of life.

36. Meltdowns • The vulnerability to “meltdowns” is a disability which can lead to failure in school, social isolation and incarceration during adolescence. • Trauma informed care will be organized around the need to reduce stress reactivity and angry outbursts that threaten others.

37. Children’s use of caregivers • Babies and toddlers need to use caregivers to calm down, a process that is difficult for abused and neglected children. • Caregivers should reach out with kindness and concern to children who do not turn to them for help when hungry, in pain, sick or frightened. Stoicism in young children is an indicator of development gone wrong.

38. Conscious breathing • Early childhood education programs have begun to use conscious breathing to help children calm down.

39. Emotional Literacy • As children reach K-12, caregivers and educators can teach emotional literacy, i.e., self awareness by inquiring of children about the 3 A’s at the time of a meltdown: • “What were you aware of when you became upset?” ; “What were you feeling?” “What were you doing?”

40. Connecting the Dots • Caregivers and teachers can help children understand their emotional reactions by sharing a narrative: • You felt I was angry at you and was going to let the other kids take your things, and then when you cried, people ignored you. That must have felt bad.

41. Executive Functioning • Complex trauma impairs the development of executive functioning skills, i.e., the ability to focus attention, control impulses, calm down and carry out plans. • Trainer shows 5 minute video of The Marshmallow Test. This test has proven to be predictive of academic success.

42. Resilience • Resilience is the capacity to withstand bounce back from adversity. Ann Masten has provided a short list of resiliency factors: • Capable caregiving and parenting • Self regulation skills • Motivation to succeed

43. Resilience (2) • Other resiliency factors include: • Self efficacy, active coping style • Faith, hope, belief • Effective schools and communities • Effective cultural practices

44. Resilience is Common • Resilience is common, and seems to depend on a handful of vital developmental assets. • Children who have talents that bring them positive social recognition are more likely to be resilient following trauma. • Neighborhoods with a high degree of collective efficacy build resilient children.

45. Engagement and Empowerment • Many parents with open child welfare cases have trauma histories, both in childhood and as young adults. • These parents often have co-occurring substance abuse and mental health disorders, and they are usually poor, often destitute.

46. Trust • Trauma victims are likely to have difficulty trusting caseworkers and other professionals. Resistance to offers of help is common.

47. Moralistic Judgment • Filthy homes, co-occurring disorders and poverty combined with pervasive neglect leaves parents vulnerable to the moralistic judgment of the community. • Helpers should substitute curiosity regarding how parents came to be in their current condition for moral judgment.

48. Trustworthiness • Caseworkers often have to demonstrate that they are trustworthy before parents will work with them. • Trustworthiness includes respect, honesty, fairness, accessibility, keeping promises and a concern with a family’s concrete needs.

49. Join to Need • The first rule of engagement is to “join to need” regardless of age, IQ, or other characteristics of trauma victims. • Needs are often basic and easily identifiable, but not always. Attention and interest are indicators of need.

50. POC Survey • A 2009 POC survey of several hundred birth parents with open child welfare cases found that birth parents and caseworkers have different ideas about what parents and families need. • Birth parents listed concrete resources such as food, clothing, etc. as their most important needs, while caseworkers listed behavioral health needs such as mental health treatment, or DV services.