Understanding Traumatic Stress

1. Understanding Traumatic Stress A Brief Overview

2. 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

3. Recognizing Trauma Part 1

4. What Is “Trauma”?

5. SAMHSA Definition Individual 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.

6. Three Types of Trauma

7. Prevalence Adverse 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

8. 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.

9. The Brain Cortex – Abstract thought, concrete thought, language Limbic System – Attachment, sexual behavior, emotional reactivity Mid-Brain – Motor regulation, arousal, appetite, sleep Brain Stem – blood pressure, heart rate, body temperature

10. 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

11. 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.

12. About “Fight or Flight”

13. 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)

14. 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

15. 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

16. 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

17. 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”

18. 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

19. 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?

20. Responding to Traumatized People Part 2

21. 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.

22. ARC Building Blocks Dev’tal tasks Executive functions Self-Dev’t & Identity Affect Identifi- cation Affect Modulation Affect Expression Caregiver Affect Mgmt Attunement Consistent Response Routines & Rituals

23. 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

24. The Still Face Experiment

25. Attachment Styles

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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?

36. 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?

37. Thank You! Questions, Comments, and Feedback welcome!