Addressing Invisible Wounds: Helping Students Manage Trauma & Achieve Success In College

1. Addressing Invisible Wounds: Helping Students Manage Trauma & Achieve Success In College College campuses who are “Trauma informed” can help victims manage trauma symptoms and succeed in post secondary education. ~ Roger P. Buck, Ph.D.

2. Six Goalsof this Presentation • 1. Define and understand the concept “trauma informed”. • 2. Explore complex variables associated with normal human responses to traumatic events and their potential long-term impact on the individual. • 3. Identify three specific categories of trauma, the associated traumatic events and unique characteristics that impact traumatic responses and symptom development. • 4.Learn specifics about military trauma and its potential impact on student veterans and their academic success. • 5. Identify positive proactive supports that help traumatized individuals. • 6. Considering the Adverse Childhood Experiences (ACE) study and other trauma research: create a clear and concise trauma informed protocol for faculty and staff (campus-wide).

3. Goal 1: Trauma Informed? • What is “trauma informed”? • Why is it important to understand trauma? • How does being trauma informed enhance my ability to provide services to students? • Does being trauma informed actually help in producing better outcomes for students with significant trauma histories? Trauma occurs in all walks of life Education and Awareness is key

4. What is Trauma Informed? • All supports and interventions are based on the recognition that symptoms exhibited by survivors are directly related to the traumatic experience. • These experiences are the cause of many mental health, substance abuse and behavioral health problems. • Understanding trauma and the human responses associated with that trauma are key to improving program effectiveness, educational success, individual adjustment, transition success and/or recovery.

5. Why A Trauma Informed Approach Matters • Establishment of the National Center for Trauma-Informed Care. (www.mentalhealth.samhsa.gov/nctic) • Improvement in program effectiveness through evidence based best practice/trauma informed principles. • Across all areas of society: Mental Health Systems, Criminal Justice, Substance Abuse, Victims Assistance, Education, Primary Medical Care etc. • Childhood trauma is rapidly becoming recognized as a public health issue due to the lifelong negative effects associated with early trauma experiences (Adverse Childhood Experiences “ACE” study).

6. Examples of Being Trauma Informed • Understanding the immediate and long term impact that campus violence has on a student, faculty and staff. • Understanding that privacy and respect are more effective than seclusion or restraint for those traumatized victims in residential care facilities (re-traumatized). • Recognize the long term negative impact early childhood trauma experiences causes on child development. (depression, personality disorders, antisocial behavior etc). • Understanding that military war veterans must learn to cope with a myriad of physical, cognitive, emotional, behavioral and spiritual/existential (PCEBS) symptoms that plague them daily.

7. How you and your campus can benefit • Enhanced awareness and sensitivity of the issues and concerns that veterans and other trauma victims bring to campus will increase your ability to effectively serve and respond to their special needs or provide added accommodations. • Creating an environment with compassionate, empathic and aware faculty and staff will foster internal support networks that potentially enhance performance and retention of traumatized students. • Awareness of other “appropriate” professional supports (both internal and external to the institution) that you can refer individuals to will go a long way in retaining traumatized students with additional needs.

8. Trauma Informed campus: Does it really help students succeed in secondary education? • FACT: Those with chronic histories of domestic violence, physical and sexual abuse and other trauma experiences often develop • Co-occurring disorders such as chronic health conditions • Substance abuse • Eating disorders • HIV/AIDS • Criminal justice involvement Trauma-Informed Trauma-Specific interventions

9. Trauma informed campus: Does it really help students succeed in secondary education? • FACT: Military combat veterans are permanently changed by traumatic war experiences that potentially cause Physical, Cognitive, Emotional, Behavioral, and Spiritual (PCEBS) symptoms to develop Trauma Informed FACT

10. Trauma informed campus: Does it really help students succeed in secondary education? • FACT: Acute trauma experiences will make an immediate impact on the victim and PCEBS symptoms will develop • Most people (80%) will successfully adjust on their own through resilience and social supports within approximately 3 months (Depending on intensity, severity, type of trauma, individual factors, social supports and other factors) FACT: Chronic (long term or repeated exposure to danger) trauma experiences will have a cumulative impact on the individual causing more severe PCEBS symptoms and other more holistic effects ACUTE TRAUMA CHRONIC TRAUMA

11. Goal 2: Explore the Complex Anatomy of Trauma Responses • Individual characteristics • Nature of the event/events • Social supports • Psycho-physiology Factors that determine trauma responses Factors that determine trauma responses

12. Five Primary Areas of Trauma Research • 1. The specific type of traumatic event. (war, rape, domestic violence, natural disasters) • 2. The individual’s characteristics. (Age, gender, culture, previous trauma, mental illness) • 3. Environmental supports. (Social support systems – family, friends, shared experiences group) • 4. Treatment/intervention strategy effectiveness. • 5. Psycho-physiological aspects of trauma responses.

13. Nature of the crisis event • Single event vs. recurring • Solitary vs. shared experience • Presence of loss factor • Separation from family members • Trusted family as perpetrator (betrayal) • Death of family member Nature of the crisis Nature of the crisis

14. Nature of the Crisis Event • Loss of familiar environment • Loss of status or body function • Physical injury/pain • Presence of violence • Element of stigma • Presence of life threat Nature of the crisis Nature of the crisis

15. Individual Characteristics • The age/developmental stage • Pre-crisis adjustment • Past experience with crisis • The gender of trauma victim • Moral/spiritual beliefs • Cultural background • Cognitive level • Biology Individual Characteristics Individual Characteristics

16. Individual characteristics • Perception/meaning of crisis event • Previous behavioral health issues • Physical disability • Subjective world view or interpretation style • Personality type Individual Characteristics Individual Characteristics

17. Factors in the Support System • Nuclear family • Extended family • School • Friends • Peers • Local community • Supportive others • Non-supportive others Support system Support system

18. Psycho-physiology • Physiological responses to stress are well documented in the literature • Individuals with PTSD show a variety of changes in memory, emotion, attention and concentration • Individuals with PTSD experience changes in brain structure, chemical functioning that impacts memory, emotions and executive thought processes Psycho-physiology Psycho-physiology

19. Specific Responses to Traumatic Events (ACUTE RESPONSES) • Acute responses occur during and immediately following crisis events. • These are normal responses to abnormal events. • The duration of these symptomatic responses are usually short lived lasting just a few days up to approximately 3 months. • Symptoms may vary and persist over a longer period of time depending on the type event, individual factors and supports in the environment. Acute Trauma Acute Responses

21. Acute Responses • There are five general categories of acute responses (P.C.E.B.S.) (refer to handout): • A. Physical responses • B. Cognitive responses • C. Emotional responses • D. Behavioral responses • E. Spiritual responses

22. Examples of Acute Trauma • Natural disasters (tornado, flood, fire) • Man made disasters (plane or car crashes, bridge collapse, building fire) • Criminal victimization (campus violence, murder, rape) Acute Trauma Acute Responses

23. Natural and man-made disasters are usually acute traumas

24. Chronic Trauma

25. Examples of Chronic Trauma • Long term trauma experiences to consider: • Long-term domestic violence (adult) • Long-term severe physical abuse (adult) • Long-term severe sexual abuse (adult) • Childhood severe domestic violence, physical abuse, sexual abuse and neglect • Repeated tours of military duty in a combat zone • Prostitution Brothels • Concentration camps • Prisoner of war camps

26. Additional Chronic and Acute Trauma Experiences to Consider • Trauma Survival and Disability • Elder Abuse • Criminal victimizations • Aftermath of homicide and/or suicide • Racial and Ethnic Intolerance • Sexual and Gender Prejudice and victimization • Community based violence • School violence, bullying, and trauma • Workplace bullying, harassment, and violence • Natural disasters (prolonged or multiple) • Genocide, Ethnic conflict and political violence • Impact of war on civilian populations • Other Chronic and Acute Trauma Chronic and Acute Trauma

27. Chronic Nature of Responses (Physiological) • Due to the chronic nature of the trauma the following potentially occurs: • Central Nervous System: • Brain memory centers (amygdala, hippocampus) increased reactivity to stimuli with potential for structural brain damage manifesting in: increased heart rate, blood pressure and anxiety responses such as panic, mood disturbance, tremors, nervousness, agitation, sleep disturbance, hyper-vigilance, and heightened memory and thought processing. • CNS may cause re-experiencing events • CNS may result in avoidance behaviors • CNS may cause prolonged hyper-arousal which ultimately results in distraction, confusion, attention deficits, concentration inconsistency, memory lapse and memory processing/recall difficulties

28. Chronic Effects of Trauma • P.C.E.B.S. – Will be similar to the Acute trauma responses but lead to labeling or diagnosing of the following: • Post Traumatic Stress Disorder (PTSD). • Depressive Disorders. • Various Anxiety Disorders. • Substance Abuse Disorders

29. Additional Diagnoses and Disruptive Behaviors • Attention Deficit • Bipolar disorder • Sleep disorders • Personality disorders • Anti-social behaviors • Criminal behaviors (Domestic violence, child abuse, workplace violence, driving infractions etc.) • Traumatic Brain Injury Symptoms

30. Chronic Trauma • Additional Issues: • Person repeatedly abused is often mistaken as someone who has a “weak character” • Survivors of chronic trauma are often misdiagnosed as Borderline, Dependent, or Masochistic personality disorder. • Survivors who are “faulted for their symptoms” as a result of victimization are unjustly blamed. Chronic Trauma Chronic Responses

31. Chronic trauma • Avoid talking and thinking about trauma • Alcohol and substance abuse to avoid nightmares/night terrors, sleeplessness and numb feelings • Self mutilation and other forms of self harm social isolation • Suicide More complex symptoms Isolation both physical and emotional

32. Goal 3: Identify three specific categories of trauma and the associated trauma events • 1.Trauma and Loss, Vulnerability and interpersonal violence • 2. Intolerance and the Trauma of Hate • 3. Community Violence, Crisis Intervention, and Large Scale Disaster

33. Responses unique to three specific types of traumatic experiences • Type I: Trauma of Loss, Vulnerability, and interpersonal violence: • Issues of loss and grief • Trauma survival and disability • Sexual trauma • Childhood trauma • Adolescent trauma • Adult trauma • Intimate partner violence • Elder abuse • Criminal victimization • Aftermath of homicide/suicide • Type 2: Intolerance and trauma of hate: • Racial and ethnic intolerance • Sexual and gender prejudice and victimization Type 3: Community Violence, large scale disaster: School violence Work and campus violence Natural disasters • Political violence • War impact military and civilian Type I, II, III Trauma Type I, II, III Trauma

34. Type I: Trauma of loss, vulnerability and interpersonal violence • Issues of loss and grief • Survival and disability • Sexual trauma • Life stage trauma: childhood, adolescent and adult • Intimate partner abuse • Elder abuse • Criminal victimization • Aftermath of homicide or suicide Type I Trauma Type I Trauma

35. Trauma of Loss, Vulnerability, and interpersonal Violence Stage theory suggests: loss leading to grief may include denial, numbness, separation anxiety, despair, and disorganization Struggles with “meaning making” to resolve grief or making sense of senselessness Restoration orientation may not occur easily - unable to create new relationships Disenfranchised Grief the grieving individual doesn’t receive social support from others necessary for effective adjustment Type I Trauma Type I Trauma

36. Disenfranchised grief • Disenfranchised Grief includes grief not recognized, validated or supported by the social world of the mourner • Grief where relationship is not recognized such as extramarital relationships, gay and lesbian relationships, other relationships that lack social sanction • Grief where loss is not acknowledged by societal norms as “legitimate” loss such as abortion, pet loss, amputation, others not worthy of sympathy • Grief where griever is excluded such as children, elderly, developmentally disabled and others who are believed to not really experience grief • Circumstances of death cause stigma or embarrassment such as AIDS, crime, alcoholism

37. Ambiguous Loss Two types of disenfranchised grief • Physically present but psychologically absent–loved one with Alzheimer’s disease or traumatic brain injury • Physically absent but psychologically present – someone is kidnapped or missing in action in war • Note: Social supports are confused and perplexed about sympathy expression • Confusing because it is unclear how one is to adjust to them • Physically present with no death suggests premature to grieve • Physically absent suggests to grieve is to give up hope of return of missing person • Uncertainty means adjustment cannot occur • Rituals are not available nor are social supports • Grief is unending as uncertainty drags on with no resolution Type I Trauma Type I Trauma

38. Type I trauma: Trauma Survival and Disability • Disability trauma is profoundly distressing. • Two types of disability/impairment: congenital and acquired. • Theory and research based literature is limited. • Lack of access to health and rehabilitation services, education, employment and high cost of medical care hinders ability to fully participate in society • Persons with an impairment become a person with disability (PWD) due to societal, systemic and environmental barriers. • Four dimensions of the Multidimensional model: impairments, activity limitations, participation restriction and environmental barriers, and facilitators. • PWD face attitudinal, environmental and institutional disability discrimination, which may last longer and feel worse than the physical trauma of loss of a limb, sight, hearing or other physical impairments.

39. Type I Trauma: Trauma Survival and Disability (Cont’d) • Attitudinal: Stereotypes and stigma exists and creates obstacles such as – women with disabilities often experience abuse which causes worse trauma than the physical disability itself (raped in their homes, communities and institutions – two times more likely to be sexually or physically assaulted or exploited than non-disabled – seen as easy targets by perpetrators) • Environmental: Two types of environmental barriers include physical environment inaccessibility (building or structure access) and social inaccessibility (limited access occurs when families don’t include the person due to certain disabilities also public health information that is not available to hearing or visually impaired ie., AIDS/HIV awareness and condom marketing campaigns)

40. Type I Trauma: Trauma Survival and Disability (Cont’d) • Institutional: Legal discrimination such as not being permitted to marry or have children, exclusion from employment or school, and non-compliance with fair voting practices • Trauma linked to disability discrimination: • PWD experience a stress pileup from accumulation of a lifetime of traumatic events • PWD may be vulnerable due to childhood trauma • PWD experience stressors in adulthood leading to depression, substance abuse, memories of previous traumas and PTSD • PWD (children and young adults of college age) may be susceptible to attachment trauma which includes physical abuse, sexual abuse, rejection, psychological abuse (cruelty), emotional neglect (unresponsiveness to emotional states), and physical neglect (failure to provide for basic needs)

41. Type I Trauma: Sexual Trauma • Sexual violence creates a plethora of mental health problems including but not limited to: • Post Traumatic Stress Disorder (PTSD)(17%-65%) • Anxiety and panic disorders • Depression • Substance abuse • Normal and expected reactions (refer to PCEBS handout) • Responses are individual and a complex interaction between the individual and their environment • Other variables to consider: perpetrator assault characteristics ie., spousal, partner, date, acquaintance, stranger and incest (over 50% report knowing the perpetrator) also was alcohol or drugs involved (15% rapes involved GHB slipped to victim)

42. Type I Trauma: Sexual Trauma • Research studies on re-victimization concentrate on: • Interpersonal factors such as high risk activities that increase exposure to potential perpetrators (binge drinking, two or more current sexual partners) • Intrapersonal factors including psychological distress, relationship insecurity, low self-esteem, self-blame, low self-efficacy, use of avoidant coping styles, and deficits in risk appraisal and situational coping (avoidant coping strategies: denial, numbing or detachment increases PTSD symptoms over time by avoiding memories and feelings associated with trauma event) • These factors reduce an individual’s ability to assess, assertively cope with and escape from potentially dangerous situations and reinforces more aggressiveness by the perpetrator

43. Type I Trauma: Life-stage trauma • Early Childhood Trauma • Adolescent Trauma • Adult Trauma Life-Stage Trauma Life-Stage Trauma

44. Type I Trauma: Life Stage Trauma • Early Childhood: • Critical time for brain development (brain is 75% adult size by age 2) • Positive early experiences are associated with increased synaptic connections • Negative, adverse or traumatic early experiences are associated with decreased synaptic connections Early Childhood Early Childhood

45. Type I Trauma: Life-Stage Trauma • Early Childhood: • 3 phases of attachment: • 1. orientation and signals with limited discrimination of figure (8 weeks) • 2. orientation and signals toward one or more discriminated figure (12 weeks) • 3. maintenance of proximity to a discriminated figure (12 weeks to 18 months) • Consistent and sensitive caregiver responses are positively associated with creation of a secure attachment (safety and security is established through successful attachment & gaining confidence) • Inconsistent, adverse, and unpredictable responses result in formation of insecure attachment characterized as (avoidant, ambivalent, resistant, disorganized, or disoriented) Early Childhood Early Childhood

46. Type I Trauma: Life-Stage Trauma • Other developmental competencies (infant to pre-school) • Begin gross motor regulation • Self regulation (eat & sleep) • Development of trust • Language • Gross motor development • Autonomy • Continued self-regulation • Egocentrism • Cause-effect thinking • Initiative • Trauma in Early Childhood • 50% of children who experience maltreatment (physical, sexual, emotional abuse and neglect) are younger than age 7 • Caregiver is the source of both support and threat resulting in a child with approach - avoidance relationship and disorganized attachment • Witnessing domestic violence resulted in numbing, increased arousal, fear, aggression, re-experiencing and hyper-arousal Early Childhood Early Childhood

47. Type I Trauma: Life-Stage Trauma • Trauma in Early Childhood: • Repeated exposure to threatening and traumatic situations results in decrease size of developing brain. • Inhibits parts of the brain responsible for learning, managing behavior and emotional reaction, social reasoning and social skill development. (essential for success in school, employment and relationship) • Causes physiological changes: increases anxiety/depression • Strong relationship between childhood trauma and: • Subsequent mental disorders • Higher suicide rate • Mood disorders • Substance abuse • Visual, auditory and tactile hallucinations • Other psychotic symptoms may also be found in trauma survivors Early Childhood Early Childhood

48. Type I Trauma: Life-Stage Trauma • Trauma in Early Childhood • Infants and children who witness violence show excessive irritability, immature behavior, sleep disturbances, emotional distress, fears of being alone and regression in toileting and language also increased likelihood of arrest as a juvenile and adult. Early Childhood Early Childhood

49. Type I Trauma: Life-Stage Trauma • Adverse Childhood Experiences (ACE) Study: • Shows 10 different types of traumatic or violent childhood experiences contributed to mental illness, adult health problems, health risk behaviors (smoking, substance abuse, obesity etc) higher use of health care services. • For other research refer to the National Child Traumatic Stress Network (www.nctsn.org) • Adverse Childhood Experiences (ACE) Study: • Those with 4 or more of the 10 traumatic experiences demonstrate:twice as likely to smoke cigarettes, • 5 times more likely to use illicit drugs • 7 times more likely to be alcoholic • 11 times more likely to use injection drugs • 19 times more likely to attempt suicide • Vulnerable to early mortality due to health problems • Suffer more chronic health problems diabetes, heart disease, and cancer ACE Study ACE Study

50. Type I Trauma: Life-Stage Trauma • Adolescent Trauma: • Approximately 4 million adolescents have been victims of a serious physical assault • Nine million have witnessed serious violence during their lifetime • School age children and adolescents experience the full range of post trauma stress reactions that are seen in adults • Adolescent responses to Trauma: • When trust is damaged by adults failing to protect them the adolescent’s basic worldviews and foundational aspects of relationships change • Inability to trust caretakers, or God makes it difficult to feel safe Adolescent Trauma Adolescent Trauma