Trauma Informed Care and At Risk Adolescents Alabama Council of Community Mental Health Boards

1. Trauma Informed Care andAt Risk AdolescentsAlabama Council of Community Mental Health Boards Dr. Lee A. Underwood May 14, 2008

2. What is Trauma? Quote: Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our Light, not our darkness, that most frightens us. We ask ourselves, who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you NOT to be? You are a child of {God}. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won’t feel insecure around you. We were born to manifest that which is within us. It is not just in some of us; it is in everyone. And as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others. --Marianne Williamson, Return to Love

3. I. Purpose To identify practical steps involved in getting providers better informed in gender and trauma-informed strategies and interventions to assist youth in breaking the cycle of sexual retraumatization and other sabotaging behaviors

4. II. Rationale To improve awareness that the essential characteristic of trauma is that the victim is rendered powerless by overwhelming force To realize that traumatic events overwhelm normal human adaptations to threats To understand that when escape is impossible, the normal system of defenses become disorganized

5. Rationale • To realize that the resources that usually work in tandem during crisis become fractured • To know that certain types of traumatic experiences increase likelihood of psychological damage • To reiterate that providers must become trauma-informed care providers

6. III. Benefits of Being Trauma Informed Increase overall sensitivity to the needs of youth Empowers youth and increase staff/youth sensitivity Builds confidence with communication & culturally sensitive skills Expands one’s view of the world & life experiences Reduces barriers to cross-cultural interactions Improves observational and clinical skills

7. IV. Overview of Modules Module 1: Exercise #1: Case Study with Avie Module 2: Relationship Centered Issues Module 3: Trauma Care & Reactions Module 4: Tips for Engaging Adolescents

8. Exercise #1: Case Study with Avie • Avie is about to be released from a facility to Aftercare. While in the facility she made a personal decision to complete high school and someday attend college to become an elementary school math teacher. • She has always been extremely bright but lost her enthusiasm for school and her family when she started to hangout with friends satisfied with street –life. It’s hard to say when Avie decided that her past life of drinking, drugs and sexual promiscuity left her feeling lonely and empty. While in the facility she started asking questions like,” Is this all there is for me?” “Is there anything more?” And, “Does someone like me really deserve better?” While Avie fears having to face her old friends, she believes that she has the courage to follow her new dream. • Avie is excited about facing the challenges of a brighter future for herself. What do you think are some of the challenges that she will have to face when she is released? Explain.

9. Exercise #1: Case Study with Avie • What do you think that Avie means when she says that she lost her enthusiasm for school and her family when she became satisfied with street-life? What makes it difficult to be satisfied with family, school success and street-life? Explain. • What are some of the problems you might have to overcome to be successful someday? Even though everyone’s problems are different in some way, most people want many of the same things for themselves when they grow up. What are those things? Are they worth having? Why/ Why not. Explain. • Avie is at the point in her life where she believes that the drinking, drugs and sex leave her empty. What do you think she might mean by that? How could something that sound like so much fun at one point in your life leave you empty later on? Explain. • Avie is asking herself some important questions. Think through each of these questions separately and discuss what they mean. “Is this all there is for me?” “Is there anything more?” Does someone like me deserve better?

10. Exercise #1: Case Study with Avie • Would you say that for some reason Avie’s thinking has changed for the better? If so, that must mean that although Avie at first saw nothing wrong with her thinking, she later realized that her thinking was in fact self destructive and left her empty. Is that statement true or false? Explain. • Make an imaginary list of all the things that Avie might have initially told herself (or said out loud to friends) that made her sexual, drinking and drug behaviors okay to do in her head. • Make an imaginary list of all the things that Avie might have told herself (or said out loud) after realizing that her sexual, drinking and drug behaviors were no longer in her best interest. • Although the circumstances of Avie’s situation might be different than yours, how might this situation apply to you? Explain.

11. Prevalence Rates • According to the U.S. Census concerning data on divorce, child custody and child support, 50% of all white children and 75% of all black and brown children born in the last two decades are likely to live for some portion of their childhood with only their mothers.

12. Prevalence Rates • “Children growing up in homes with absent fathers are more likely to fail or drop out of school, engage in early sexual activity, develop drug and alcohol problems, and experience or perpetrate violence in greater numbers than children growing up in homes with fathers present.” Benson Cooke

13. Prevalence Rates Boys & Girls • Girls are 3-4 times more likely to be victims of sexual abuse than boys. • Girls are more likely to be victimized physically, and sexually by a family member. • Victimized girls are more likely to present serious mental health symptoms.

14. Prevalence Rates Cont’d Boys & Girls Cont’d • Girls have higher prevalence rates of depression, anxiety, PTSD, eating, sleeping, somatization and borderline personality disorders and features. • Girls have higher rates of co-occurring mental health and substance use rates. • Girls are more likely to run away from home to escape violence.

15. Prevalence Rates Cont’d Boys & Girls Cont’d • Boys and girls respond differently to abuse. Boys generally become aggressive. • Girls tend to internalize the injury, sometimes becoming aggressive and other times becoming depressed, or both at the same time. • Boys tend to minimize their negative emotions.

16. Prevalence Rates Cont’d Boys & Girls Cont’d • Boys tend to have disruptive relationships, overcompensate for control and severe their emotions. • Initial treatment for girls should focus on empowerment. • Initial treatment for boys should focus on relationships and on expanding their emotional repertoire.

17. Module 2 Relationship Centered Issues

18. The Relationship Focused Female Offender • She may feel guilty about not measuring up to her internalized standards. If so, conflict produced by the feelings of inadequacy and guilt may be internalized with consequent neurotic symptoms or acted out in anti-social behavior. • In addition to guilt over self worth, she may feel conflict over values. Or, without conflict, she may admire and identify with delinquent models, internalizing their delinquent values.

19. PERCEPTION OF THE WORLD

20. Internalized Standards • She has typically internalized a set of ideals, standards and values by which she judges her own and others’ behavior. • Consciously feels remorseful, inadequate or guilty when she does not measure up to these standards or shows some evidence of discomfort or conflict regarding standards.

21. Differentiates herself from the Stereotyped Norm • Has a sense of self that she recognizes is different from the conventional or stereotyped standard. • Sees herself and wants others to see her as non-average, unique, different from others her own age. • Begins to evaluate herself along certain dimensions as better or worse than others.

22. Status Concerns • She has status and prestige concerns. • Wants to get ahead and make something of herself. • Wants recognition from those she admires – recognition of her special or different qualities; i.e., her interests, potentialities or accomplishments.

23. Identification • Tries to model self after those she looks up to, whom she sees as being special or accomplished – wanting to be like them in actions, attitudes or attributes. (In a negative identification pattern, may wish to be just the opposite of a non-admired model). • Goals and plans influenced by those she admires (or, less frequently, by those she hates or for whom she has contempt).

24. Some Perception of Causal Factors • Some perception of the factors which impinge on her both internally and environmental and some perception of the interplay between these forces. • Potential for considerable insight into meanings, dynamics, and cause and effect.

25. Some Perception of Needs and Motives in Self and Others • Shows some ability to look for or understand reasons for behavior. • May see her actions and those of others as motivated by feelings and past events. • Able to perceive feelings and motivations which are not just like her own. • May be only poorly able to describe this perception, especially if of low intelligence or culturally deprived.

26. Some Ability to Look into the Future • Able to think about the future with personal meaning • Plan in relatively realistic ways (including certain impossibilities for herself), even though distortion may be present.

27. Some Ability to Look into the Future • May worry or plan for the future (even though she may not always be able to carry through on plans). • She can perceive that self and circumstances can be different several years from now, and she can decide some of the possibilities. • Oriented toward goals.

28. Relationship Ability • Shows an ability to enter into two-way (reciprocal) relationships of more than just a dependency or supportive nature. • Able to relate with another person in terms of the individualized needs, feelings, standards or ideals held by themselves and the other person.

29. Concept of Accountability is Meaningful to Her • Typically able to assume some responsibility for herself and others. • May recognize the need to be responsible but may be unable to carry this out because of skill deficits.

30. Capacity to Delay Response to Immediate Stimuli • Because she can respond to stimuli that are not immediately present and because she can anticipate the way in which she may later judge her present actions, she shows some capacity to delay response to immediate stimuli.

31. Rigidified Guilt • Guilt based on past internalization of childlike perceptions of identification figure. Internalization of the “bad me”, and resulting “negative life script”.

32. Damaged Goods • Investment in maintaining “bad me” concept. Initially, worker may see primarily a defense against guilt – compensating “I am special” defenses and/or overlays of guilt about more recent inadequacies (non-achievement in school, inadequate social skills, inability to fill-in for absent parent, etc.)

33. Non-Self • May characterize aspects of her past and present behavior as non-self, not like her, and as incomprehensible to her, ego -alien.

34. Anxiety Regarding Self • Anxiety is not situationally determined but rather is constantly with her. Felt anxiety is typically related to perception of self as inadequate, to identification conflicts or to interpersonal difficulties.

35. Wants to Change in Order to Improve • Wants to be a better person, to hurt herself less, and/or to stop hurting others. May have plans for self-improvement or may be asking for help either to achieve new personality integration or to increase the efficiency or protective value of her neurotic mode of functioning.

36. Case Study Bobby, Does images of my face haunt your nightly dreams? Do you still hear my dreams or feel my bloody flesh? I hope so! I hope every night and day, you are haunted by a little five year with long blonde hair and a bruised body with tears streaming from her face. The girl you raped for a year—you killed her. You killed her innocence, you stole her happiness. Your face broke into her worst nightmare. I saw you and felt you all fucking night. Your sweat dripping your mustache scratching, your hands destroying your tearing and murdering.

37. Case Study Do you think you’re a man? I’ve hated you so long. My flashback stealing and destroying my life. But I’m over that. I forgive you. You’re nothing to me. Someday it will drive you insane. It will drive you to the point of desperation, like it did to me. I am free of your essence. I am clean of you. I’ve finally washed myself free of you. I won’t even get on the subject of how you affected my life. I lost my trust. Hate took the place of love. You did this. You locked me into my past. Well I found the key and I’m free. Melissa

38. Case Study Breakout Questions • If a youth gave you this letter and asked you to read it, what would be your response? • Please discuss and describe what you believe Melissa is attempting to share with you. • How would you go about processing the information without shaming Melissa? • Please describe at least five ways in which you would empower Melissa to break her cycle of sexual re-traumatization.

39. Module 2 Relationship Centered Issues Continued

40. WAYS OF RESPONDING TO THE WORLD

41. Delinquency as Part of the Neurosis • Delinquency may be the acting-out of a family problem, or a long-standing internal conflict - particularly a conflict involving the internalization of a parental or authority image. • Delinquent behavior has some private meaning and does not represent simply a material gain (or the gain is not the object of the act), or simply a response to cultural or peer pressure.

42. Selectivity in Friendships • If she has friends, there is some selectivity (other than coincidence) to her friendships. Relationships, when present, are with specific other person, as opposed to having someone to fulfill the friendship role. May be a social isolate.

43. Focuses on Reducing Immediate Anxieties • Consciously attempts to reduce anxiety by controlling the immediate situation -- through self-control, intellectualizations or superficial insights or helping others • Fearful of looking into life-long patterns of difficulties or fears

44. Building on Youth and Family Strengths

45. Envision and expect meaningful success with the female youth you work with on a day to day basis.

46. Support an adolescent in developing a meaningful and positive vision of the future.

47. Support and assist youth to understand and develop the strength of accountability for past delinquent behavior, including practical ways to give back or to make restitution beyond those that are required by a court.

48. Recognize positive leadership: reinforce how this asset may assist them in positive bonding to her community.

49. Maintain high standards of behavior and achievement – avoid lower standards because of stereotypes of what delinquents are, or are not capable of accomplishing.

50. Find out what interests inspire a female youth. Talk to them about this and devise practical ways to build bridges for their interest and their current circumstances.