BEST TREATMENT PRACTICES FOR TRAUMA RECOVERY

1. BEST TREATMENT PRACTICES FOR TRAUMA RECOVERY

2. TRAUMA DEFINED • A traumatic event involves a single experience, or an enduring, or repeated events, that completely overwhelm the individual’s ability to cope or integrate ideas and emotions involved in that experience. • It involves a feeling of COMPLETE HELPESSNESS in the face of real or perceived threat to one’s life, or that of a loved one’s, to bodily integrity, or sanity. • There is frequently a violation of a person’s familiar ideas about the world and their human rights, putting the person in an extreme state of confusion, and insecurity. • Reactions: physiological and psychological.

3. POSSIBLE TRAUMATIC EXPERIENCES • Abuse: Physical, Emotional, Verbal, Sexual, Neglect, Abandonment • Violence (murder, rape, robbed, physically attacked) • The threat of violence or sexual abuse, or witnessing violence • Catastrophic events (hurricanes, earthquakes, volcanic eruptions, war or other mass violence) • Car accidents, plane crashes, fires

4. POSSIBLE TRAUMATIC EXPERIENCES • Paramedics, fire fighters and rescue teams experiences • Long-term exposure to conditions like parents who are substance abusers, having a parent incarcerated, poverty or milder forms of abuse such as verbal abuse can be traumatic. • Medical Procedures, Being diagnosed with a life threatening illness • Being Kidnapped, Held hostage • Combat • Battering Relationships, Being Stalked, Bullied, Harassed

5. It’s not the event that determines whether something is traumatic, but the individual’s experience of the event

6. CHILDHOOD TRAUMA & ABUSE

7. ABUSE STATISTICS • 1 out of 3 women will experience sexual abuse by the time they are 18 years old. (The Public’s Health) • 1 out of 5-7 men will experience sexual abuse by the time they are 18 years old. (childhelp.org) • 90% of sexual abuse victims know their perpetrator and 68% are abused by family members. (National Center for Child Abuse) • 90% of cases go unreported and untreated, as the symptoms of CSA are often misdiagnosed and unappreciated. (The Public’s Health 2009) • Over 3 million cases of child abuse are reported each year in US. Those reports can have multiple children in them. (NCAS)

8. PYCHOLOGICAL AFFECTS OF ABUSE • PTSD Depression • Anxiety/Panic Failure to thrive • Agoraphobia/Phobias Rage • Irritability Mood Disorders • Substance Abuse Eating Disorders • Personality Changes/ Disorders Suicidal and Homicidal Ideation • Dissociative Disorders Self-Injury/Cutting • Negative Self-concept Abusive Partners • Obsessive Compulsive Feelings of Powerlessness

9. RELATIONSHIP ISSUES • Trusts too easily or does not trust at all • Difficulty communicating • Does not set boundaries or sets too many boundaries • Wants to be rescued • Isolation and withdraw • Sexual problems/promiscuity • Fear of abandonment • Fear of Intimacy • May be abusive or choose abusive partners • People pleasing

10. ACADEMIC ISSUES • Inability to concentrate • Lower test scores • Comprehension problems • Memory deficits • Peer relational issues • Communication problems • Attendance issues • Teen Pregnancy

11. POST TRAUMATIC STRESS DISORDER

12. PTSD SYMPTOMS • Intrusive re-experiencing of the trauma ● flashbacks, nightmares, triggers 2) Hyper-arousal ● Problems falling or staying asleep ●Difficulty concentrating or completing tasks ●Anger and irritability ● Startle response ● Hyper-vigilant ●Panic attacks, shortness of breath or chest pain 3) Avoidance of stimuli and numbing response ● Making efforts to avoid thoughts, feelings, conversations, people, or places that remind them of the trauma. ●Restricted range of emotions/Numbing of emotions ●Feeling detached from others ● Dissociation ● Substance Abuse ●Loss of interest in activities they used to enjoy

13. DISSOCIATION • Detachment from immediate surroundings • Detachment from physical or emotional experience • It is a disconnect between material in the conscious mind and material in the unconscious mind. • Adaptive Survival Skill can become maladaptive • Can be done consciously or automatically • It can become pathological and interfere with daily functioning

14. PTSD SYMPTOMS • Survivor’s Guilt • Rage • Depression and Grief • Anxiety and Panic • Shame and Fear • Trust Issues • Loss of appetite • Sexual dysfunction • Poor coping skills • Feelings of hopelessness

15. RISK FACTORS • Previous traumatic experiences, especially in early life • Family history of PTSD or depression • Being Female • History of physical or sexual abuse • History of substance abuse • History of depression, anxiety, or another mental illness • High level of stress in everyday life • Lack of support after the trauma • Lack of coping skills Mayo Clinic

16. PTSD TYPES Acute • Less than 3 months Chronic • Longer than 3 months Delayed onset • 6 months later Complex (Disorder of Extreme Stress) • Exposed to prolonged traumatic events, especially during childhood, such as childhood sexual abuse(severe and sustained) • Often have a personality disorder. • Long-term effect on adult functioning

17. DEVELOPMENTAL TRAUMA ● Trauma that is stressful that occurs repeatedly and cumulatively over a period of time, within specific relationships and context(child abuse) ● Domains of impairment: *attachment *biology *affect (emotional) regulation *dissociation *behavioral control *cognitive processes *self-concept

18. DISSOCIATIVE DISORDERS • Marked by a dissociation from or interruption of a person's fundamental aspects of waking consciousness (such as one's personal identity, one's personal history, etc.) • Most dissociative disorders stem from trauma. • Coping mechanism : the person literally dissociates himself from a situation or experience too traumatic to integrate with his conscious self. Types • Dissociative Identity Disorder (Multiple Personality Disorder) • Dissociative Amnesia • Dissociative Fugue • Depersonalization Disorder • Dissociative Disorder NOS Scales for this: Dissociative Experience Scale(DES), SCID-D, SDQ-20

19. TRAUMA AND ATTACHMENT • Trauma that happens in childhood at the hands of a caregiver is doubly destructive because it destroys the attachment relationship that the child would normally need to depend on to manage the trauma of the abuse. • The resolution of attachment issues is a central component of trauma recovery

20. TYPES OF ATTACHMENT Secure • Parent is aligned with the child and in tune with the child’s emotions, trustworthy, and reliable. • Adult is able to create and maintain relationships Ambivalent • Parent is inconsistent, unpredictable and sometimes intrusive parent communication • Adult is anxious and insecure, controlling, blaming, erratic, unpredictable, and sometimes charming Avoidant • Parent is unavailable or rejecting, and punitive • Adult avoids closeness, or emotional connection, distant, superficial relationships, critical, rigid or intolerant Reactive • Parent is extremely unattached or malfunctioning, and abusive • Adult cannot establish positive relationships, withdrawn, substance abuse Disorganized • Parents ignored, or did not see the child’s needs. Parental behavior was frightening or traumatizing. Often sexual, or physical abusive • Adult is chaotic, insensitive, explosive, abusive, untrusting, while craving security

21. SECURE ATTACHMENTS HELP US: • Feel safe • Develop meaningful connection with others • Explore our world • Deal with stress • Balance emotion • Experience comfort and security • Make sense of our lives • Create positive memories & expectations of relationships • Ability to rebound from disappointment, discouragement and misfortune

22. INSECURE ATTACHMENTS: • Unavailable or avoidant • Self-absorbed • Insecure • Disorganized • Aggressive • Angry • Distrusting of others • Lack of empathy • Clinginess • Trouble learning/Developmental delays • Lack of Self-control • Obsession with food

23. ADVERSE CHILDHOOD EXPERIENCE STUDYBY KAISER PERMENENTE 1995-1997 17,000 middle class insured individuals in the primary care setting Confidential Survey for the incidence of: Abuse: • Sexual, physical, verbal abuse Neglect: • Emotional neglect, physical neglect Household Dysfunction: • Household substance abuse • Parental separation and divorce • Incarcerated household member • Household member with a mental illness • Mother treated violently

24. ADVERSE CHILDHOOD EVENTS(ACE STUDY) (Kaiser Permanente) People with 4 or more ACE were at greater risk for serious health issues

25. ACE STUDY FINDINGS • Alcoholism and alcohol abuse Illicit Drug Use • Smoking Early Initiation of Smoking • Depression Suicide Attempts • COPD Ischemic heart disease (IHD) • Fetal death Health-related quality of life • Liver disease Obesity • Autoimmune Disease Increased risk for Cancer • Autobiographical Memory Disturbance Hallucinations • Risk for intimate partner violence Multiple sexual partners • Sexually transmitted diseases Unintended pregnancies • Early initiation of sexual activity Adolescent pregnancy

26. MEDICAL RISKS(The Public’s Health 2009) • Obesity Hypertension • Headaches Stomach Problems • Lowered Immune System Chronic Fatigue • MS, Lupus, Fibromyalgia Early hysterectomies • Gynecological issues Diabetes • Heart disease Substance Abuse • Sexual Disorders STD’s • Somatic complaints and Body aches MS, Lupus • Fibromyalgia Autoimmune Disorders • Increased Risk of Cancer Premature Death

28. HOW TRAUMA IMPACTS THE BRAIN

29. EMOTIONAL NERVOUS SYSTEM TWO PARTS OF NERVOUS SYSTEM Limbic System Autonomic Nervous System

30. Limbic System • Primary responsible for our emotional life • Helps with formation of memories • Arousal and hyper-arousal • Fight, Flight, or Freeze • It plays a central role in memory processing

31. Amygdala • Fear center or alarm system/Fight or flight • Stores highly charged emotional memories • After trauma can overreact(hyper-responsivity) • To remember a threat, generalize it to other possible threats and carry it out to the future. Imprints it • Explicit or unconscious memory Hippocampus • Plays a role in organizing memories. Explicit or Conscious Memory • Interacts with the amygdala during the encoding of emotional memories. • Encoding of context during fear conditioning • Stores memory of time and space; puts our memories into their proper perspective and place in our life's time line. • After trauma can shrink in size and diminish in functioning • Gets damaged in child abuse/ high stress (gaps in memory_

32. LIMBIC SYSTEM

33. AUTONOMIC NERVOUS SYSTEM: 1)PARASYMPATHETIC 2)SYMPATHETIC RESTRICTED ACTIVATED

34. Medial Prefrontal Cortex • Moral center, planning complex cognitive behaviors, personality expression, decision making, moderating correct social behavior-delaying gratification • Appears to be volumetrically smaller and is hypo-responsive(under) during symptomatic states Corpus Coliseum • Facilitates communication between the 2 hemispheres. • During trauma decreased blood flow and communication between hemispheres.

35. WHEN TRAUMA OCCURS • The brains main function is to get though the event. • The brain helps us survive by activating biological reactions involved in helping us mount that fight or flight response. • The sympathetic nervous system releases adrenaline, increases heart rate, pupils dilated, accelerated pulse which readies you to move in the fight or flight decision. • The brain actually lowers the chemicals released to help us with regular functions which means your parasympathetic nervous system energy is diverted to help you cope with what you need to do to survive. • Hormones are released to reign in the stress response to stop long-term damage to your body.

36. During the first 4 years of life 90% of a child’s brain develops through the experiences of that child. • The mind and the emotional content of the brain are created in the first few years of life through the attachment bond between the infant and the mother • Bruce Perry published a huge number of studies showing abnormal brain development following neglect and abuse of children including significantly smaller brains, decreased activity in their prefrontal cortex(the moral center/the restraint center/the maturity center.) • Depressed and angry mothers regularly produce insecurely attached infants who grow up be violent adults. The Bomb in the Brain (Freedomain Radio)

37. Abusive mothers who are depressed or angry the cortisol levels of both elevated in the mother and the child. If you are depressed or angry your cortisol levels are higher in both you and your child. The mother and the child are a system particularly for the 1st few years of life • Their hippocampus shrinks and they can have memory issues • The amygdala of insecurely attached children is larger and they have a greater surging of fight or flight, adrenaline and cortisol. • Their prefrontal cortexes are smaller so they are less able to control their fears and other irrational emotional reactions in interpersonal relationships. • Physical problem in the brain-fight and flight is strong and restraint is weak. The Bomb in the Brain (Freedomain Radio)

38. Ainesworth 100 studies over past two decades have shown that violence is the result of insecure early disorganized attachment • Violence and Crime-Bessel Vander Colk concludes people with childhood, abuse and neglect make up almost the entire criminal justice population in the United States. Suffered severe abuse. • Poorly integrated cerebral hemispheres- this poor integration and underdevelopment of the orbital frontal cortex is the basis for such symptoms as difficulty regulating emotions, and lack of cause and effect thinking The Bomb in the Brain (Freedomain Radio)

39. TRAUMA AND SUBSTANCE ABUSE

40. THE WAY WE USED TO LOOK AT SUBSTANCE ABUSE AND TRAUMA MENTAL ILLNESS SUBSTANCE ABUSE TRAUMA

41. THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE TRAUMA MENTAL ILLNESS SUBSTANCE ABUSE

42. THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE • Those who have been traumatized are at risk for substance abuse; and those who use substances are at risk for experiencing trauma. • 90 % of women who are addicted to alcohol were physically or sexually abused as children (National Trauma Consortium) • Victims of trauma are 4-to-5 times more vulnerable and therefore likely to experience alcohol or substance abuse than the general public. • 82% of adolescents in residential or inpatient programs have been a victim of sexual or physical abuse.

43. THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE • Escape • Numbing • Control • Distraction • Self-destructive • Feel powerful • Diminish shame and guilt • Protection • Acceptance • Increase or decrease hyper-vigilance/anxiety

44. BEST TREATMENT PRACTICES • Psycho-education(normalization of symptoms) * About Effects of Trauma, PTSD 2) Regulation *Trigger Recognition *Grounding, *Containment & Distancing *Guided Imagery/Calm Place * Breathing * Meditation * Yoga * Mindfulness * Journaling * Music * Developing a Support System

45. 3) Processing the Trauma ● Trauma Focused Cognitive Behavior Therapy (TF-CBT by J.A Kohen) ● Somatic Experiencing/Body Psychotherapy(SE , Peter Levine, Pat Odgen) ● Acceptance and Commitment Therapy(ACT by Steve Hayes, Kelly Wilson) ● Eye Movement Desensitization and Reprocessing(EMDR, Francine Shapiro) ● Emotional Freedom Technique(EFT, Gary Craig, Nick Ortner)

46. EYE MOVEMENT DESENSITIZATION AND REPROCESSING • Created by Francine Shapiro in 1987. • Bilateral stimulation through eye movements • Natural way brain processes information and heals self(REM Sleep) • Treats PTSD and a wide range of mental health issues. • Trauma overloads the brains natural coping mechanism. • Unprocessed memories and feelings are stored in limbic system of your brain in a “raw” and emotional form, rather than in a verbal “story” mode. These memories can be continually triggered when a person experiences event similar to past traumatic events. • EMDR helps create connections between memories, enabling the brain to process the traumatic memory in a very natural way.

47. TREATING TRAUMATIC MEMORIES Normal Event PROCESSING MEMORY STORED NORMAL EVENT

48. PROCESSING TRAUMATIC EXPERIENES Distress (No Processing) Traumatic Event

49. PROCESSING TRAUMATIC EXPERIENES Exposure/EMDR Traumatic Event Grading Memories/Less Distress

50. EMDR PROCESS • Sudden Units of Distress(0-10) • Emotions Experienced • Negative Belief About Self • Validity of Cognition/Positive Belief(0-7) • Body Scan • Future Templates