trauma 101 trauma informed practice feb. 11, 2013 kathy savicki, lcsw, mid-valley behavioral care...
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TRAUMA 101
TRAUMA INFORMED PRACTICE
Feb. 11, 2013
Kathy Savicki, LCSW,
Mid-Valley Behavioral Care Network
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WHAT DO WE MEAN BY TRAUMA?.
“Traumatization occurs when both internal and external resources are inadequate to cope with the external threat.” Van der Kolk
Critical role of environmental support Link with abuse and neglect – toxic stress
for children Fear + disrupted attachment
Limitations of the Diagnostic System
Acute Stress Disorder – 1st month after event PTSD
1st described Vietnam vets and rape victims Poor fit for children and youth DSM V will change criteria
Proposed but rejected by APA: Developmental Trauma Disorder Complex Trauma/Disorders of Extreme Stress
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Generational TraumaParental trauma responses affect their children Parental problems and crises impact kids Parental coping tools and relational styles
are passed down Children can learn a ‘trauma response’ to
life
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Trauma in Our Lives Up to 70% of American adults experience
at least one traumatic event At any time 5% of Americans have active PTSD 8% of us will experience PTSD in our lifetime
Approx. 25% experience multiple traumas
Prevalence in women is 2x that in men
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Ability to Cope with TraumaDepends on:
Single vs. repeated trauma Age when trauma occurred or began Agent – natural vs. human Nature of the trauma – accidental vs.
purposeful Innate resilience
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Select Traumatic Events and Risk for PTSD
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31.9
23.7
16.8 15.4 14.310.4
7.33.8
05
10152025303540455055
Risk of PTSD (%)
Source: Breslau, 1996 Detroit Area Survey of Trauma
Neurobiology of Trauma
What happens in our brains?
These slides are available on the BCN website at
http://www.mvbcn.org/home/mv1/smartlist_176/trauma-sensitive_services.html
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Trauma and the Brain Thalamus (temporal lobe) receives sensory
signals Amygdala sorts for immediate danger
- Shuts down ‘thinking brain’
- Diverts energy to physical response Hippocampus stores episodic long term
memory Reactivation of this pathway strengthens it
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Memory & Perception
Narrative, verbal
Visual imagery
Sensory, somatic
Affective, feeling
Interpersonal, behavioral
A memory includes:
Traumatic memories are encoded or “remembered” in a different way from
normal, everyday events.
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Traumatic Memory Sensory Linked with intense arousal Fragmented ‘Body’ rather than verbal memory
Role of psychotherapy is to develop the use of the frontal cortex to make sense of and manage reactivity
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PTSD Symptom Clusters (DSM IV)RRee--LLiivviinngg tthhee
EEvveennttAAvvooiiddiinngg
RReemmiinnddeerrssHHyyppeerr--AArroouussaall
Recurringnightmares,flashbacks
Intrusive images“pop” into head
Extreme emotional orphysical reactions toreminders (shaking,chills, panic, racingheartbeat)
Avoid places, people,thoughts or otherassociated activities
Emotional numbing,Loss of interest ineveryday activities
Withdrawal fromfamily, friends
“Avoid awareness”that trauma occurred
Overly alert, easilystartled, “on guard” atall times
Irritability or suddenanger
Difficulty sleeping,Lack of concentration
1 + symptoms present 3 + symptoms present 2 + symptoms present
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Developmental Trauma DisorderExposed to over a year of interpersonal violence, with significant disruptions of protective caregivingAffective and Physiological DysregulationAttentional and Behavioral DysregulationSelf and Relational DysregulationPTSD SymptomsFunctional Impairment
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Complex PTSD, also called Disorders of Extreme Stress
Proposed for DSM-IVR by trauma treatment experts, but not adopted
Superb clinical description of adults who experienced on-going child abuse and neglect and multiple or pro-longed trauma
Better way of understanding many people otherwise labeled with personality disorders
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Generational TraumaParental trauma responses affect their children Parental problems and crises impact kids Parental coping tools and relational styles
are passed down Children can learn a ‘trauma response’ to
life
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Systems Trauma Simply put, systems trauma is the trauma
that people experience or re-experience as a direct result of their interaction with a powerful system
Although it may be connected to a single trauma, more often it is part of complex trauma
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Systems Trauma The experience of powerlessness is key to
retraumatization, especially when people have experienced authority figures as cruel.
People are often retraumatized when they experience being treated in a way that is similar to past traumas.
The more trauma a person has experienced, the more vulnerable they are to retraumatization
If you have a negative sense of self, feeling judged can be powerfully retraumatizing
When Under Stress………. We all tend to use our more primitive defensive
brain Use of that part of the brain curtails the use of the
more-highly organized, intelligent part of the brain
We become more tuned in to immediate survival, and less tuned in to the abstract future
We opt for simple and swift as opposed to complex and thoughtful reactions
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Retraumatization: Feeling States
Being retraumatized often invokes intense feelings Hopelessness Helplessness Extreme vulnerability Intense desires to die, disappear or run Pervasive shame Anger or rage Terror Self-hatred/condemnation
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Retraumatization: Common responses Strong negative emotions that may be difficult for
the person to explain, and expressed in ways that we might not understand (or appreciate)
Defensive or angry verbalizations/avoidance Withdrawing emotionally/shutting down/self-
sabotage Telling people “in authority” what they think the
person wants to hear/overly “compliant” Disengaging from services/leaving
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SYSTEMS WHICH FREQUENTLY
RE-TRAUMATIZE Law Enforcement Criminal Justice Child Welfare Hospitals and related medical systems Mental Health Substance Abuse Treatment
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Many Parents Encountering Child Welfare Have experienced abuse as children Have experienced multiple life traumas and
developmental interruptions Have not had the natural and therapeutic
supports needed to initiate their own recovery Have had little or no experience, training or
support in being a parent Have multiple life stressors and limited
resources
CHILD WELFARE Parents experience Child Welfare staff as
extremely powerful Parents who encountered the Child Welfare
System as children know that power What’s at stake is the primary attachment to
one’s child Actual and perceived negative experiences
create difficulties in building a relationship
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CHILD WELFARE The Child Protective Services System
works with a legal system that can feel adversarial
Fact-based reports can feel accusatory, triggering intense feelings of guilt
Parents often experience this process as frightening, unfair, humiliating and painful
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Potentially traumatizing experiences
Not being informed of or understanding the plan for the children when they have been taken into custody, not knowing the process
Having – or feeling that - important decisions are made about them or their children without their knowledge, participation or consent
Multiple conflicting priorities without the resources or support to accomplish them
Negative evaluations of their character or value as parents
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Potentially traumatizing experiences Judgments and stereotypes related to the
parent’s addiction, mental health, or family history
Being treated as hopeless or as if their past history dooms them to failure
Fear of their children having negative experiences (big or little) in foster care
Loss of contact with child or termination of rights
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Basic Skills: Trust and Respect Kindness, courtesy, politeness Reliability Attentive listening – open ended questions Emphasize choice Owning our mistakes Assume symptoms (including lies) have a
positive intent and an adaptive function
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Reconsidering Our Words Frequent flyer
Perjorative label reflecting our helplessness/frustration Manipulation
An indirect method of achieving a goal when being direct isn’t see as an option or likely to succeed
Secondary Gain Reflects a primary need not met in other ways
Attention Seeking Why do people have to work so hard to get our attention?
Borderline Person with an attachment disorder
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We Have to Believe in RecoveryStay strengths-based and respectful Remember that change is terrifying Know that the person is doing their best to
survive in the moment If they rage at you, assume you’ve reactivated
previous traumatic relationships and don’t over-react yourself
Peer supports are invaluable to help people feel truly understood and hopeful about change
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We Have to Believe in RecoveryStay grounded in Recovery Principles Recovery is not linear, but marked by growth,
setbacks and learning from experience Honoring attempts that don’t work
Moving from destructive to healthy coping involves daily choices for health and safety The process can be laborious Small steps need to be recognized and valued Beware when you feel “Here we go again” Holding on to hope
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