trauma informed care stephanie sundborg, ms ssund2@pdx.edu 503-931-0536 mandy a. davis, lcsw, phd...

TRAUMA INFORMED CARE

Stephanie Sundborg, MSssund2@pdx.edu503-931-0536

Mandy A. Davis, LCSW, PhD madavis@pdx.edu503-725-9636

TIC101- RECOGNIZING

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Trauma Informed Care“A program, organization, or system that is trauma-

informed:1. Realizes the widespread impact of trauma and

understands potential paths for recovery;2. Recognizes the signs and symptoms of trauma in

clients, families, staff, and other involved with the system;

3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

4. Seeks to actively resist re-traumatization” (SAMHSA, 2014)

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Trauma Informed Care“A program, organization, or system that is trauma-

informed:1. Realizes the widespread impact of trauma and

understands potential paths for recovery;2. Recognizes the signs and symptoms of trauma in

clients, families, staff, and other involved with the system;

3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

4. Seeks to actively resist re-traumatization” (SAMHSA, 2014)

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Environment Brain Behavior

Input from the environment• vision, hearing, smell, taste, touch

“In-between” stuff – mental activities• Perception, attention, memory, learning

Output in the environment• Running, yelling, fighting, eating, listening, speaking,

WHY

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Sensory Perception – Bottom Up

Visual• Least accurate of all

senses• Does not reach full

adult functioning until age four

Touch• First of five senses to

develop and most prominent at birth

• Critical part of growth and nurturing

Taste• 2,000-5,000 taste

buds• Four types of

taste:

Auditory• Can be powerful triggers• Studies show trauma survivors

are more aware of oddball sounds earlier

Olfactory (Smell) Can detect around 10,000

smells Only sensory input that is

directly connected to limbic system (memory & emotion)

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Sensory / Perception… and the Trauma brain

• More sensitive to incoming sensory information – sounds are louder, smells are stronger.

• Sensory information act as triggers

• Top down input may be distorted – not available

Connecting to behavior: Do you notice survivors are more aware or bothered by sensory input?

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Attention… and the Trauma brain

• Selective attention is worse in general but better for threatening stimuli

• Divided attention – hyper vigilance – not wanting to inhibit distractors

Connecting to behavior: Do you notice survivors have a harder time focusing attention? Are they easily distracted?

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Memory… and the Trauma brain

• Short term (Working memory) isn’t very good – frontal lobe activation is decreased

• LT Declarative memory is usually impaired – damage to hippocampus and problems with working memory

• HOWEVER – LT - Implicit memory is strong for threatening stimuli

Connecting to behavior: Do survivors forget appointments, treatment plans, what was discussed last time? But, is their memory for threat situations or details good?

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Executive Function… and the Trauma brain

• Frontal lobe function is impaired – affecting judgment, decision making, planning, reasoning

• Impulse control is more difficult

• Needed regulation is not online - attention and emotion can get out of wack • Anxiety related, perseverative loops - OCD

Connecting to behavior: Do survivors perseverate, fixate? Do they show problems with impulse control? Struggle with making decisions or planning?

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Top Down Processing

• Pre-existing knowledge is used to rapidly organize features into a meaningful whole

• Past experiences, motives, contexts, or suggestions prepare us to perceive in a certain way (Perceptual Expectancy)

“We don’t see things as they are. We see them as we are”

Anais Nin

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• Long-term memory

• Learning• Judgment• Problem solving• Decision making

Upstairs Brain

• Incoming sensory

• Orienting attention

• Reflexive Perception (e.g. startle)

• Perception• Selective

attention• Working

Memory

Downstairs Brain

Response

Mezzanine

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Opportunity to help navigate, control, filter sensory input

What to expect

“We know the noise in the waiting area can be overwhelming – perhaps bringing headphones…”

Opportunity to make sure attention is focused? Perception isn’t distorted? Info is getting into short term memory?

“With so much going on in this room, I know it can be difficult to stay focused on me, but if you could give me your attention for just a few minutes…”

“I know I just gave you a lot of information, can you tell me your understanding of next steps”

Draw on context, experience, and LT memory to shape incoming info. If needed, create new stories / memories to replace old ones… “Remember last time this happened, you were able to XYZ”

Stress Response

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Stress Response….

Considers sensory info for real or perceived danger

Offers rational thinking, planning, decision making, sense making

Memory formation – checks memories for context

If stress response warranted – HPA axis initiates

Incoming sensory information

Illustration: Hallorie Walker Sands

Selective Attention and working memory

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• Dominant at birth

• Sensory experiences – no language

• Emotional Processing

• Relational hemisphere – focused on attachment

• Developing slower ~ 18-24 months• More logical,

analytical, and sequential• Focuses on details –

construct narratives

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Cortisol and other Brain Chemicals

• Norepiniphrine (NE)• Alertness / arousal / attention• fight/flight (SAM sys chemical)• Solidifying threat memories

• Cortisol • fight/flight (HPA axis chemical)• Damages hippocampus (memory)• Needed to shut off stress response – neg feedback loop• Lower levels in PTSD

• Serotonin (5HT)• Dampen NE firing• Reduces sensory stimulation in amygdala – only in presence of cortisol• Reduced levels in PTSD, depression

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Cortisol and other Brain Chemicals

• GABA (benzodiazepine)• Inhibitory NT – reduces excitatory activity• Reduces re-experiencing / hyperarousal• Frontal lobe “squirts” GABA into amygdala• Impaired in PTSD

• Endogenous Opiates• Analgesia• Related to dissociative symptoms• Acute stress response elevates secretion of opioids• Chronic stress response may lead to lower concentration of

opioids

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When Trauma Happens….• Freeze, Flight, Fight, Fright

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When Trauma Happens….• Chronic Trauma, Complex trauma overtime

• Central Nervous system becomes unbalanced

Parasympathetic Nervous Sys:Rest and Digest Sympathetic

NS:Arousal system Fight or Flight

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Neurobiology Take Aways

• Simple to complex – Survival mechanisms act first and faster than the thinking brain.

• When we are threatened – brain moves resources away from thinking toward survival.

• Our brain learns patterns. Fire-together-wire-together.

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Neurobiology Take Aways• Attention can be a problem:

• Amygdala in survivors is hyper-vigilant – scanning for real or perceived threat; attentional control from frontal lobe is decreased

• Communication is challenging: dominance of RH • Decreased verbal (left hemisphere) – hypersensitive to

nonverbal (right hemisphere) – prone to misinterpret.

• Memory is impaired – damage to hippocampus due to excess cortisol: • Explicit memory (hippocampus) – facts, stories, pictures –

impaired • Implicit memory (amygdala – acute trauma) often clear and

sharp

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Stretch

TRAUMA INFORMED CARE 201

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Principles of PracticeWith a foundation of awareness and understanding, organizations can strive to reflect three central principles of TIC, by creating policies, procedures, and practices that:

• create safe context,• restore power, and• value the individual.

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Trauma Informed Care (TIC) recognizes that traumatic experiences terrify, overwhelm, and violate the individual. TIC is a commitment not to repeat these experiences and, in whatever way possible, to restore a sense of safety, power,

and worth

Commitment to Trauma Awareness

Understanding the Impact of Historical Trauma

Create Safe Contextthrough:Physical safetyTrustworthinessClear and consistent boundariesTransparencyPredictabilityChoice

Restore Power through:ChoiceEmpowermentStrengths perspectiveSkill building

Value the Individual through:CollaborationRespectCompassionMutualityEngagement andRelationship Acceptance and Non-judgment

Agencies demonstrate Trauma Informed Care with

Policies, Procedures and Practices that

Trauma Informed Care

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What is required to Provide TIC?• Secure, healthy adults;• Good emotional management skills;• Intellectual and emotional intelligence;• Able to actively teach and be role model;• Consistently empathetic and patient;• Able to endure intense emotional labor;• Self-disciplined, self-controlled, and never likely to abuse power.

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The Reality• We have a workforce that is under stress.• We have a workforce that absorbs the trauma of the consumers.

• We have a workforce populated by trauma survivors.

• We have organizations that can be oppressive.• All of this has an impact

• We have organizations that come to resemble the behavior we’re trying to help.

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SafetyEmotional ManagementDissociationSystematic ErrorAuthoritarianismImpaired CognitionImpoverished relationshipDisempowered –HelplessnessIncreased AggressionUnresolved GriefLoss of Meaning

Adapted from Sandra Bloom’s Sanctuary Model