deborah borne, msw, md trauma-informed care. getting to know you

DEBORAH BORNE, MSW, MD

Trauma-Informed Care

Getting To Know You

Our Goals

Expose you to the concept and principles of Trauma Informed Care

Plant the seeds for further conversation and implementation at your setting

Understand that trauma informed care is a long and ongoing process

Take something back for yourself…..

Goals PART 1

Explain the nature of traumatic stress.Explore the relationship between

homelessness and trauma.Outline the body’s response to stress

and traumatic stress.Identify the impact of traumatic stress.Review the mechanisms of healing

from trauma

Defining Stress and Trauma

Why Trauma-Informed?

Misunderstood or ignored signs of trauma may:

Interfere with help-seekingLimit engagement into servicesLead to early “drop-out” Inadvertently re-traumatize people we are trying

to helpFailure to make appropriate referrals

Homelessness & Trauma

Developmental trauma that predates becoming homeless

Becoming homeless as traumaExposure to trauma as part of being homelessHomelessness as increasing vulnerability to trauma

responseTrauma response as affecting access to services and

recovery

Source: Poems, Pictures, and Other Great Stuff. (1996). Salem-Keizer Public Schools. Salem, Oregon.

Traumatic stress is different from other kinds of stressors.

What is Traumatic Stress?

Overwhelming experience.

Involves a threat.

Results in vulnerability and loss of control.

Leaves people feeling helpless and fearful.

Interferes with relationships and beliefs.

Source: Herman, J. (1992). Trauma and recovery. New York: Basic Books.

Sources of Traumatic Stress

Loss of a loved oneAccidentsHomelessnessCommunity/school

violenceDomestic violenceNeglectPhysical abuseSexual abuseMan-made or natural

disastersTerrorismPhoto credit: K. Volk

Trauma

Psychological

Complex

Historical

Sanctuary

Vicarious

Impact of Trauma on the Helper

Constant stress and anxiety

Negative attitudeInability to focusFeelings of

incompetence and self doubt

Triggered PTSD reactions and other mental health issues especially if the worker has unresolved trauma

Compromised physical health

Disruption of relationships

Blurred boundariesHopelessnessDecrease in ability

to experience pleasure

Decreased productivity

ACE STUDY

Adverse Childhood Experiences(ACE; Anda & Felitti – www.acestudy.org)

1. Recurrent physical abuse

2. Recurrent emotional abuse

3. Contact sexual abuse

4. An alcohol and/or drug user in the household

5. An incarcerated household member

6. Household member who is chronically depressed, mentally ill, institutionalized, or suicidal

7. Mother is treated violently

8. One or no parents

9. Emotional or physical neglect

ACE Study: Two Major Findings

ACE’s are vastly more common than recognized or acknowledged

ACE’s have a significant impact on later adult health and well-being

ACE’s have a strong influence on…

Adolescent healthTeen pregnancySmokingAlcohol misuseIllicit drug misuseSexual behaviorMental healthRisk of re-victimizationStability of relationshipsPerformance in the workforce

ACE’s increase the risk of…

Heart diseaseChronic lung diseaseLiver diseaseSuicideInjuriesHIV and STD’sOther risks for the leading causes of death

Adverse Childhood ExperiencesACE score ≥ 4

Twice as likely to smokeSeven times as likely to have alcohol abuse/dependenceTwice as likely to have cancer or heart diseaseFour times as likely to have emphysema or COPDTwelve times as likely to have attempted suicide

Men with an ACE score ≥ 6 were 46 times more likely to have injected drugs

People with ACE score ≥ 7 had 360% higher risk of ischemic heart disease (and didn’t smoke, drink to excess, and were not overweight)

The Neurobiology of

Traumatic Stress

Goal of this section

Understand that the Brain and our experience shape how we think, feel, and behave

Trauma has an impact on the Brain

The brain, and clients can heal

How we will Do it

Review the parts of the brain.Learn the physiological parts of the stress/trauma response

Understand how the brain is affected by trauma

Identify methods to help heal the brain

The Brain……..

Right Brain/Left Brain

Left hemisphere better at math, judging time and rhythm, and coordinating order of complex movements Processes information sequentially

and is involved with analysis About 95 percent of our left brain

is used for language

Right hemisphere good at perceptual skills, and at expressing and detecting other’s emotions Processes information

simultaneously and holistically

The limbic system is a sort of “primitive core” of the brain strongly associated with emotion and memory.

Doing Brain

TWO TYPES OF STRESS RESPONSES:Nervous System and Endocrine System

Similarities: They both monitor stimuli and react so as

to maintain balance.Differences:

The Nervous System is a rapid, fast-acting system whose effects do not always persevere.

The Endocrine System acts slower (via blood-borne chemical signals called Hormones) and its actions are usually much longer lasting.

Autonomic Nervous System

Flight

Freeze

Fight

SYMPATHETIC NERVOUS SYSTEM

How Does It all work together ?

TriggerTrigger

Amygdala Amygdala

Sympathetic Nervous System


Norepinephrine epinephrine


Fight, flight or freeze


HypothalamusHypothalamus

Stress Hormone (Cortisol)


Regulates responseRegulates response

Slow Slow

FastFast

Memory

TriggerTrigger

Amygdala Amygdala







HypothalamusHypothalamus



Regulation response not work over timeRegulation response not work over time

Slow Slow

FastFast

Memory

Brain Parts

THINKING, DOING and REPTILE BRAIN

RIGHT and LEFTFight/Flight/Flee vs. Rest/digest

STRESS RESPONSE: FAST and SLOW

Principles of Neurodevelopment

The brain is underdeveloped at birth

The brain organizes from the “bottom” up - brainstem to cortex and from the inside out

Organization and functional capacity of neural systems is sequential

Experiences do not have equal influence throughout development (sensitive periods)

Altered cardiovascular regulationBehavioral impulsivity

Increased anxietyIncreased startle response

Sleep abnormalities

Trauma and Altered Neurodevelopment

The Effects of Trauma on the BrainNeurological consequences of trauma

Manifestations

Reduction in the size of the Hippocampus

Decreased levels of Serotonin

Increased levels of “Stress”

Specific memory problems: - Declarative Memory (Facts, lists etc.) - Fragmentation of long-term memory - (Especially autobiographical and trauma related) - Dissociative amnesia (Gaps/black-outs) - Motor memories (activities learnt at the time of trauma)

Difficulties with concentration Problems with impulsivity and aggression Responses that are inappropriate to the situation

Anxiety and nervousness Numbing of responsiveness to environment Dramatic mood swings

Stress results in decreased dendritic branching of neurons in the CA3 region of the hippocampus (Woolley et al. 1990)

Non-Stressed Stressed

Academic tasks that are difficult when traumatized

Concentrate

Sit still

TalkBe Physical

Set Goals

Listen

Neurogenesis and Plasticity

Neurogenesis: Production of new brain cells

Plasticity: Brain’s ability to change its structure and functions

TRIGGERS

Triggers

Triggers include seeing, feeling, or hearing something that reminds us of past trauma.

Triggers activate the alarm system.

When the alarm system is activated, but there is no danger, it is a false alarm.

The response is as if there is current danger.

What Determines How People React to Trauma?

Response to trauma depends on many “mediating factors.”

Identifying these factors is essential to understanding survivor responses and risk for long-term difficulties.

Effects of Trauma

Every person’s response to a traumatic event is unique.

Both previous experiences and current beliefs shape a survivor’s reactions to abuse and traumatic stress

The trauma that happens in childhood at the hands of caregivers is doubly destructive — because it destroys the attachment relationship that the child would normally need to depend on to manage the trauma of abuse.

Factors that Influence Responses to Trauma

1.History and current functioning.

2.Characteristics of the traumatic event.

3.Culture.

4.Stage of development.

5.Nature of relationships and social supports.

Risk Factors for More Severe Trauma Responses

Poor current functioning and history of trauma.

Traumatic experiences across the lifespan are chronic and severe.

Trauma that begins early in development.

Insecure attachment/poor early relationships and limited current social support.

Nature of Relationships and Social Supports Influences Response to Trauma

“The interactive ‘dance’ [between caregiver and child] lays the foundation for the exchanges

that the baby, then child, then adult will echo throughout life…Adult relationships – be they between politicians or business people or a

shopper and the grocery clerk in the check out line – are all influenced by this, our first and

most profound relationship.”

- R. Karr-Morse & M. Wiley

Source: R. Karr-Morse & M. Wiley (1997) Ghosts from the nursery. New York: The Atlantic Monthly Press.

Attachment

Enduring emotional bond.

Biologically driven.

Determines future relationships and self-regulation.

• Secure “container”

• Provides for basic needs and safety

• Gives the freedom to explore and learn

• Lack of availability and predictability

• Lack of safety and security

• Diminished ability to develop trusting relationships and coping skills

Secure Insecure

Attachment in Adulthood

In adulthood, relationships expand beyond primary caregiver.

Early trauma makes forming adult relationships difficult. It decreases our ability to trust, seek out safe supports, etc.

Leads to decreased social supports.

PHYSICAL + MIND + SOCIAL

Robustness

Webster: Having or exhibiting strength or vigorous health Having or showing vigor, strength, or firmness Capable of performing without failure under a

wide range of conditions

Proactively addresses issues before they become crisis

Lessens or eliminates trauma associated with an event

Brings more resources to a crisis when it does happen

Robustness

Siebert 2005

The Atoms of Robustness

Environmental Experience

Relational Experience

Genetic Expression

Physical HealthPhysical Health

Mind HealthMind Health

Social HealthSocial Health

Physical Health

Physical Health is the foundation for Mind and Social Health

Key aspects of Physical Health Diet Exercise Sleep

A physically healthy person: Lowers stress/cortisol levels Increases brain functioning and growth Improves learning and memory Improves mental health and emotional capacity

Mind Health

Mind Health is a combination of: Emotional Functioning Mental Functioning Spiritual Wellbeing

Role of Expectations

Role of Positive Thinking

Social Health

Homelessness can lead to isolation Isolation leads to depression and other mental health issues

Assessment and attention should be paid to social support and the building of health relationships

Strong social bonds Increase well-being Lower stress Result in more stable mental health Increase cognitive performance Multiply our emotional, intellectual and physical resources Create a greater sense of purpose Recover faster from setbacks

Schwartz 2010

Resiliency

Robustness

ResiliencyResiliency

Distress

Definition of RESILIENCE1: the capability of a strained

body to recover its size and shape after deformation caused by compressive stress

2: an ability to recover from or adjust easily to misfortune or change

Re·sil·ience noun \ri-ˈzil-yən(t)s\

Siebert 2005

The action taken to recover and grow from experiencing a stressful event

Tenacity in the face of distress

Surviving the trauma associated with a disruptive event

Resiliency

Siebert 2005

QUESTIONS ?

Resources

National Health Care for the Homeless Councilwww.nhchc.org

Homelessness Resource Centerwww.homeless.samhsa.gov

The National Center on Family Homelessnesswww.familyhomelessness.org

National Child Traumatic Stress Networkwww.nctsn.org

T3 (Think. Teach. Transform.)www.ThinkT3.com

http://www.nhchc.org/

http://www.homeless.samhsa.gov/

http://www.familyhomelessness.org/

http://www.nctsn.org/

http://www.ThinkT3.com/

Resources

CDC ACE Studyhttp://www.cdc.gov/ace/index.htm

SAMHSA: National Center for Trauma Informed Carehttp://www.samhsa.gov/nctic/

http://www.cdc.gov/ace/index.htm

Contact Information

Deborah Borne, MSW, MDSan Francisco Department of Public [email protected]

http://www.nhchc.org/

mailto:[email protected]

History and Current Functioning Influences Response to Trauma

Prior exposure to trauma

Mental health concerns

Current living situation

Strengths/coping skills

History

Current Functioning

Characteristics of Traumatic EventsInfluence Response to Trauma

What was the nature of the event?

How severe was it?

How long did it last?

Culture Influences Response to Trauma

“A broad understanding of culture leads us to realize that ethnicity, genderidentity and expression, spirituality, race, immigration status, and a host of other factors affect not just the experience of trauma but help-seeking behavior, treatment, and recovery.”

- National Child Traumatic Stress Network

Source: National Child Traumatic Stress Network, Culture and Trauma Briefs. (2006). Volume 1(4). Available at www.NCTSN.org.

Developmental Status Influences Response to Trauma

Development and Trauma

Skills specific to each developmental stage build on learning from previous stages.

Children exposed to trauma invest energy into survival instead of developmental mastery.

Development in adulthood may continue to be impacted.

deborah borne, msw, md trauma-informed care. getting to know you

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