TRAUMA ACROSS GENERATIONS :

Providing Trauma Informed Care

Laurie Berlin, LMFTSchool-Based Outpatient Therapist

Northeast Youth and Family Services

What is Trauma?

• Acute Trauma: Experiencing a serious injury, facing threats of serious injury, or experiencing a violation of personal physical integrity to yourself or someone else, or witnessing the death of someone else. These experiences usually are associated with overwhelming feelings of terror, horror, or helplessness.

• Chronic Trauma: Exposure to trauma occurring repeatedly over long periods of time. These experiences are often associated with intense feelings of fear, loss of trust in others, decreased sense of personal safety, anger, guilt, and shame.

Traumatic Stress Reactions and Common Responses

Trauma effects everyone differently.

At the core of psychological trauma is the confusion of past and present.

Common Characteristics of Trauma

Effects of trauma persist through the abnormal coding of memories

A conflict emerges between denial of the event and the urge to scream out about the event

Not feeling understood is a major hurdle for many victims

Avoidance of Reminders

Survivors of trauma will often try very hard to avoid reminders of the event (eg. places, sounds, smells) and related feelings (eg. fear, helplessness, numbing, horror)

Analogy of a hurt knee

Traumatic Defense Cascade1. Freeze Response: an orienting response, attentive

immobility2. Fight and/or flight Response: bodily activation,

muscle tension, feeling of unreality3. Fright Response: fast onset of unresponsive

immobility, onset of dissociation, cognitive ability severely impaired, high emotional arousal

4. Flag Response: unresponsive immobility, “shut-down”, numbing of all emotions, in extreme cases will result in Fainting Response

5. Slow termination of immobility Source: Schauer, Neuner, & Elbert. Narrative Exposure Therapy. Hogrefe Publishing, 2011.

TRAUMA CAN IMPACT A PERSONS:

• Brain physiology and functioning, Disruption of Memory

• Emotions• Behaviors• Body• Thoughts• Relationships• Occupational or academic functioning

TRAUMA AND THE BRAINOur brains are structured into three main parts:

Cortex: the outer surface, where higher thinking skills arise; includes the frontal cortex, the most recently evolved portion of the brain, the thinking brain

Limbic System: the center of the brain, where emotions evolve

Brain Stem: the reptilian brain that controls basic survival functions

Source: Dialogues Clin Neurosci. 2006 Dec; 8(4): 445–461.

HIPPOCAMPUS: Plays an important role in the formation of memory. Declarative memory: situational memory. Very vulnerable to stress. Decreased functioning following trauma.

- Cortisol (weakened immune system, damages cells in the Hippocampus)

- Glucocorticoids (have enhancing effects on memory consolidation, impairs ability to retrieve memories) AMYGDALA: The structure of the brain that prepares the body

for danger. Emotional and sensory memory. Activated during trauma.

- Norepinephrine (mobilizes the brain and body for action, fight or flight) MEDIAL PREFRONTAL CORTEX: Inhibits activation of the

amygdala. Orchestrates thoughts and actions. Thinking, judgment, decision-making. Decreased functioning during trauma.

Trauma actually changes the structure and function of the brain

Traumatic memories often are very vivid and rich in sensory detail, but often it is difficult for the victim to put the memory into coherent speech and chronological order

Traumatic stress tends to produce two emotional extremes:

- Feeling either too much emotion, or too little emotion.

- Flooding versus numbness

•Shock, denial, or disbelief•Anger, irritability, mood swings•Guilt, shame, self-blame•Feeling sad or hopeless•Confusion, difficulty concentrating•Anxiety and fear•Withdrawing from others•Feeling disconnected or numb

EMOTIONAL AND PSYCHOLOGICAL SYMPTOMS OF TRAUMA:

Because numbing of emotions may hide what is going on inside emotionally, there can be a tendency for family, counselors, and helpers to underestimate the impact of the trauma.

Numbing/Emotional Detachment

Behavioral Responses to Trauma• Avoidance

• Re-EnactmentsExamples Include: self-injurious behaviors, hypersexuality, walking alone in unsafe areas or other high-risk behaviors, driving recklessly, increased drug or alcohol use, or involvement in repetitive destructive relationships (e.g., repeatedly getting into romantic relationships with people who are abusive or violent).

Physical Impact of Trauma• somatic complaints: headaches, sore throats, etc • sleep disturbances, nightmares• change in appetite, nausea• cardiovascular disturbances, elevated heart rate,

respiration, and blood pressure• neurological changes, sweating or shivering, faintness,

tremors or shaking, musculoskeletal aches and pains• extreme fatigue or exhaustion • increased startle response, hyperarousal• dermatological disorders, hives, rashes• urological problems, constipation, diarrhea • substance use disorders

Sources: Briere & Scott, 2006b; Foa, Stein, & McFarlane, 2006; Pietrzak, Goldstein, Southwick, & Grant, 2011. Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma. Available from: http://www.ncbi.nlm.nih.gov/books/NBK207191/

Hyperarousal

A common symptom that arises from traumatic experiences is hyperarousal (also called hypervigilance). Hyperarousal is the body’s way of remaining prepared. It is characterized by sleep disturbances, muscle tension, and a lower threshold for startle responses and can persist years after trauma occurs. It is also one of the primary diagnostic criteria for PTSD.

Cognition Distortions • Traumatic experiences can affect and alter

thoughts and beliefs.

• Trauma challenges the just-world or core assumptions that help individuals navigate daily life (Janoff-Bulman, 1992). They may see others and the world as unsafe and unpredictable, and see the future as hopeless.

• A sense of safety and security in the world could be lost, particularly if the trauma was unexpected.

An Altered Sense of Self

• Trauma can lead individuals to see themselves as incompetent or damaged, believing that personal suffering will continue, or negative outcomes will continue for the foreseeable future.

• Subsequently, this set of cognitions can greatly influence a persons belief in their ability to use internal resources and external support effectively.

Intrusive Thoughts“Experiencing, without warning or desire, thoughts and memories associated with the trauma.” (

http://www.apa.org/topics/trauma/) These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while.

TriggersA trigger is any sensory reminder of the traumatic event: a noise, smell, temperature, other physical sensation, or visual reminder. Triggers can be anything that resembles or represents a previous trauma, such as revisiting the location where the trauma occurred, being alone, having your children reach the same age that you were when you experienced the trauma, seeing the same breed of dog that bit you, or hearing loud voices. Triggers are often associated with the time of day, season, holiday, or anniversary of the event.

FlashbacksA flashback is “re-experiencing a previous traumatic experience as if it were actually happening in that moment.” (http://www.apa.org/topics/trauma/) It includes reactions that often resemble the victim’s reactions during the trauma.

Flashbacks are:

• very brief and typically last only a few seconds, but the emotional after effects linger for hours or longer.

• commonly initiated by a trigger, but at times they occur out of the blue.

• can feel like a brief movie scene that intrudes on the client.

Dissociation• Dissociation is a mental process that severs

connections among a person’s thoughts, memories, feelings, actions, and/or sense of identity.

• The individual has a distorted sense of time, space, or identity.

• Dissociation helps distance the experience from the individual. People who have experienced severe or developmental trauma may have learned to separate themselves from distress to survive.

Potential Signs of Dissociation

• Fixed or “glazed” eyes• Sudden flattening of affect• Long periods of silence• Monotonous voice• Stereotyped movements• Responses not congruent with the present context or

situation• Excessive intellectualization• it is important when working with trauma survivors that

the intensity level is not so great that it triggers a dissociative reaction and prevents the person from engaging in the process.

(Briere, 1996a)

Advice to Workers: Helping Clients Manage Flashbacks, Triggers,

and Dissociation

If a client experiences a trigger, help them focus on what is happening in the here and now; that is, use grounding techniques. Providers should be prepared to help the client get re-grounded so that they can distinguish between what is happening now versus what had happened in the past

Staying grounded:

A trauma self-help exercise

Resilience• Most people who experience trauma have no long-lasting

disabling effects. Personal resiliency and social supports often stabilize functioning within days, weeks, and months. Extinction occurs through inhibition and habituation.

• For others, though, the symptoms of trauma are more severe and last longer.

• The most common mental health diagnosis associated with trauma is PTSD, but trauma is also closely associated with substance use disorders, mood disorders like depression, anxiety disorders, and personality disorders.

Resilient Responses to Trauma

• Increased bonding with family and community.

• Redefined or increased sense of purpose and meaning.

• Increased commitment to a personal mission.

• Revised priorities.• Increased charitable giving and

volunteerism.

How to Work with Traumatized Clients

First and Foremost, Build Safety and Trust, Acceptance, Understanding

Building Supports• A key ingredient in the early stage of TIC is to establish or

re-establish a support system as soon as possible. Social supports and relationships can be protective factors against traumatic stress. (National Child Traumatic Stress Network. (n.d.). Types of traumatic stress. Retrieved October, 2015, from www.nctsnet.org)

• Many survivors of abuse and violence have experienced a significant sense of betrayal. They have often encountered trauma at the hands of trusted caregivers or family members or through significant relationships. Although this fear of trusting others is protective, it can lead to difficulty in connecting with others and greater vigilance in observing the behaviors of others, including service providers.

Advice to Workers:• Support your clients and provide a message of

hope—that they are not alone, they are not at fault, and recovery is possible and anticipated.

• Psycho-Education: Normalize trauma symptoms. For example, explain to clients that their symptoms are not a sign of weakness, a character flaw, they are not damaged or going crazy. What they are experiencing is a normal reaction.

Trauma Across GenerationsEach age group is vulnerable in unique ways to the stresses of trauma, with children and the elderly being at greatest risk.

• Young children may display generalized fear, nightmares, heightened arousal and confusion, and physical symptoms, (e.g., stomachaches, headaches).

• School-age children may exhibit symptoms such as aggressive behavior and anger, regression to behavior seen at younger ages, repetitious traumatic play, loss of ability to concentrate, and worsening school performance.

- Children and survivors of childhood trauma are more vulnerable to dissociation

• Adolescents may display depression and social withdrawal, rebellion, increased risky activities such as sexual acting out, wish for revenge and action-oriented responses to trauma, increased drug or alcohol use, and sleep and eating disturbances (Hamblen, 2001).

• Adults may display sleep problems, increased agitation, anger, hypervigilance, isolation or withdrawal, difficult with work, impaired relationships, and increased use of alcohol or drugs.

• Older adults may exhibit increased withdrawal and isolation, reluctance to leave home, worsening of chronic illnesses, confusion, depression, and fear (DeWolfe & Nordboe, 2000b).

Advice to Workers: How to Help Young Children

• Provide comfort, rest, and an opportunity to play or draw.

• Provide reassurance that the traumatic event is over and that the children are safe.

• Help children identify and verbalize their feelings so that they don’t feel alone with their emotions.

• Provide structure and consistency by ensuring that children are picked up from school at the anticipated time, meals and bedtime remain consistent, and by informing children of parents’ whereabouts to provide a sense of security.

• Accept a regression in behavior for a period of time following a traumatic event.

- Older children will also need encouragement to express fears, sadness, and anger in a supportive environment.

- These school-age children may need to be encouraged to discuss their worries. It is important to acknowledge the normality of their feelings and to correct any distortions of the traumatic events that they express.

- Parents/helpers can be invaluable in supporting the children in reporting to teachers when their thoughts and feelings are getting in the way of their concentrating and learning.

Advice to Workers: How to Help Older Children

Advice to Workers: How to Help Adolescents

- Provide space for a discussion of the event and feelings about it, however do not force discussion of the event. Listen without passing judgement. Normalize their feelings and re-assure them that the event was not their fault.

- Give them a sense of control by letting them make choices about things such as meals, what to wear, etc.

- Maintain normal rules, routines, and expectations for the adolescent to give them a sense of structure and normalcy.

- Help adolescents understand “acting out” behavior as an effort to voice anger about traumatic events. It may also be important to discuss thoughts of revenge following an act of violence, address realistic consequences of actions, and help formulate constructive alternatives that lessen the sense of helplessness the adolescents may be experiencing.

(National Child Traumatic Stress Network. (n.d.). Types of traumatic stress. Retrieved October, 2015)

Advice to Workers: HELPING ADULTSWorkers can provide space for survivors to process the trauma.Encourage them to… Get plenty of rest, drink water, and eat regularly Not isolate Participate in social activities Stick to a daily routine Break large jobs into smaller, more manageable

tasks Encourage activities that make them feel better and

occupy their mind such as drawing, art, yoga, going for walks, playing with children or animals

IS PROFESSIONAL HELP NEEDED BY A THERAPIST?

• Having trouble functioning at home or work• Suffering from severe fear, anxiety, or depression• Unable to form close, satisfying relationships• Experiencing terrifying memories, nightmares, or

flashbacks• Avoiding more and more things that remind them of the

trauma• Emotionally numb and disconnected from others• Using alcohol or drugs to feel better• If weeks have passed with no or little improvement of

symptoms

An immediate referral should be made if the person is experiencing thoughts or impulses of self-harm or suicide.

Therapeutic Treatments for Trauma

Somatic Experiencing EMDR (Eye Movement Desensitization and

Reprocessing) Narrative Exposure Therapy Cognitive-behavioral therapy (used in addition

to one of the previous therapies)

Laurie BerlinRoseville School-Based Therapist

Northeast Youth and Family Services

Laurie@nyfs.org

Office: 651-486-3808 Direct Line: 651-379-3438

www.nyfs.org

REFERENCES• Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville

(MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma. Available from: http://www.ncbi.nlm.nih.gov/books/NBK207191/

• Bremner, J.D. Dialogues Clin Neurosci. 2006 Dec; 8(4): 445–461.Traumatic stress: effects on the brain.

• Emotional and Psychological Trauma: Causes, Symptoms, Effects, and Treatment. Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., and Lisa Flores Dumke, M.A., contributed to this article. Last modified on: 9/16/05. www.helpguide.org/mental/emotional_psychological_trauma.htm

• Help Guide.org: www.helpguide.org/articles/ptsd-trauma/emotional-and-psychological-trauma.htm

• National Child Traumatic Stress Network. (n.d.). Types of traumatic stress. Retrieved October, 2015, from www.nctsnet.org

• Schauer, Neuner, & Elbert. Narrative Exposure Therapy. Hogrefe Publishing, 2011.