POLYVICTIMIZATION AND COMPLEX TRAUMA: WHAT PRACTIONERS NEED TO KNOW! DR. JERRY B. YAGER

Transcription

1 POLYVICTIMIZATION AND COMPLEX TRAUMA: WHAT PRACTIONERS NEED TO KNOW! DR. JERRY B. YAGER

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3 Because many aspects of our world are unpredictable the circuits of the brain relies on experience to customize connections to serve an individual s needs

4 The brain s ability to change in response to internal and external stimuli is called: Neuroplasticity. Our ability to express our potential is influenced by the our genetic capacity which is either expressed or inhibited by our experiences, both internal and external. 4

5 Neurons

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8 Pruning

9 Myelination

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11 Brain Development Brain develops in a sequential, hierarchical manner from the bottom to the top and right side to left. High, more complex functions depend upon the structure and organization of low, simpler functions. Higher brain regions develop the capacity to monitor and influence lower brain regions. This allows a person to integrate sensory information, with emotional and cognitive information and choose how to respond. (c 11

12 Neuroaxis Reward/social Attachment Sexual Emotional Reactivity Abstract thought Concrete Thought Problem solving Response Flexibility Empathy Heart rate Blood pressure Body temperature Motor coordination Arousal Appetite Sleep 12

13 Executive Functions Working memory Problem solving Organizing thoughts Body regulation Attunement Affect regulation Response flexibility Empathy Fear modulation Insight Intuition Morality

14 Neurobiology The impact of experience is not equal throughout life. Early experiences exert a disproportionate impact on influencing the developmental trajectory of an individual by shaping the properties of the developing brain. Although most systems are in these sensitive periods early in life there are systems that are open and significantly influenced later in development

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16 Complicated Clinical Presentation Nature of the Trauma Duration of the trauma Stage of Development of the victims Presence or absence of a regulating caretaker State of the brain

17 Stress Response System Healthy Tolerable Toxic

18 Bruce McEwen, 2012

19 Adverse Childhood Experience Study (ACE) Exposure to early childhood adverse events has a significant impact on behavioral, psychological, social, physical development. 19

20 Adverse Experiences (ACE) Someone who is chronically depressed, mentally ill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglect Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuser in the household An incarcerated household member 20

21 Gradient Relationship Between Exposure and Risk alcoholism and alcohol abuse chronic obstructive pulmonary disease (COPD) depression fetal death health-related quality of life illicit drug use liver disease risk for intimate partner violence multiple sexual partners sexually transmitted diseases (STDs) smoking suicide attempts unintended pregnancies ischemic heart disease (IHD) 21

22 Gradient Relationship Between Exposure and Risk 22

23 What is Polyvictimization? Cyber-Bullying Fraud Peer/Sibling Abuse Polyvictimization occurs when a victim is exposed to multiple types of violence, crime, and abuse. Assault Kidnapping Neglect Harassment Sexual Violence Possession/Receipt/Distribution of Images of Child Sexual Assault Human Trafficking Bullying Child Abuse Theft Homicide Domestic Violence Arson Identity Theft Robbery Drug or Weapons Trafficking Traffic Offenses Stalking Burglary (c) 2013 National Crime Victim Law Institute Monya Cohen, Psy.D

24 Cumulative Experiences Vogt, King & King, 2007 Violence domestic and community Degraded and humiliated Isolated Loss of control of body Intermittent reward along with threat of or actual assault to self or significant other Betrayal by attachment figure Economic deprivation and social marginalization Homelessness Victims of political oppression Developmentally, intellectually, psychologically challenged Although psychological factors significantly contribute in the severity and risk of post traumatic symptoms, simply having been exposed to a greater breadth of types of victimization appears to play a major role in determining long term negative outcomes.

25 Juvenile Victims Questionnaire 2020 children and youth age % experienced at least 1 victimization in previous year, 2/3 experienced 2 or more with average 3 and range up to 15 If physically abused as child 60% greater risk to have future assault by peer 5.8% greater risk for anger management problem 20.2% greater risk for having depression 10.3% greater risk for anxiety disorder This suggests that victimization becomes a condition rather than isolated events

26 Revictimization Clients with history sexual abuse were more than twice as likely to be victims of adult sexual abuse (Chu & Dill, 1990) In emergency rooms and crisis centers adults with histories of childhood abuse more likely to be victims of multiple rapes and other forms of victimizations (Briere & Runtz, 1987; Dutton et al, 1994; Follerte et. al, 1996) Women with histories of childhood physical abuse were 17:1 odds of being physically abused as an adult (Chu & Dill 1990)

27 Victimization vs. Traumatization Many types of victimizations may be humiliating, degrading, stigmatizing and painful but do not create an internal sense of terror or a threat to bodily integrity and the person did not experience a sense of helplessness and powerlessness associated with traumatic stress.

28 Complex Trauma Exposure to severe stress Repetitively and prolonged Involves harm or absence of caretaker Courtois/Ford 2007 Occurs during developmentally sensitive periods of life

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30 Childhood Abuse, Brain Development and Impulsivity M. Tiecher MD, PhD Early childhood maltreatment acts as a severe stressor, that produces a cascade of physiological and neurohormoral responses which leads to enduring alterations in the patterns of brain development, and that alterations in brain function set the stage for the emergence of later developing psychiatric disorders.

31 Amygdala Hippocampus

32 Positive approach Based action La CA Negative Avoidance Action

33 Deficient Hemispheric Teicher et al,2004 Integration M Teicher, MD, PHD Diminished right-left hemisphere integration Right hemisphere asymmetry Smaller Corpus Callosum Less able to use logic and reason to regulate their behavior. Hypersensitive to perceived threats in the environment that are reacted to with an automatic hormonal and behavioral response

34 ComplexTrauma Sequelae among Children and Adolescents BIOLOGY Sensorimotor developmental problems Analgesia Problems with coordination, balance, body tone Somatization Increased medical problems across a wide span (e.g., pelvic pain, asthma, skin problems, autoimmune disorders, pseudoseizures) BEHAVIORAL CONTROL Poor modulation of impulses Self-destructive behavior Aggression toward others Pathological self-soothing behaviors Sleep disturbances Eating disorders Substance abuse Excessive compliance Oppositional behavior Reenactment of trauma in behavior or play ( e.g., sexual, aggressive) Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et. al. (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35:5, ATTACHMENT Problems with boundaries Distrust and suspiciousness Social isolation Interpersonal difficulties Difficulty attuning to other people s emotional states Difficulty with perspective taking SELF CONCEPT Lack of continuous, predictable sense of self Poor sense of separateness Disturbances of body image Low self-esteem Shame and guilt AFFECT REGULATION Difficulty with emotional self-regulation Difficulty labeling and expressing feelings Problems knowing and describing internal states Difficulty communicating wishes and needs COGNITION Difficulties in attention regulation and executive functioning Lack of sustained curiosity Problems with processing novel information Problems focusing on and completing tasks Problems with object constancy Difficulty planning and anticipating Problems understanding responsibility Learning difficulties Problems with orientation in time and space DISSOCIATION Distinct alterations in states of consciousness Amnesia Depersonalization and derealization Two or more distinct states of consciousness Impaired memory for state-based events Children's Bureau Grantee Kickoff Meeting

35 Significant Group Effects in Childhood (6 to 12 Years in Age) Van der Kolk social competence academic performance school avoidance depression dissociation sexual behavior problems cortisol dysregulation (free cortisol levels) Antinuclear antibody levels Urinary Catecholamines family cohesion depressed mothers = Abuse Greater; = Abuse Less

36 Significant Group Effects in Late Adolescence and Early Adulthood (16-23 Years) B. Van der Kolk pathological dissociation persisting PTSD Sx depression rapes or sexual assaults (2X) domestic violence(1.6x) self harm / suicidality (4X) lifetime traumas Body Mass Index (BMI) overall physical health (including GI problems) healthcare utilization sleep disturbances sexual distortion

37 Summary of Longitudinal Study Serious disorders and high comorbidity (affective, anxiety, suicide, risk taking, self-mutilation, somatization, dissociation, conduct problems, attention, impulse problems, hyperactivity) Biological Dysregulation (HPA axis, sympathetic nervous system, obesity, pubertal development?) Dysfunctional relationships & sexuality (earlier voluntary intercourse, earlier childbearing, more partners, dysfunctional relationships, more DV, more abused children

38 Significant Group Effects in Early to Middle Adolescence (12-15 years) cognitive abilities (verbal IQ, problem solving) age at first voluntary intercourse depression dissociation PTSD symptoms rate of pubic hair growth through puberty LH and FSH in 12 and older = Abuse Greater; = Abuse Less

39 Take Away! 1. The impact of experience on the brain is not constant throughout life 2. Early Experiences have a disproportionate impact in shaping the functional properties of the immature brain 3. Many neural connections in different regions of the brain pass through periods of development when experiences have significantly more impact than when the person is an adult. 4. If certain experiences fail to occur during these sensitive periods or the experiences are abnormal then developmental mechanisms can be derailed. 5. Exposure to adversity is a common experience in our society. However, not all children and adolescents victimized are traumatized.

40 Assessment The psychological, biological, cognitive and social effects of accumulated trauma during developmental sensitive periods produce a wide range of symptoms, involving different levels of complexity and manifesting differently in different individuals. The type and extent of difficulties related to trauma exposure varies based upon the: Nature of the Event(s) Timing, Duration, Stage of development State of the brain Relational environment

41 Domains to Assess Environmental Safety Caretaker capacities Physiological regulation Sleeping/Eating Attention/Arousal Motor skills Anxiety Depression Anger/Aggression Attachment style Relational/Social skills Risk for self- destructive behaviors Dissociative Defenses Self- Image/Esteem Substance use/abuse Sexual behaviors Grief/Loss Expressive and Receptive language Strengths and protective factors

42 How to Inquire About Previous Victimizations Without Causing Harm Be transparent about role and purpose Approach your client with respect and understanding Make time to develop a relationship Convey an attitude of openness Question in a nonjudgmental and supportively neutral position Divided attention to verbal as well as non-verbal communication Stop your questioning if the client becomes symptomatic and focus regulation ( 42

43 Trauma Reminders Internal Alleghney General Hospital Thoughts Memories Feelings Behavior Own body or body parts Physical sensations

44 External Trauma Reminders Another person Place Situation Smell Types of food or just eating Sounds/songs Words Colors Times of Day Facial Expressions Gestures Prosody of Voice

45 Interactions Either due to a lack of verbal skills or an inability to access declarative, verbal memories (Brocca s Area shuts down, ineffective communication between hemispheres) interviewer may have to use alternative strategies to illicit information: Art Writing Behavioral demonstration

46 Grounding Techniques Focus on the here and now sensory experience (sight, hearing, touch, smell, and taste) Approach by calling them by their name and identify yourself Tell them where they are, what day it is and that you know they are frightened but they are safe now. If room is dark turn on lights or open drapes Ask them to name things they see in the room, sounds they hear, places they are touching and if they can smell anything or taste anything. If they are willing ask them to physically move, look out of a window or into a mirror. When possible ask them to go to their safe place ( discussed prior to dissociative episode)

47 Balancing Demands Acceptance and facilitative toward goal Centered, grounded and flexible Nurturing and developmentally demanding Emotionally attentive and attuned yet good boundaries Problem accepting and problem solving Unconditional positive regard and allowing for natural consequences Awareness of immediate needs yet awareness on short and long term goals Being responsive to the care of child and being responsive toward own self care Being aware of own needs but not at the expense of child s needs

48 What To Do Safety comes first Structure choices to remain in control Relationship-based approach Model desired behaviors Understand the child-gap between chronological and developmental age Acknowledge good decisions and choices Non-verbal and body language speak louder than words! Support parents and care givers Manage your own reactions-slow down! Maintain your role Maintain self-regulation Self Care Structure and Consistency -Reflection check in -Regulation Time in, not time out -Relaxation Connect Team work! Consequences, not punishment