Trauma-Informed Care: Part One

Transcription

1 2011 National Healthcare for the Homeless Council Regional Training Detroit, MI Trauma-Informed Care: Part One Scott R. Petersen, LCSW, CACIII Denver, CO September 20, 2011

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6 Why Trauma-Informed? Misunderstood or ignored signs of trauma may: Interfere with help-seeking Limit engagement into services Lead to early drop-out Inadvertently re-traumatize people we are trying to help Failure to make appropriate referrals

7 Homelessness & Trauma Developmental trauma that predates becoming homeless Homelessness as trauma Homelessness as increasing vulnerability to trauma response Trauma response as affecting access to services and recovery

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

10 What makes a stress traumatic?

11 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. We cannot accurately predict who will be traumatized by events typically described as traumatic. Subjective and defined by the experience of the survivor. It is the subjective experience of objective events (Allen, 1995). Source: Herman, J. (1992). Trauma and recovery. New York: Basic Books.

12 Sources of Traumatic Stress Photo credit: K. Volk Accidents, injury, illness Homelessness Community/school violence Domestic violence Neglect Physical abuse Sexual abuse Rape/sexual assault Human-made or natural disasters Terrorism War Torture Immigration/refugee experience Witnessed violence/cruelty to others Deprivation caused by extreme poverty Emotional and psychological abuse Gang and drug related violence Repeated abandonment or sudden loss Environmental degradation Imprisonment Oppression

13 Adverse Childhood Experiences (ACE; Anda & Felitti 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

14 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

15 ACE s s have a strong influence on Adolescent health Teen pregnancy Smoking Alcohol misuse Illicit drug misuse Sexual behavior Mental health Risk of re-victimization Stability of relationships Performance in the workforce

16 ACE s s increase the risk of Heart disease Chronic lung disease Liver disease Suicide Injuries HIV and STD s Other risks for the leading causes of death

17 Adverse Childhood Experiences, cont. ACE score 4 Twice as likely to smoke Seven times as likely to have alcohol abuse/dependence Twice as likely to have cancer or heart disease Four times as likely to have emphysema or COPD Twelve 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)

18 Anda & Felitti (1998)

19 Adverse Childhood Experiences: Two Basic Etiologic Mechanisms (Felitti & Anda, 2010) Conventional (indirect) risk factors that actually are attempts at self-help through the use of agents like nicotine, with its multiple psychoactive benefits, in addition to its now well-recognized health risks. The direct effects of chronic stress as mediated through the mechanisms of hypercortisolemia, pro-inflammatory cytokines, and other stress responses on the developing brain and body systems, dysregulation of the stress response, and pathophysiological mechanisms yet to be discovered. Overweight is overlooked and that s the way I need to be.

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21 The Stress Response The human brain has a built-in alarm system that signals us when we may be in danger.

22 The Stress Response

23 The Stress Response Thinking brain checks out situation If there is no danger, the doing brain goes back to normal functioning. Doing brain senses danger If there is danger, the thinking brain shuts down, allowing the doing brain to act.

24 There are a variety of common responses after a traumatic experience.

25 To protect itself, the body uses increased energy to respond to danger in 1 of 3 ways: Flight Fight Freeze

26 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.

27 Continuum of Responses Response is long-term, intrusive, and severe. Small % Response is intense, but recovery is relatively quick. Everybody responds

28 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.

29 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.

30 Effects of Trauma, cont. Personal resources Duration and severity Meaning (or lack of) Support and presence (or not) provided by community, family, other social networks

31 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.

32 1. History and Current Functioning Influences Response to Trauma Prior exposure to trauma Mental health concerns History Current living situation Strengths/coping skills Current Functioning

33 2. Characteristics of Traumatic Events Influence Response to Trauma What was the nature of the event? How severe was it? How long did it last?

34 3. Culture Influences Response to Trauma A broad understanding of culture leads us to realize that ethnicity, gender identity and expression, spirituality, race, immigration status, and a host of other factors affect not just the experience of trauma but helpseeking 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

35 4. Developmental Status Influences Response to Trauma

36 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.

37 5. 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.

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39 Attachment Enduring emotional bond. Biologically driven. Determines future relationships and self-regulation.

40 Secure Attachment Insecure Attachment Secure container Provides for basic needs and safety Lack of availability and predictability Lack of safety and security Gives the freedom to explore and learn Diminished ability to develop trusting relationships and coping skills

41 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.

42 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. One s cultural background and meaning-making of the traumatic experience or risk of trauma associated with a particular group.

43 Homelessness and Trauma

44 Homelessness and Trauma Many who are homeless have experienced multiple traumas. Traumatic experiences are often interpersonal in nature, prolonged, repeated, and severe. Traumatic experiences often occur within the care giving system during critical developmental stages. These experiences have a short and long-term impact in many areas of people s lives.

45 Complex Trauma

46 Post-Traumatic Stress Disorder The person has been exposed to a traumatic event Re-Experiencing the traumatic event through flashbacks or nightmares. Hyperarousal in the form of difficulty falling or staying asleep, angry outbursts, heightened focus on potential danger, or difficulty concentrating. Avoiding reminders of the event such as diminished interest or participation in significant activities, feeling detached, numb, or disconnected from others.

47 PTSD vs. Complex Trauma PTSD typically develops from one incident, often experienced as an adult. Single blow. Complex Trauma (DESNOS) is associated with repeated/recurrent incidents (e.g., domestic violence, ongoing childhood abuse, torture, war, homelessness).

48 The Stress Response and Complex Trauma When danger is ever-present, alarm goes off too frequently. Brain treats all potential threats as actual threats. Brain continues to release chemicals, so body becomes unbalanced.

49 TRAUMA Impacts Everything How we feel How we act Who we meet What we do Where we go

50 What does trauma feel like? Speechless Terror Intense Fear Fear of Complete Destruction Total Helplessness Profound Emptiness Loss of Control Anger and Rage Intense Shame and Guilt Total Disconnection

51 Traumatic Events Impact: (Saakvitne, et al., 2000) Body & Brain: neurobiology - fight/flight/freeze response; survivors often feel the biological responses of fight/flight/freeze all the time, and can t act on it, leaving them in constant state of hyper-arousal, fear and anxiety; Medical chronic pain, GI distress; headaches. Memory & Perception: often fragmented; difficulty concentrating Judgment: insight, perspective, ability to see and weigh consequences; boundaries

52 Traumatic Events Impact, cont: (Saakvitne, et al., 2000) Beliefs: what it means to feel safe, trust, have self-esteem, feel connected, and to feel in control and effective in our lives. Frame of Reference: identity (who am I?); world view (what is the world really like?); spirituality (what do I believe?) Feelings: ability to identify and manage feelings; connect to others

53 Triggers and Complex Trauma More reminders of past danger. Brain is more sensitive to danger. Thinking brain automatically shuts off in the face of triggers. Past and present danger become confused.

54 What are some common triggers for the people you serve?

55 Common Triggers Reminders of past events. Lack of power/control. Conflict in relationships. Separation or loss. Transitions and routine/schedule disruption. Feelings of vulnerability or rejection. Feeling threatened or attacked. Loneliness. Sensory overload.

56 What are some examples of fight, flight, or freeze that you notice when clients are triggered?

57 Impact of Complex Trauma Emotional Behavioral Physical Cognitive Relational Photo credit: M. Ko

58 Questions for Discussion 1. What are some of the emotional effects of trauma that you see in the people who you serve? 2. What are some of the common physical issues? 3. What are some common behaviors? 4. How do you see the impact of chronic trauma on cognitive skills play out with your clients? 5. What are some of the relational effects of trauma?

59 Understanding Responses to Complex Trauma Coping strategies for survival. Caused by the brain s response to trauma. Challenges day to day functioning.

60 Example Scenario: Jennifer is a particularly difficult client to work with. In meetings with her case manager she is often either shut down or defensive, angry and verbally aggressive. She frequently splits staff members, making the same request of multiple people, hoping to get the answer that she is looking for. Staff feel that they have tried to help her many times and yet Jennifer refuses to take the initiative to do what is needed to meet her goals. When she does accept help, she does not appear appreciative of the support and can become angry again as soon as something does not go right.

61 Our response to Jennifer depends on how we view her behaviors.

62 Without knowledge of trauma, what are some words that we might use to describe Jennifer? Manipulative Lazy Resistant Entitled Unmotivated Disrespectful

63 Now lets look at Jennifer through a trauma lens. How might we describe her? Overwhelmed Triggered Constantly on the lookout for danger Frozen Mistrustful of others due to her history of abuse In fight mode Getting her needs met in ways that have worked in the past Terrified of success

64 Clinical Example: Laura s Story

65 In the midst of trauma, people can and do recover.

66 Being homeless is a humbling experience, yet it was during those years that I found my voice. - Amy Grassette We who have recovered from mental illness know from our personal experience that recovery is real. We know that recovery is more than remission with a brooding disease hidden in our hearts. We have experienced healing and we are whole where we were broken. - Daniel Fisher Sources: Olivet, J. (2005). Every Success Story is a Great Story. Nashville: National Health Care for the Homeless Council; Fisher, D. Healing and Recovery Are Real, National Empowerment Center. Full article available at

67 The [survivor s] s] recovery is not based on the illusion that evil has been overcome, but rather on the knowledge that it has not entirely prevailed and on the hope that restorative love may still be found in the world (Herman, 1997, p. 211).

68 Provider Perception s (Najavits, 2002) Through my work I have continued to become a better human being, not just a better therapist. As difficult as it is, this work pushes me to find new aspects of my own humanity, to honor that, and then to turn it around and use it to help my clients they are my teachers!

69 Pathways to Healing.... How do we work with others and support their recovery given what we know about the impact of trauma?

70 Adopting a New Perspective

71 Becoming Trauma-Informed.... Using what we know about trauma and its impact to do our work differently.