WHAT S THE BIG DEAL ABOUT TRAUMA?

Transcription

1 WHAT S THE BIG DEAL ABOUT TRAUMA?

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3 BETWEEN 2001 AND JUNE 30, ,245 Americans were KILLED in AFGHANISTAN 4,199 people were KILLED in PHILADELPHIA

4 Police say the violence in neighborhoods has become so commonplace that many residents have mentally checked out, too desensitized to take an effective stand agains the people who turn their communities into war zones and force their children to learn to duck at the sound of gunfire before they ve even started school (p.4).

5 HEALING HURT PEOPLE 5

6 Positive Traumatic Tolerable STRESS Toxic Relentless

7 Our inner cities are plagued by an epidemic of urban violence that affects our nation s children on a daily basis. The hippocampus plays a role in new learning and memory. If stress impairs the ability of children to learn, this could have important public health implications. Bremner, 1999 Does Stress Damage the Brain?

8 Cholera epidemic killed 150,000 Americans In 1850, women had about a one in five chance of dying in childbirth. 19 th Century breakthrough: germ theory of disease proposed that microorganisms are the cause of many diseases. Although highly controversial when first proposed, germ theory was validated by the late 19th century, but not before U.S. President Garfield died needlessly in 1881

9 Then it was germs, now it is violence and the clock is ticking for every child in America

10 HALF A CENTURY OF ACCUMULATED SCIENTIFIC RESEARCH THE PSYCHOBIOLOGY OF ATTACHMENT & CHILD DEVELOPMENT THE PSYCHOBIOLOGY OF STRESS THE NEGATIVE IMPACT OF PUNISHMENT THE MAGNITUDE OF CHILDHOOD EXPOSURE TO VIOLENCE AND THE DAMAGE THAT CAUSES TO BRAIN, BODY AND MIND

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12 Exposure to systematic adversity and trauma as a central organizing principle of human thought, feeling, belief, and behavior that is largely overlooked in existing explanations of and responses to human behavior.

13 a philosophical or theoretical framework P A R A D I G M

14 DEEPLY HELD ASSUMPTIONS THAT: Are largely unconscious Determine much of what we think, feel and do Help our brains automatically organize information. Are self reinforcing

15 SICK? BAD? MENTAL SICK HEALTH & SYSTEM BAD?

16 INJURED! MENTAL HEALTH SYSTEM

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18 Brains are built over time, from the bottom up 700 new neural connections are formed every second. After this period of rapid proliferation, connections are reduced through a process called pruning, so that brain circuits become more efficient.

19 Scientists now know a major ingredient in this developmental process is the serve and return relationship between children and their parents and other caregivers.

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21 Allow us to have a theory of the minds and hearts of others Allow us to use this information to modulate and guide our interactions with those around us Enables us to maintain a sense of self and others Governs moral reasoning Governs humor

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23 Diminished corpus callosum size = decreased right left cortical integration Diminished left hemisphere development (language) Diminished left hippocampal volume (memory & learning) Increased EEG abnormalities

24 Impairs connection of brain circuits and in extreme cases, results in smaller brain development Development of low threshold for stress, resulting in over reactivity (chronic hyperarousal) High levels of stress hormones, including cortisol, can suppress body s immune response Sustained high levels of cortisol can damage the hippocampus, responsible for learning and memory. Cognitive deficits can continue into adulthood.

25 Adolescent delinquents show delayed frontal lobe development At present most research seems to support the idea that the ORBITAL MEDIAL PREFRONTAL CORTEX is at the heart of antisocial pathology

26 What society does to its children, its children will do to society. Cicero, B.C.E.

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28 In 1998, largest study of its kind ever (almost 18,000 participants) Examined the health and social effects of adverse childhood experiences over the lifespan Majority of participants were 50 or older (62%), were white (77%) and had attended college (72%). THE ADVERSE CHILDHOOD EXPERIENCES STUDY (ACEs STUDY)

29 PHYSICAL ABUSE SEXUAL ABUSE EMOTIONAL ABUSE PHYSICAL NEGLECT EMOTIONAL NEGLECT MENTAL ILLNESS SUBSTANCE ABUSE DOMESTIC VIOLENCE PARENTAL SEPARATION/DIVORCE INCARCERATION 1 POINT /CATEGORY ADD TO GET TOTAL ACE SCORE

30 0 ACES 36% 1 ACES 26% 2 ACES 16% 3 ACES 10% 4 or more 7%

31 HEART DISEASE PULMONARY DISEASE HEPATITIS DIABETES OBESITY STD S

32 DEPRESSION SUICIDE ATTEMPTS REVICTIMIZATION TEEN PREGNANCY

33 ALCOHOLISM OTHER SUBSTANCE ABUSE

34 POOR SELF RATED HEALTH POOR JOB PERFORMANCE VIOLENT RELATIONSHIPS

35 Given an exposure to one category As the number of ACE increases there is 80% likelihood of exposure to another. the number of comorbid conditions increases.

36 Adverse Childhood Experiences play a significant role in determining the likelihood of the ten most common causes of death in the United States. ACE Score of 0 majority of adults have few, if any, risk factors for these diseases. ACE Score of 4 or more majority of adults have multiple risk factors for these

37 ACEs In Adults Five States, 2009 (December, 2010) Arkansas, Louisiana, New Mexico, Tennessee, Washington Sample = 26, % ACEs score 1 or more 9% 5 or more ACEs No significant racial, ethnic differences

38 Twice as likely to smoke Seven times more like to be alcoholic Six times more likely to have had sex before the age of 15 Twice as likely to have been diagnosed with cancer Twice as likely to have heart disease Four times as likely to suffer from emphysema or chronic bronchitis Twelve times as likely to have attempted suicide Ten times more likely to have injected street drugs

39 States With ACE Studies ?? 21 States No data Source: Behavioral Risk Factor Surveillance System, CDC.

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41 JUSTICE DEPARTMENT RELEASES SURVEY FINDINGS OF THE NATURE AND EXTENT OF CHILDREN S EXPOSURE TO VIOLENCE More than 60% of the children surveyed were exposed to violence within the past year, either directly or indirectly. Nearly ½ of the children and adolescents surveyed were assaulted at least once in the past year, and more than 1 in 10 were injured as a result. Nearly ¼ of respondents were victim of a robbery, vandalism or theft 1/10 of respondents were victims of child maltreatment, including physical and emotional abuse, neglect, or family adduction 1 in 16 were victimized sexually

42 Dr. Hallam Hurt, neonatologist; babies, ½ in utero cocaine exposure By age 6, lags in developmental and intellectual measures If it wasn t cocaine, what was it? By age 7: 81% had seen someone arrested 74% had heard gunshots 35% had seen someone get shot 19% had seen a dead body outside Conclusion: Poverty is a more powerful influence on the outcome of inner city children than gestational exposure to cocaine

43 ADVERSE CHILDHOOD EXPERIENCES

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46 State of high alert Inability to think clearly Extreme thoughts Attention to threat Intense and prolonged anxiety Drive to take action

47 Epinephrine (adrenalin) Cortisol Beta endorphins

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51 FLASHBACKS: Recurring intrusive recollections of traumatic event CHRONIC HYPERAROUSAL: Persistent symptoms of increased physiological hyperarousal DEAD INSIDE: Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness

52 POST TRAUMATIC STRESS DISORDER 77% of patients had full blown PTSD 50% of patients had an ACE Score of 4 or more CHILDHOOD ADVERSITY

53 PTSD appears to represent a maladaptive generalized activation of the alarm response, with symptoms representing exaggerations of appropriate functions: hypervigilance instead of appropriate prediction and early detection of future danger avoidance and re enactment rather than adaptation and survival.

54 An abnormal reaction to an abnormal situation is normal behavior. Viktor Frankl, M.D., PhD. Nazi Concentration Camp Survivor

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57 TRAUMA SHATTERS THE SENSE THAT WE CAN UNDERSTAND, MANAGE, AND FIND MEANING IN OUR WORLD

58 MALADAPTIVE COPING ADAPTIVE COPING

59 capacity of a system, enterprise, or a person to maintain its core purpose and integrity in the face of dramatically changed circumstances

60 Social support Social support Social support Social support Social support Social support Social support Social support Social support

61 Community Friends, teachers, other adults Family Self

62 SENSE OF COHERENCE (Antonovsky, 1979) COMPREHENSIBILITY: the ability for people to understand what happens around them MANAGEABILITY: to what extent they were able to manage the situation on their own or through significant others in their social network MEANINGFULNESS: the ability to find meaning in the situation.

63 RESILIENCE

64 Substance use Avoidance of triggers Pain as a distraction Avoidance of grief Risky behavior Controlling behavior Dissociation Empowerment through violence Addiction Anxiety, phobias, agoraphobia Self harming Depression, suicidality Addiction to trauma Alienation from others Reenactment, revictimization Criminal, antisocial behavior

65 Many traumatized people expose themselves, seemingly compulsively, to situations reminiscent of the original trauma. It includes creating relationship patterns that repeat earlier life experiences This includes reenacting the event or putting oneself in situations where the event is likely to happen again. These behavioral reenactments are rarely consciously understood to be related to earlier life experiences.

66 Problems with cognition Communication problems Problems with authority Loss of emotional management Confused sense of justice Lack of basic safety/trust Children, Adults, Families Inability to grieve and anticipate future TRAUMA ORGANIZED PERSON

67 Cognitive Skills Communication Skills Leadership Skills Emotional Management Skills Judgment Skills Safety Skills Children, Adults, Families Grieving and Imagination TRAUMA INFORMED RESPONSES

68 HOW DO WE TREAT TRAUMA? CAN PEOPLE SUFFERING FROM TRAUMA HEAL?

69 Chronic Stress: Biological stabilization Basic Safety and Trust: Safety skills with supportive people Loss of Emotional Management: Emotional management skills Miscommunication and Alexithymia: Communication skills, words for feelings

70 Dissociation, Fragmentation: Grounding, reconstruction of memory, integration: trauma specific approaches Systematic Error and Reenactment: Pattern recognition and change Impaired Executive Function: Healthier use of power and executive functions self control, self discipline Impaired Cognition: Better judgment, decision making

71 Inadequate relationship skills: Social skills, relationships Learned Helplessness: Mastery Experiences Aggression: Ability to manage aggressive impulses Unresolved Grief: Mourning for what is lost Demoralization and Failure of Imagination: Belonging to a meaningful, worthwhile, nonviolent and caring culture & Imagining a different and better future

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73 Safety Regulation of basic physical functions Management of intrusions Control over self destructive behaviors Remembrance, Integration, Mourning Paced, in depth exploration of trauma Integration of memory, feelings, thoughts, not just catharsis Period of intense grieving Reconnection With others

74 HEALING HURT PEOPLE PROCESS

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76 SAFETY EMOTIONS LOSS FUTURE S.E.L.F.: A compass to guide change

77 SAFETY IS THE CORNERSTONE

78 FOUR KINDS OF SAFETY

79 EMOTIONS

80 LOSS

81 FUTURE

82 What are the Safety issues for this person (for myself) at this time? Physical, psychological, social, moral What are the Emotional management issues? Mad, Sad, Glad, Scared, Shamed What are the Loss issues? What losses has person already had? What will he/she have to lose to change? What are the Future issues? Why change? What is the goal(s)?

83 I walk down the street There is a deep hole in the sidewalk I fall in I am lost... I am helpless It isn't my fault. It takes forever to find a way out. By Portia Nelson

84 I walk down the same street, There is a deep hole in the sidewalk, I pretend I don't see it. I fall in again. I can't believe I am in the same place. But it isn't my fault. It still takes a long time to get out.

85 I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I still fall in... it's a habit. My eyes are open. I know where I am. It is my fault. I get out immediately

86 I walk down the same street. There is a deep hole in the sidewalk. I walk around it.

87 YOUR FUTURE AHEAD I walk down a different street.

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89 SANDRA L. BLOOM, M.D. CO DIRECTOR, CENTER FOR NONVIOLENCE AND SOCIAL JUSTICE SCHOOL OF PUBLIC HEALTH, DREXEL UNIVERSITY