Domestic Violence Trauma Informed Care. Version

Transcription

1 Domestic Violence Trama Informed Care Version

2 Introdction Victims of domestic violence, both adlts and children, are srvivors of tramatic experiences. Being hrt by someone yo love and who is a part of yor family can have serios conseqences on how srvivors of domestic violence think, act, and feel. In a 2010 srvey of Ohio s domestic violence programs, over 90% of respondents responded that most or all adlts and children who experience domestic violence have a tramatic experience that impacts their thoghts, feelings, or behaviors. Therefore, helping professionals working in domestic violence services and programs need a basic nderstanding of how tramatic experiences impacts srvivors. Understanding trama and trama reactions will inform and gide domestic violence staff in their interactions and decision-making process with adlts and children who seek services. 2

3 Introdction The idea, design, and creation process for this manal, Trama-Informed Care Best Practices and Protocols, has been one which has involved nmeros individals from arond the state of Ohio who have dedicated their time and expertise to ensring that the voices of women, children, and men who are victimized by the tramatic experiences of domestic violence are a central part of this docment. The time for trama-informed care is now! It is the right, ethical and jst approach to tilize in domestic violence programs, trainings and services becase we serve people with histories of violence, repeated harm and trama. 3

4 Understanding Trama 4

5 What is Domestic Violence Domestic violence is a pattern of coercive and assaltive behaviors inclding physical, sexal, and psychological attacks, as well as economic coercion, that adlts and adolescents se against their intimate partners. Domestic violence is not a single isolated attack, bt rather a pattern of mltiple tactics and repeated events. Domestic violence impacts people mch differently than stranger violence, de to the fact that an abser ses tactics sch as intimidation, isolation, coercion, control, emotional abse, financial control, and often physical and sexal violence against their partner. While physical assalt may occr infreqently, other forms of coercive behavior may occr daily. Anything that happens in the relationship bilds on past interactions and has a significant impact on the ftre. All tactics of the pattern interact with each other and have profond effects on the victims. 5

6 Domestic violence incldes a wide range of coercive behaviors with a wide range of conseqences, some physically injrios and some not; however, all are psychologically damaging. Some parts of the pattern are clearly chargeable as crimes in most states sch as: Physical assalt Sexal assalt Menacing Arson Kidnapping Harassment Other battering episodes that are not illegal: Name calling Interrogating children Denying access to the family atomobile Control of financial resorces 6

7 Srvivors of domestic violence often report that the psychological impact of domestic violence has been even more damaging in the long term than physical incidents of violence. Srvivors often state, Brises heal, bt internal scars seem to stay forever. 7

8 What is Trama 8

9 A hallmark of tramatic experience is that it typically overwhelms an individal mentally, emotionally, and physically. When working with srvivors of domestic violence, an advocate s first concern is often that of establishing physical safety for the srvivor and helping the srvivor work throgh the immediate crisis. Focsing on physical and emotional safety is important and effective work that advocates do, and or approach to advocacy shold be informed by a thorogh nderstanding of trama. Althogh it is obvios that experiencing abse at the hands of an intimate partner is tramatic, it can be difficlt to view domestic violence throgh the lens of trama dring daily advocacy activities. Certainly, advocates will be more effective and responsive to the needs of srvivors if they nderstand domestic violence in the context of trama. 9

10 The common denominator of psychological trama, according to the Comprehensive Textbook of Psychiatry, is a feeling of intense fear, helplessness, loss of control, and threat of annihilation. Srvivors of domestic violence certainly experience these feelings as they enconter violence at the hands of their partners. In addition, trama typically involves threats to harm a person or an enconter with violence. Again, this certainly applies to the sitations of domestic violence srvivors. Tramatic events are so devastating to people that they interfere with or ability to cope with what life throws at s. These events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning, and leave people feeling powerless. People are often changed by trama in many ways, and those changes can be pretty significant. Trama often impacts all parts of a person s life, at least for a period of time. The following sections of this chapter explain some of these changes that may occr for srvivors as well as how tramatic responses may manifest in or interactions with the women we serve. 10

11 What is it abot an event that makes it tramatic? A person can become tramatized when his/her ability to respond to a perceived threat is in some way overwhelmed. A tramatic experience can impact a person in obvios and sbtle ways. Trama is in the eye of the beholder. What one person may consider tramatic may not be tramatic to another person. Tramatic reactions are NORMAL responses to ABNORMAL sitations. 11

12 What impacts how individals respond to trama? Many people who have stdied the responses of individals to tramatic sitations have noticed that different people have vastly different responses to trama. Researchers have identified several factors that impact how people respond to trama. It is important to note that the impact of a tramatic event that occrs once (sch as a natral disaster or a car accident) is often very different than the common responses to ongoing chronic tramatic stress, sch as sitations of abse at the hands of a family member. The following factors inflence how people respond to trama. 12

13 History and crrent fnctioning When people are experiencing stress and are having difficlty fnctioning, and/or have a history of trama or abse, trama reactions may be more severe. Characteristics of the tramatic event When tramatic experiences are chronic and severe and sometimes occr across the lifespan, trama reactions may be more severe. Cltre How a particlar event is viewed or nderstood by a specific cltral grop may impact the ways in which people respond. When the trama occrred/began occrring in life When trama occrs at a yong age or when the sorce of trama is someone the person knows and has a close relationship with, trama reactions are more severe. Natre of relationships and social spports When early relationships in life were difficlt and the person has limited social spport, trama reactions are more severe. 13

14 What is Trama-Informed Care 14

15 Trama-informed care views service provision throgh a lens of trama. It involves having a basic nderstanding of trama and how trama impacts srvivors, nderstanding trama triggers and niqe vlnerabilities of trama srvivors, and designing services to acknowledge the impact of violence and trama on people's lives. Finally, a tramainformed approach is sensitive and respectfl: advocates seek to respond to tramatized individals with spportive intent and consciosly avoid re-tramatization. It is critically important for trama-informed services to strive to do no harm 15

16 The Center for Mental Health Services National Center For Trama Informed Care (NCTIC) cites that a trama-informed approach is based on the recognition that many behaviors and responses expressed by srvivors are directly related to tramatic experiences. Often behaviors sch as hyperarosal, constriction, and other responses to trama are viewed as symptoms of a mental health condition, when in fact these are normal responses to tramatic experiences. 16

17 Characteristics of Trama-Informed Trama-informed services are not specific types of services, bt share a set of principles that place trama at the center of or nderstanding of srvivors we are working with. Any agency, regardless of the services they provide, can become trama-informed. In fact, it is wise to consider trama-informed care as a niversal precation becase a hge percentage of people we serve in a wide variety of social services have experienced trama, and many have long histories of tramatic stress. Likewise, regardless of yor agency, yor position or what type of work yo do, yo can become a trama-informed service provider. 17

18 Trama-Informed Services Focs on nderstanding the whole individal and context of his or her life experience Infsed with knowledge abot the roles that violence and victimization play in the lives of women Designed to minimize the possibilities of victimization and re-victimization Hospitable and engaging for srvivors Facilitates recovery Facilitates growth, resilience and healing Respect a woman s choices and control over her recovery Form a relationship based in partnership with the srvivor, minimizing the power imbalance between advocate and srvivor Emphasize women s strengths Focs on trst and safety Collaborate with non-traditional and expanded commnity spports (sch as faith commnities, friends and families, etc.) Provide cltrally competent and sensitive services 18

19 Dynamics of Domestic Violence 19

20 20

21 The perpetrator is working towards dominating the srvivor psychologically, which occrs by: Systematic, repetitive infliction of psychological trama, which reslt in disempowerment and disconnection Sometimes the perpetrator ses violence, bt sometimes not. It often isn t necessary to se violence to keep the victim in a state of fear, becase of past experiences with abser, so sometimes threats and intimidation work effectively. Inconsistent and npredictable otbrsts Yelling and belittling a srvivor, and often inslting the srvivor in extremely personal and painfl ways Undermining her perception of her abilities and options 21

22 How Domestic Violence Differs from Other Tramatic Experiences 22

23 Domestic violence is, by its natre, chronic There are not discreet episodes of trama; rather, domestic violence is an ongoing tramatic experience for all members of the family. While the physical violence may be episodic and/or infreqent, the other forms of abse are ongoing and complicate the srvivor s experience of trama. The perpetrator of the tramatic experience is a loved one with whom the srvivor is connected to in mltiple ways Most srvivors will be interacting with their perpetrator on a reglar basis. The violation of trst and disrption to interpersonal connections is more severe de to trama occrring in context of an intimate relationship. The abser (the sorce of tramatic stress) often remains to be a part of a srvivor s life, even if a srvivor leaves a relationship. Often leaving the relationship cases an escalation in danger, both physically and emotionally. Most srvivors will be interacting with the abser on a reglar basis for many reasons, whether still in the relationship or after leaving the relationship. In many models of nderstanding trama, the tramatic event (war or an assalt) is over and the person is no longer living in a sitation where they are in danger. This is not tre for domestic violence srvivors. 23

24 Domestic Violence, Trama, and Mental Health Symptoms 24

25 One of the fndamental principles of the battered women s movement is the belief that women who are in absive relationships aren t in them becase of mental illness or disorder. While some women do need additional services to address isses of depression, anxiety or other mental health disorders, a lot of women who we wold call depressed find themselves feeling remarkably better when they are able to be in an environment where they are safe and feel spported. The potential conseqences of being labeled with a mental health diagnosis can have enormos implications in many areas of the srvivor s life, particlarly arond isses of parenting and child cstody. Therefore, it is important to remember a few key points: 25

26 Everyone deserves or high qality services, regardless of mental health condition Many women who have been diagnosed with mental health conditions were not asked abot their relationships or trama histories, and were diagnosed de to symptoms that cold be trama reactions Many normal responses to trama (sch as depression, anxiety or hyperarosal) are criteria sed to diagnose mental disorders It is important to share information abot trama with srvivors, so that their reactions and responses can be normalized; instead of feeling crazy, srvivors are validated rather than frther stigmatized. 26

27 Brain Processes Dring Trama The latest research on trama has given s information abot how trama affects the brain. Althogh the action of trama on brain processes is not flly nderstood, the following will give a brief overview of crrent knowledge abot the brain s role in processing tramatic experiences. While brain processes are extremely complicated, we will provide a simple overview of how trama impacts the brain. There are two important parts of or brain that are involved when we respond to danger: 27

28 The DOING brain. Called the amygdala, this part of the brain is located in the limbic system where response to threat, extreme danger, and intense emotion occrs. This is designed to act as a smoke alarm that goes off when or brain thinks we are in danger. It is designed to help s take care of orselves. The THINKING brain. This part of the brain, called the pre-frontal cortex or cerebrm, helps s plan, problem-solve, and organize the world arond s. It helps s analyze sitations rationally and make thoghtfl decisions. 28

29 Fight, Flight, or Freeze Reactions At the time when people experience tramatic events, a nmber of physiological changes immediately occr in their bodies. It is important to note that individals do not control these instinctive reactions to signs of danger. Rather, it is a part of the way that or body is wired to respond to perceived danger and keep s safe. These changes are often characterized as fight, flight, or freeze reactions. These phenomena are explained in the following section. 29

30 Fight Flight Freeze The person responds by fighting back when faced with tramatic event with physical or verbal resistance. A good example of this is the response of soldiers in combat. In the face of trama, the person s reaction is to flee the sitation. The body mobilizes to leave the tramatic experience. Natre provides many examples of animals fleeing dangeros sitations. This tramatic response involves a shtting down of physical reactions to the violence that is occrring. Srvivors may have feelings of being nable to move and/or may instinctally freeze to endre the trama. Women may be more likely to have this type of reaction as they are socialized by both cltre and religion to yield in the face of powerfl events. It s important to recognize that srvivors sally do not consciosly choose their particlar fight, flight, or freeze response. In addition, srvivors may have very deep feelings of shock or shame abot how they reacted in dring moments of trama. 30

31 Trama Triggers Triggers are those events or sitations which in some way resemble or symbolize a past trama to individal srvivors. These triggers case the body to retrn to the fight, flight, or freeze reaction common to tramatic sitations. When triggered, srvivors do not necessarily retrn to a fll-blown tramatic response, bt may experience discomfort or emotional or physical distress. Events or sitations that might otherwise be insignificant become associated with the srvivor s trama. Similar events or sitations may become triggers that indicate danger to a srvivor. Sometimes a srvivor is very aware of the ways in which certain events impact her, while other times she might not be naware of what is triggering her reaction. We can help her nderstanding that the her response is her body s natral way of keeping her safe and does not indicate that she is going crazy or is ot of control. 31

32 Common Trama Triggers Being aware of these common triggers provides programs with information that can be sed to make changes that will redce triggers. Common triggers inclde: Reminders of past events Smells Lack of power and control Sonds Conflict in relationships Movements Separation or loss Objects Transitions and schedle disrptions Anniversaries Feelings of vlnerability or rejection Significant life events Feelings of being threatened or attacked Any event that resembles or symbolizes the trama Loneliness Sensory overload 32

33 Three Common Trama Responses The three categories of tramatic responses are not individal and discrete, however. They overlap and intertwine and may occr in an oscillating pattern for srvivors of violence. Hyperarosal This refers to the physiological changes that occr in the brains of trama srvivors which prepare them for fight, flight, or freeze on a contining basis. Being in a state of hyperarosal leads the srvivor to startle easily, be constantly on the alert for danger, and be very sensitive to the reactions of others. Intrsion or re-experiencing events These symptoms refer to the experience of the trama intrding pon a srvivor s life after the trama is over. Intrsion may inclde nightmares, flashbacks, or intrsive images. There is a sense of re-experiencing the tramatic event that is ot of the control of the srvivor. Constriction or avoidance This refers to the narrowing down of consciosness or nmbing of feelings and thoghts associated with the tramatic sitation. In constriction, the srvivor avoids all circmstances associated with the trama and may withdraw from others in an attempt for emotional safety. 33

34 Emotional Reactions to Trama This is a list of ways in which srvivors emotionally react to trama. Historically, many helping professionals have viewed these reactions negatively, sometimes viewing them as evidence that something is wrong with the trama srvivor. A trama-informed approach nderstands these reactions as the srvivor trying to process their experiences, attempting to cope with extremely difficlt sitations, and does not view them as evidence of a srvivor s problems, bad decisions, personal shortcoming, or weaknesses. 34

35 Shock and disbelief Fear and/or anxiety Grief Gilt or shame Denial or minimization Depression or sadness Anger or irritability Panic Apprehension Despair Hopelessness Increased need for control Emotional nmbing Difficlty trsting Mood swings Feeling isolated Intensified or inappropriate emotions Emotional otbrsts Feeling overwhelmed Diminished interest in activities Desire to withdraw Spontaneos crying Exaggerated startle response Feelings of powerlessness Emotional detachment Feeling lost or abandoned Hyper-alertness or hypervigilance Re-experiencing of the trama 35

36 Psychological and Cognitive Reactions to Trama Being sensitive to the normal reactions to abnormal experiences will make services more effective and empowering to srvivors. When working with srvivors, taking the following trama reactions into accont is critically important to effective advocacy with srvivors. Below are some of the ways in which trama impacts how people think: Difficlty concentrating Slowed thinking Difficlty making decisions Confsion Difficlty with figres Blaming self or others Poor attention span Mental rigidity Disorientation Uncertainty Memory difficlties Difficlty with problem solving Nightmares Flashbacks Intrsive thoghts Distressing dreams Sspiciosness 36

37 Physical Reactions The ways in which srvivors are impacted by hyperarosal, intrsive reactions, and avoidance reactions does create physical responses for people, and domestic violence programs need to be aware of these physical reactions and make the services we provide accommodating to these realities. Sleep distrbance Aches and pains Appetite distrbance Increased ssceptibility to illness Fatige Fainting Inability to rest Dizziness Angry otbrsts Weakness Rapid heartbeat Grinding of teeth Nasea or pset stomach 37

38 Becase bodies express what cannot be verbalized, tramatic memories are often transformed into physical otcomes inclding: Chronic pain Gynecological difficlties Gastrointestinal problems Asthma Heart palpitations Headaches Mscloskeletal difficlties Chronic danger and anticipation of violence stresses the immne and other bodily systems, leading to increased ssceptibility to illness. Other Difficlties Associated with Tramatic Experiences: Eating problems Sbstance abse Problems in relationships Physical problems that doctors can t diagnose Self-harmfl behavior, self-mtilation Sexal difficlties: promiscity, dangeros sexal practices, or denial of sexality 38

39 Behavioral Reactions One of the biggest areas of life in which trama impacts individals is how they act with others, which directly relates to their relationships with other people, with helping professionals, and even their nderstanding of their self and the world. Becase recovery from trama occrs in the context of relationships, it is important for trama srvivors to be able to re-establish safe connections with others. Change in interaction with others Withdrawal or isolation Decrease of hmor Irritation with others Lack of patience Change in how people relate with each other and the world Avoiding people, places and things that remind yo of the event Implsivity Self-injry Alcohol and drg se to cope with ncomfortable trama symptoms Trying to avoid thoghts, feelings, or conversations abot the trama 39

40 Impact of Trama on Belief Systems Particlarly in the context of domestic violence, srvivors often report that their views of the world or their vales have been fndamentally altered by their experiences. Often srvivors have difficltly reconciling the reality that the person who promised to love them also hrt them deeply. In addition, if the srvivor soght help from a system that she didn t view as helpfl or spportive (sch as the police or a shelter), she might no longer believe that police, corts, or even shelter advocates are there to help her, and might decide that she mst deal with anything in the ftre on her own. Srvivors who stay with their partners might feel like they have disappointed advocates who are working with them, so they might not contact them in the ftre. Some srvivors who have managed to escape an absive relationship report that their trst in intimate partners has been destroyed, and do not want to enter other relationships. 40

41 Cltral Isses in the Experience of Trama Advocates can begin by exploring and discssing the meaning of violence within the srvivor s family and cltre. This shold be done with all women as it shold not be assmed that the advocate and the woman have the same cltral frame of reference, even if they come from the same cltral grop. Advocates may need to work to reframe the srvivor s experience of domestic violence while respecting her cltral norms and traditions. 41

42 Some considerations to keep in mind when working with all srvivors: Early Messages What early messages did she receive abot violence in general? Abot domestic violence? How does her family view domestic violence? Political Trama Is she from a region or contry where there has been political nrest or violence? Has she or other family members been sbjected to wars or other civil nrest? What does this mean to her crrent trama experience? Was she raped or tortred as a part of political oppression? Environmental Trama Has she been exposed to other tramas by virte of living in a particlar region or contry? Is she a target for racism, heterosexism, or ableism in addition to her experience of domestic violence? How do these other oppressions impact her experience of trama and access to services? Safety Planning Safety planning is a niqe process for every woman, and advocates need to attend to the implications of cltre when discssing safety planning activities. A onesize-fits-all approach to safety planning may be dangeros for battered women from any and all cltres. 42

43 What Promotes Healing from Trama? Social spport plays a critical role in the process of healing from trama. Tramatic life events case damage to relationships (both in people s natral spport system and when working with helpers), so the response of the person s social spport system can facilitate healing from trama or case more damage and make healing more difficlt. Often trama has damaged a person s sense of self, and that sense of self can only be rebilt in the context of connection with others. 43

44 Often the srvivor craves the presence of a sympathetic and empathetic person. Becase trama and domestic violence are sch isolating experiences, srvivors have had their belief in the world as a safe place shattered. Victims often need clear assrances that they will not be abandoned again. Often in the aftermath of domestic violence, a victim is still in danger. In many cases, a victim of domestic violence cannot assme that they will have a spportive social system or commnity that will help her. If a srvivor of trama meets with a helpfl response, the care and protection of family, friends, and helpers can have a strong healing inflence. This helps a srvivor re-establish a sense of trst and safety, and provides srvivors with the opportnity to process throgh their experiences in ways that no longer dominate their lives. After a srvivor regains a sense of basic safety, the srvivor needs the help of others to rebild a positive view of themselves 44

45 Sggestions from Srvivors on How to Best Spport Them Lesson One: Spport Client Strengths, Competencies, and Resorceflness Don t treat srvivors as people who are different or damaged. This makes it more difficlt to see srvivors strengths and to trst that they know what is best for them. The professional s role is to norish, encorage, assist, spport, and stimlate strengths within the srvivor. Lesson Two: Listen, Accept and Honor Stories of Sffering Sometimes helpers respond negatively to stories of tramatic experiences by doing sch things as minimizing its significance, ignoring stories, or showing that they are ncomfortable with hearing the trama. This can make srvivors feel silenced. Create a safe, accepting and respectfl space for srvivors to share their stories. 45

46 Lesson Three: Convey an Otlook of Hope and Possibility Don t cast a shadow (from the past) on srvivor s abilities to srvive, persevere, and eventally thrive. Let srvivors know that healing can occr for anyone. Remember that change is happening all the time and that srvivors are in the healing process. Sometimes jst showing p for services is an important step. Be patient with srvivors and don t rsh into fixing srvivors; instead, provide srvivors with hope and reassrance that they will discover the answer for fixing themselves. Lesson For: Commnicate Empathy, Acceptance and Compassion Convey compassion throgh bearing witness to srvivors sffering and expressing a desire to relieve it. Show a willingness to nderstand the worlds that srvivors navigate, which allows helpers to accompany them in their healing jorneys. Helpers need to focs on nderstanding people, not fixing them. Think abot trying to nderstand srvivors from within the relationship as opposed to otside the relationship. Let go of professional expectations, assmptions, and the desire to jdge a person s behavior/motives. 46

47 Lesson Five: Demonstrate Hmility Both the helper s and the srvivor s expertise are crcially important. Let go of the idea that helpers know more and ths are sperior to the srvivor. It might not be effective to say things sch as, Yo re the expert withot also offering inpt, gidance, or information. Helpers do not need to discard their backgrond, skills, or knowledge. Yor expertise is essential in helping and spporting srvivors in their healing jorneys. Draw from both the experiences of srvivors and of helpers, and acknowledge that both of yo have important roles and ways to facilitate healing. Lesson Six: Spport Self-Determination Spport each srvivor in discovering her own point of view, her own choices, and her own vision of the ftre. Acknowledge that srvivors often have had their self-esteem and feelings of selfworth damaged, and they often need additional spport and encoragement. 47

48 Lesson Seven: See the Person, Not the Diagnosis Remember that trama symptoms often look like many symptoms sed to diagnose mental health disorders. 0nly a licensed individal shold be determining mental health diagnosis, bt it is important to nderstand the ways in which mental health systems have often not incorporated a trama-informed framework into providing treatment. Generally these systems have overemphasized symptoms and deficits instead of focsing on srvivor competencies, capabilities and desires. A diagnosis shold never be viewed as a crcial featre of a srvivor s identity. 48

49 How we are with Srvivors Effective advocates who work with trama srvivors behave in several important ways: Be empathetic: Srvivors need to feel spported and nderstood, not pitied. This incldes commnicating an nderstanding of the person s feelings, and acknowledging those feelings are real and important. Be flexible: To demonstrate care and concern, advocates mst be flexible. Some srvivors need to talk for a long time abot their experiences, while other srvivors find this extremely painfl. This can inclde being willing to change normal rotines and procedres to accommodate the niqe sitations of individals. 49

50 Be self-aware: Being aware of yor thoghts, feelings, and how they come across will make trama srvivors feel safer in sharing their feelings with yo. This will lead to a stronger relationship. Be able to reglate yor own emotions: Srvivors may come to yo nable to reglate their own emotions de to the trama they have experienced, so it is yor job to keep yor emotions nder control. Be willing to learn from srvivors: Respect and acknowledge and celebrate that srvivors are the experts in their lives. Providing srvivors with opportnities to teach s abot their world and their needs is the best way to become knowledgeable and make sre yor help is actally helpfl. Be willing to connect emotionally with the trama srvivor s experiences of trama: Feelings and emotions play a central role in yor work with srvivors. Srvivors will feel geninely accepted and cared for when yo can connect emotionally with them. 50

51 Be a good listener: Actively listen to srvivors and focs solely on what they are saying, which shows that what happened to them is important. Be comfortable with the nknown: No two people experience trama in the same way. It is okay that yo have not had the same experience as the srvivor, bt yor empathy is still critically important. Believe in hope and recovery: As an advocate, yo mst believe that srvivors can go on to live better days, and that people can recover from trama and lead flfilling lives after their experiences. 51