ANY QUESTIONS ABOUT COMMUNITY MEETING? 10/24/2016. Sandra L. Bloom, M.D Who are you? What are you feeling right now?

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1 Sandra L. Bloom, M. D. Dornsife School of Public Health, Drexel University Simple anytime, anywhere Grounds us to help make a transition Experience of predictable safety Honors emotions Levels hierarchy build team Keeps relationships at the forefront Who are you? What are you feeling right now? (just one) What is your goal for today s class? Who (at the table) can you ask for help if you need it? CREATING SANCTUARY TIMELINE ANY QUESTIONS ABOUT COMMUNITY MEETING? ACUTE INPATIENT ADOLESCENTS AND ADULTS GENERAL HOSPITAL PSYCHIATRY THE SANCTUARY PROGRAMS Multiple, interactive problems Polyvictimization Began in childhood, extended through adolescence and into adulthood

2 CREATING AND DESTROYING SANCTUARY TIMELINE COMPLEX EFFECTS ACUTE INPATIENT FOR ADULTS WHO WERE ABUSED AS CHILDREN Body Identity THE SANCTUARY PROGRAMS Relationships Meaning making 2001 When a person s life becomes fundamentally and unconsciously organized around the impact of chronic and toxic stress, even when this undermines their adaptive ability. They were in danger from themselves or others They could not keep themselves safe They did not know what safety was They didn t trust others and were very sensitive to betrayal of trust Experience with disrupted attachment impaired emotional regulation They had difficulties managing emotional arousal (dysregulation) They did not understand the connections between what they felt and problems from the past They wanted to stay emotionally numb rather than feel the pain of the previous experiences often through using drugs and/or alcohol The history of multiple disrupted attachments and the emotional dysregulation interfered with cognitive development. This impacted academic performance even in the context of normal or superior intelligence. As a result, they tended to make many repetitious mistakes and felt great shame and loneliness They were likely to lash out if something we did or said broke through that emotional numbness

3 They were unlikely to make the connection between their present problems and previous experiences (AMNESIA) They were unlikely to want to talk about their previous bad experiences (AVOIDANCE) They had no words for the worst parts of the experiences (ALEXITHYMIA) They could not communicate well inside themselves or with others (DISSOCIATION) They had all been exposed to the abusive use of power at the hands of someone else They did not know how to use their own personal power without hurting self or others They often engaged in bullying behavior or were bullied by others or both. Confused about right/wrong, fair play, social responsibility Balancing individual needs with the common good Extraordinary amount of repetitive loss Inability to grieve Failure to envision any alternative or positive futures Their past experience of chronic hyperarousal had compelled the development of coping skills to protect the CNS The symptoms we saw were the remnants of original adaptive and necessary coping skills. These coping skills had over time become bad habits that the person no longer could see or control. As a result, the capacity to create and sustain interpersonal trust was severely compromised Loss of emotional management Lack of basic safety/trust Problems with cognition Communication problems Children and Adults Problems with authority Confused sense of justice Inability to grieve and anticipate future TRAUMA ORGANIZED PERSON

4 Psychobiology of stress Impact of trauma Developmental neuroscience Social neuroscience Spiritual neuroscience THE BIG DEAL ABOUT TRAUMA CHILD DEVELOPMENT THE PROLONGED PROCESS OF INTEGRATION EMOTION SENSATION KNOWLEDGE AWARENESS YOU MORAL FRAMEWORK JUDGMENT Scientists now know a major ingredient in this developmental process is the serve and return relationship between children and their parents and other caregivers.

5 Brains are built over time, from the bottom up and keep developing until around age In infancy, 700 new neural connections are formed every second. Pruning follows rapid proliferation so that brain circuits become more efficient. Biological Regulation Moral Development Emotional Development Social Development Cognitive Development THE POISON IN OUR LIVES The wear-and-tear on the body and brain resulting from chronic over-activity of physiological systems that are normally involved in adaptation to environmental challenge

6 Poverty Racism Parenting alone Multigenerational caregiving Multiply challenged children Severe injury/illness in primary caregiver Severe medical/mental illness/injury in close family Irritability Impatience Depression Shame Poor quality decisions Substance abuse Violence Impaired parenting Intergenerational transmission RELENTLESS STRESS IN PARENTS Strong and prolonged activation of the body s stress management systems Particularly problematic during critical developmental periods Effects basic brain architecture 33 Fetal period when the basic structures of the brain are being organized Infancy and early childhood when the brain is doing much of its basic wiring Adolescence when changes in sex hormones are shaping and altering the way the brain processes chemical messages.

7 SMALLER BRAIN DEVELOPMENTAL INSULTS, DELAYS, DISTORTION CHRONIC HYPERAROUSAL STRESS HORMONES AFFECT IMMUNITY WHOLE BODY LEARNING MEMORY LANGAGUE 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) 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 The ACE Score is used to assess the total amount of stress during childhood and has demonstrated that as the number of ACE increase, the risk for the following health problems increases in a strong and graded fashion: 0 ACES 36% 1 ACES 26% 2 ACES 16% 3 ACES 10% 4 or more 7% Alcoholism and alcohol abuse COPD Depression Fetal death Health related quality of life Illicit drug use Heart disease Liver disease Autoimmune disease Obesity intimate partner violence Multiple sexual partners STDs Smoking Suicide attempts Unintended pregnancy Early smoking Adolescent pregnancy Cancer Stroke

8 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 5 or more DISEASES OF STRESS Twice as likely to smoke Seven times more like to be alcoholiccs 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 Negative emotions generated by stress trigger immune responses Same cascade as body deploys against physical pathogents Wears out heart muscles, vascular system heart disease, hypertension Autoimmune disease and other inflammatory processes Ten times more likely to have injected street drugs INFLAMMATION AND ACES Cardiovascular disease Digestive disorders Cancer Diabetes Pulmonary disease INFLAMMATION Neurological disorders Alzheimer s Arthritis Autoimmune disease

9 TRAUMATIC STRESS Occurs when both internal and external resources are inadequate to cope with external threat. Van der Kolk, 1989 ITS ALL ABOUT THE BRAIN AWARENESS EMOTION SENSATION BEHAVIOR Integrated Experience Can be recalled Weathering of memory Fight Flight Freeze Fear simultaneously initiates two informationprocessing systems: the low road and the high road (LeDoux, 1996).

10 24 milliseconds 12 milliseconds Epinephrine (adrenalin) The problem with extreme stress Heart Rate Under Stress State of high alert Inability to think clearly Extreme thoughts Attention to threat Intense and prolonged anxiety Driven to take action Hair trigger tempers Aggression Epinephrine (adrenalin) Cortisol Endorphins

11 Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an imaginable past. B. A. van der Kolk MD, Bessel (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma Knowledge Behavior Emotions MEMORY Sensation ALL TRAUMA IS PREVERBAL B. A. van der Kolk, The Body Keeps the Score One name for the Devil is Diabolos which means the divider, the splitter-into-fragments. Robin Skynner, Life and How to Survive It

12 Dissociation = A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment POST-TRAUMATIC REMINDERS - TRIGGERS FOR BEHAVIOR Triggered by sensory element Original fear revived Traumatic moment re experienced FLASHBACKS SIGHTS SOUNDS TASTES SMELLS PRESSURE PAIN BALANCE TEMPERATURE POSITION SPEED Haunting images Voices, words Disgust, eating problems Olfactory hallucinations Repelled by touch Recurrent or chronic pain Faint, falling over Cold, heat Lying down, being held Time perception

13 Loss of emotional management Daytime fatigue Sleep problems Irritability Always on edge Triggered outside of conscious awareness by otherwise normal environmental situations Avoid people, places, things, relationships Easily triggered by minor stimuli into fight flight freeze Intrusive experiences Experience danger everywhere can look like paranoia Avoidance people/places/thing Feelings, particularly positive feelings, disappear numb, shut down, depressed Haunting images Disturbing physical sensations Chronic fear Exhaustion Helplessness Hopelessness THE TRAUMATIZED BRAIN IN SHOCK LOSS OF INTEGRATED FUNCTION FRAGMENTED PERCEPTIONS, SENSATIONS ACTION INITIATED PERCEIVE DANGER CONSCIOUS AWARENESS OVERWHELMING EMOTIONS LANGUAGE CAPACITY OFF LINE NEURAL OVERLOAD 2 Fearless Fearless

14 LIFE IS UNPREDICTABLE LIFE IS INCOMPREHENSIBLE LIFE IS NOT MANAGEABLE LIFE NO LONGER HAS MEANING SHATTERED SENSE OF COHERENCE Community Friends, teachers, other adults Family Self

15 Substance use Avoidance of triggers Pain as a distraction Avoidance of grief Addiction Anxiety, phobias, Agoraphobia Self harming, Fighting Depression, suicidality Ramping down Habits Risky behavior Addiction to trauma Controlling behavior Alienation from others Dissociation Reenactment, revictimization Empowerment through violence Criminal, antisocial behavior Trapped in time Unconscious repetition of painful or negative relationships that become ingrained patterns over time and that are reenacted with other individuals or groups. Haunted by the past Unable to be fully present in the present Unable to envision a different future A sudden and passively endured trauma is relived repetitively, until the person learns to remember simultaneously the emotions and thoughts associated with trauma through access to language. 87 Repeat the traumatic past Those who cannot remember the past are condemned to repeat it (p284). George Santayana, 1905, The Life of Reason: Or, The Phases of Human Progress, Fearless COPING FAILURE OF INTEGRATION HABIT FORMATION

16 Personality disorder Depression Problems with cognition Communication problems Problems with authority Generalized anxiety disorder Panic disorder Conduct disorder Loss of emotional management Confused sense of justice Oppositional disorder ETC ETC ETC Lack of basic safety/trust Clients Inability to grieve and anticipate future TRAUMA ORGANIZED PERSON It s not What s wrong with you? It s What happened to you? Emotional Management Skills Cognitive Skills Communication Skills Leadership Skills Judgment Skills Safety Skills Children, Adults, Families Grieving and Imagination TRAUMA INFORMED RESPONSES WHO IS SUPPOSED TO HELP WITH THIS COMPLEXITY?

17 TASKS OF RECOVERY 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 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 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 Parents Educators Other Caregivers Mental health workers Child welfare workers Healthcare providers Law enforcement, Judiciary, Corrections, Probation, Parole Secure, reasonably healthy adults, With good emotional management skills, With intellectual and emotional intelligence, Able to actively teach and be a role model, Are consistently empathetic and patient, Able to endure intense emotional labor, Are self disciplined, self controlled and never abuse power

18 A growing proportion of the U.S. workforce will have been raised in disadvantaged environments that are associated with relatively high proportions of individuals with diminished cognitive and social skills. Knudsen, Heckman et al. (2006) Proceedings of the National Academy of Science TOO MUCH TO DO DEMANDS FUNDING POOR COMMUNICATION After law enforcement, persons employed in the mental health sector have the highest rates of all occupations of being victimized while at work or on duty. An interconnected, complex, adaptive, living world Problems with cognition Communication problems Problems with authority Organizations, like individuals, are living, complex, adaptive systems and that being alive, they are vulnerable to stress, particularly chronic and repetitive stress. Organizations, like individuals, can be traumatized and the result of traumatic experience can be as devastating for organizations as it is for individuals. Loss of emotional management Confused sense of justice Lack of basic safety/trust STAFF Inability to grieve and anticipate future TRAUMA ORGANIZED STAFF

19 ORGANIZATIONAL TRAUMA COMMUNICATION BREAKS DOWN FEEDBACK LOOPS ERODE RISK INCREASES

20 INTERPERSONAL CONFLICT INCREASES TASK CONFLICT DECREASES ORGANIZATIONAL DISSOCIATION

21 Silencing of dissent Authoritarianism Increased aggression Bullying as norm LOSS OF COMPLEX THINKING SKILLS Problems with cognition Communication problems Problems with authority Loss of emotional management Confused sense of justice DEMORALIZATION SYSTEM COLLAPSE Lack of basic safety/trust ORGANIZATION TRAUMA ORGANIZED SYSTEM Inability to grieve and anticipate future Expecting a protective environment and finding only more trauma. Dr. Stephen Silver (1986) An inpatient program for post traumatic stress disorder: Context as treatment. Trauma and Its Wake. When two or more systems whether these consist of individuals, groups, or organizations have significant relationships with one another, they tend to develop similar thoughts, feelings and behaviors. SANCTUARY TRAUMA K. K. Smith et al, 1989

22 CHRONIC ORGANIZATIONAL STRESS: WHAT NEEDS TO BE DONE? Reduce hyperarousal Establish safety to promote trust Provide emotional management tools and use them Clean up network of communication; re-establish feedback loops Identify and discuss the undiscussables Actively engage conflict management tools Focus on real teamwork CHRONIC ORGANIZATIONAL STRESS: WHAT NEEDS TO BE DONE? Recover forgotten strategies that work Identify repetitive and useless or even destructive patterns Engage the engageable; help others out the door Allow dissent, enable democratic processes, discourage authoritarianism Respond to every episode of aggression as a problem for and of the entire group Refuse to tolerate bullying Expect high, creative, innovative activities, thought, and action From diverse backgrounds With a wide variety of experiences On the same page Speaking the same language Sharing a consistent, coherent and practical theoretical framework CHANGING ORGANIZATIONAL CULTURE pattern of shared basic assumptions that a group has learned as it solved its problems and that has worked well enough to be considered valid and taught to new members Organizational Culture How we do things around here Will only happen when fear is not running the show Must include all levels of safety: physical, psychological, social and moral Must involve the people who comprise the system all of them Accumulated Wisdom Largely unconscious More transparency, honesty, openness cognitive and emotional. Unearth the skeletons and give them proper burial

23 CHANGING ORGANIZATIONAL CULTURE Must deal with power who has it, who abuses it, who wants it who/what has the power to heal? Must honor the past and allow grieving for what is lost, and know that all change involves loss. Awaken hope, get people moving, remobilize imagination and innovation. Social support Social support Social support Social support Social support Social support Social support Social support Social support WHAT IS A COMMUNITY? SHARED KNOWLEDGE Clients Staff Managers Systems SHARED VALUES SHARED LANGUAGE SHARED PRACTICE SHARED MISSION THE FOUR PILLARS THE SANCTUARY MODEL Trauma informed and trauma responsive Whole culture approach Clear and structured methodology Evidence supported Context for trauma specific treatment

24 Evolutionary neuroscience Developmental neuroscience Psychobiology of stress, toxic stress, allostatic load and traumatic stress UNIVERSAL PRINCIPLES Social neuroscience Group dynamics Spiritual neuroscience Healing and Recovery Resilience SHARED KNOWLEDGE THE SOLID FOUNDATION SHARED VALUES Those beliefs about human conduct Those that beliefs are common about human to human conduct rights that cultures are common around the to world, human regardless rights of gender, cultures ethnicity, around religious the world, belief, or regardless of gender, location on ethnicity, the globe.. religious belief, or location on the globe. SHARED VALUES THE SANCTUARY COMMITMENTS Social Responsibility Democracy Growth and Change Nonviolence Open Communication Emotional Intelligence Social Learning Nonviolence: Are we morally, socially, psychologically and physically safe with each other? Emotional Intelligence: Do we keep asking questions until we achieve understanding and get the whole story? Social Learning: Does our system guarantee that each of us learns the maximum knowledge from our mistakes? Open Communication: Are there blocks in our communication network? Social Responsibility: How do we balance the needs of individuals with the needs of the group? Democracy: Does everyone have an opportunity to truly participate? Growth and Change: Do we help people change by honoring their loss and envisioning the future? Nonviolence: Trust Emotional Intelligence: Recognizing patterns Social Learning: Constantly learning from failure Open Communication: Maintain flow of ideas Social Responsibility: Common goals, common focus Democracy: Everyone has a contribution to make Growth and Change: The heart of innovation SHARED VALUES THE SANCTUARY MODEL COMMITMENTS The Sanctuary Commitments structure the organizational norms that determine the organizational culture.

25 BOARD/REGULATOR DECISIONS LEADERSHIP DECISIONS DEPARTMENT DECISIONS TEAM DECISIONS CLIENT/CAREGIVER DECISIONS 10/24/2016 SANCTUARY COMMITMENTS THE SANCTUARY COMMITMENTS SHARED VALUES Democracy Growth & Change Social Responsibility Open Communication Nonviolence Emotional Intelligence Social Learning SHARED VALUES The defining, characteristic of a flying buttress is that it is not in contact with the wall it supports, like a traditional buttress, and so transmits the lateral forces across the span of intervening space between the wall and the pier. S.E.L.F. SANCTUARY TOOLKIT SHARED LANGUAGE KEY COMPASS POINTS TO PRODUCE ALIGNMENT FOR ANYBODY, ANYWHERE, ANYTIME S E L F WHAT ARE THE SAFETY ISSUES? WHAT ARE THE EMOTIONS? WHAT WILL WE HAVE TO GIVE UP TO CHANGE? WHY CHANGE? SHARED PRACTICE Those beliefs about human conduct A range that of are practical common skills to that human enable rights individuals cultures around and organizations the world, regardless to: of gender, ethnicity, religious belief, or more effectively deal location with difficult on the globe. situations build community. develop a deeper understanding of the effects of adversity and trauma PRIMARY: Trauma informed Universal knowledge about trauma, adversity and its effects with universal precautions. SHARED MISSION Those beliefs about human conduct that are common Children to human rights cultures around the world, regardless Adults of gender, ethnicity, religious belief, or Families location on the globe. Organizations. Systems Communities Society SECONDARY: Trauma responsive Policies and practices in place to minimize damage and maximize opportunities for healthy growth and development in populations at risk and in the staff who serve them. TERTIARY: Trauma specific Therapeutic interventions that specifically explore the trauma in the initial phases of therapy and then utilize those discoveries as a foundation as the therapy moves into current issues

26 TRAUMA INFORMED COMMUNITY TRAUMA RESPONSIVE SYSTEMS TRAUMA SPECIFIC TREATMENT TOWARD A TRAUMA-INFORMED PHILADELPHIA for public healthpractice/toward a trauma informed city/ Philadelphia ACEs Task Force CAMPAIGN FOR TRAUMA-INFORMED POLICY AND PRACTICE (CTIPP) The Sanctuary Model SANDRA L. BLOOM, M.D. ASSOCIATE PROFESSOR, HEALTH MANAGEMENT AND POLICY DORNSIFE SCHOOL OF PUBLIC HEALTH, DREXEL UNIVERSITY PHILADELPHIA, PA