Trauma-Informed Care Part I SCOTT R. PETERSEN, LCSW, CAC III DEBORAH BORNE, MSW, MD

Trauma-Informed Care Part I SCOTT R. PETERSEN, LCSW, CAC III DEBORAH BORNE, MSW, MD

Getting To Know You

Our Goals Expose you to the concept and principles of Trauma Informed Care Plant the seeds for further conversation and implementation at your setting Understand that trauma informed care is a long and ongoing process Take something back for yourself..

Goals PART 1 Explain the nature of traumatic stress. Explore the relationship between homelessness and trauma. Outline the body s response to stress and traumatic stress. Identify the impact of traumatic stress. Review the mechanisms of healing from trauma

Goals PART 2 Understand the principles of Trauma Informed Care Apply Trauma Informed Care for service delivery Practice using Trauma Informed Care clinical tools

Defining Stress and Trauma

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

Homelessness & Trauma Developmental trauma that predates becoming homeless Becoming homeless as trauma Exposure to trauma as part of being homeless Homelessness as increasing vulnerability to trauma response Trauma response as affecting access to services and recovery

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

Traumatic stress is different from other kinds of stressors.

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. Source: Herman, J. (1992). Trauma and recovery. New York: Basic Books.

Sources of Traumatic Stress Loss of a loved one Accidents Photo credit: K. Volk Homelessness Community/school violence Domestic violence Neglect Physical abuse Sexual abuse Man-made or natural disasters Terrorism

Trauma Psychological Complex Historical Sanctuary Vicarious

Impact of Trauma on the Helper Constant stress and anxiety Negative attitude Inability to focus Feelings of incompetence and self doubt Triggered PTSD reactions and other mental health issues especially if the worker has unresolved trauma Compromised physical health Disruption of relationships Blurred boundaries Hopelessness Decrease in ability to experience pleasure Decreased productivity

ACE STUDY

Adverse Childhood Experiences (ACE; Anda & Felitti www.acestudy.org) 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

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

ACE 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

ACE 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

Adverse Childhood Experiences 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)

The Neurobiology of Traumatic Stress

Goal of this section Understand that the Brain and our experience shape how we think, feel, and behave Trauma has an impact on the Brain The brain, and clients can heal

How we will Do it Review the parts of the brain. Learn the physiological parts of the stress/trauma response Understand how the brain is affected by trauma Identify methods to help heal the brain

The Brain..

Right Brain/Left Brain Left hemisphere better at math, judging time and rhythm, and coordinating order of complex movements Processes information sequentially and is involved with analysis About 95 percent of our left brain is used for language Right hemisphere good at perceptual skills, and at expressing and detecting other s emotions Processes information simultaneously and holistically

The limbic system is a sort of primitive core of the brain strongly associated with emotion and memory. Doing Brain

TWO TYPES OF STRESS RESPONSES: Nervous System and Endocrine System Similarities: They both monitor stimuli and react so as to maintain balance. Differences: The Nervous System is a rapid, fast-acting system whose effects do not always persevere. The Endocrine System acts slower (via bloodborne chemical signals called Hormones) and its actions are usually much longer lasting.

SYMPATHETIC NERVOUS SYSTEM Flight Fight Freeze

How Does It all work together?

Trigger Amygdala Slow Fast Hypothalamus Memory Sympathetic Nervous System Norepinephrine epinephrine Stress Hormone (Cortisol) Fight, :light or freeze Regulates response

Trigger Amygdala Slow Fast Hypothalamus Memory Sympathetic Nervous System Norepinephrine epinephrine Stress Hormone (Cortisol) Fight, :light or freeze Regulates response

Trigger Amygdala Slow Fast Hypothalamus Memory Sympathetic Nervous System Norepinephrine epinephrine Stress Hormone (Cortisol) Fight, :light or freeze Regulation response not work over time

Brain Parts THINKING, DOING and REPTILE BRAIN RIGHT and LEFT Fight/Flight/Flee vs. Rest/digest STRESS RESPONSE: FAST and SLOW

Principles of Neurodevelopment The brain is underdeveloped at birth The brain organizes from the bottom up - brainstem to cortex and from the inside out Organization and functional capacity of neural systems is sequential Experiences do not have equal influence throughout development (sensitive periods)

Trauma and Altered Neurodevelopment Altered cardiovascular regulation Behavioral impulsivity Increased anxiety Increased startle response Sleep abnormalities

The Effects of Trauma on the Brain Neurological consequences of trauma Manifestations l Reduction in the size of the Hippocampus l Specific memory problems: - Declarative Memory (Facts, lists etc.) - Fragmentation of long-term memory - (Especially autobiographical and trauma related) - Dissociative amnesia (Gaps/black-outs) - Motor memories (activities learnt at the time of trauma) l Decreased levels of Serotonin l l l Difficulties with concentration Problems with impulsivity and aggression Responses that are inappropriate to the situation l Increased levels of Stress l l l Anxiety and nervousness Numbing of responsiveness to environment Dramatic mood swings

Non-Stressed Stressed Stress results in decreased dendritic branching of neurons in the CA3 region of the hippocampus (Woolley et al. 1990)

Academic tasks that are difficult when traumatized Sit still Concentrate Listen Talk Be Physical Set Goals

Neurogenesis and Plasticity Neurogenesis: Production of new brain cells Plasticity: Brain s ability to change its structure and functions

TRIGGERS

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.

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.

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.

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.

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.

Robustness PHYSICAL + MIND + SOCIAL

Robustness Webster: Having or exhibiting strength or vigorous health Having or showing vigor, strength, or firmness Capable of performing without failure under a wide range of conditions Proactively addresses issues before they become crisis Lessens or eliminates trauma associated with an event Brings more resources to a crisis when it does happen Siebert 2005

The Atoms of Robustness Physical Health Environmental Experience Mind Health Relational Experience Genetic Expression Social Health

Physical Health Physical Health is the foundation for Mind and Social Health Key aspects of Physical Health Diet Exercise Sleep A physically healthy person: Lowers stress/cortisol levels Increases brain functioning and growth Improves learning and memory Improves mental health and emotional capacity

Mind Health Mind Health is a combination of: Emotional Functioning Mental Functioning Spiritual Wellbeing Role of Expectations Role of Positive Thinking

Social Health Homelessness can lead to isolation Isolation leads to depression and other mental health issues Assessment and attention should be paid to social support and the building of health relationships Strong social bonds Increase well-being Lower stress Result in more stable mental health Increase cognitive performance Multiply our emotional, intellectual and physical resources Create a greater sense of purpose Recover faster from setbacks Schwartz 2010

Resiliency Distress Robustness Resiliency

Re sil ience noun \ri-ˈzil-yən(t)s\ Definition of RESILIENCE 1: the capability of a strained body to recover its size and shape after deformation caused by compressive stress 2: an ability to recover from or adjust easily to misfortune or change Siebert 2005

Resiliency The action taken to recover and grow from experiencing a stressful event Tenacity in the face of distress Surviving the trauma associated with a disruptive event Siebert 2005

QUESTIONS?

Resources National Health Care for the Homeless Council www.nhchc.org Homelessness Resource Center www.homeless.samhsa.gov The National Center on Family Homelessness www.familyhomelessness.org National Child Traumatic Stress Network www.nctsn.org T3 (Think. Teach. Transform.) www.thinkt3.com

Resources CDC ACE Study http://www.cdc.gov/ace/index.htm SAMHSA: National Center for Trauma Informed Care http://www.samhsa.gov/nctic/

Deborah Borne, MSW, MD San Francisco Department of Public Health Deborah.Borne@sfdph.org 646-281-3219 http://www.nhchc.org/ Contact Information

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

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

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 www.nctsn.org.

Developmental Status Influences Response to Trauma

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.

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.

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

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

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.