The Impact of Trauma in Treatment Courts: Understanding Neurobiology, and the Brain and Healing Steve Hanson
Substance Abuse Trauma
55 year old incarcerated male My father was drunk all the time and would beat my mother. She would tell us to go to our room so we wouldn t hear the beating, but we could. One night when I was 6 years old, he came home and started beating her. Then he put his hands around her throat. He yelled at us to go to bed. I was woken up the next morning by my grandmother. She said my mom was dead and that we would have to live with her. My father and grandmother then were beating us, everyday.
Trauma Prevalence and Behavioral Health While most people experience at least one traumatic event in their lifetimes, studies indicate that as many as 43 to 80% of men and women in psychiatric hospitals have experiences physical or sexual abuse, most of them as children. Up to two thirds of both men and women in substance abuse treatment report childhood abuse or neglect. Majority of adults and children in inpatient psychiatric and substance use disorder treatment settings have trauma histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010) 5
Reported Prevalence of Trauma and Behavioral Health 43% to 80% of individuals in psychiatric hospitals have experienced physical or sexual abuse 51% 90% public mental health clients exposed to trauma (Goodman et al, 1997; Mueser et al, 2004) 2/3 adults in SUD treatment report child abuse and neglect (SAMHSA, CSAT, 2000) Survey of adolescents in SU treatment > 70% had history of trauma exposure (Suarez, 2008) Juvenile justice involved youth, esp females, report more exposure to trauma than the general population; one study reported over 60% juvenile detainees experience trauma (Ford et al, 2008; Kretschmar, et al, 2014)
Trauma and Co Occurring Disorders Now understood to be an almost universal experience of people in the public mental health, substance abuse and social service systems. Trauma survivors are at a much higher risk for co occurring mental and substance use disorders, violence victimization and perpetration, self injury, and a host of other risks/coping mechanisms which have devastating human, social, and economic costs. 7
Stress
Three Types of Stress: Acute Physical Stressors: Require immediate physiological response in order to survive. e.g. attack or natural disaster (Catastrophe) Body does well! Chronic Physical Stressors: e.g. starvation, drought. Body does OK. Psychological and Social Stressors: pressures in our social, cultural and economic environment. e.g. abuse, stressful environment, violence Can be based on thoughts alone! Body does not do so well.
Eustress Good Stress Getting into college Winning the lottery Getting engaged
Distress Bad Stress Difficult work environment Overwhelming sights or sounds Threat of personal injury
General Stress Everyone has this kind It resolves itself in a day or two No intervention required
Cumulative Stress Stress builds up in your body It becomes more difficult to alleviate symptoms You have more serious physical symptoms You have more serious mental anguish
Acute Traumatic Stress Critical incident stress Produces considerable psychological distress A normal reaction to abnormal events
Post-Traumatic Stress Severs stressed produced by severe psychological trauma Created by unresolved critical incident Produced lasting changes
Stress Effects of long term release of cortisol Increased blood pressure Inhibits inflammatory response Suppresses immune system Damages brain cells
Stress and Health Forty three percent of all adults suffer adverse health effects from stress. 75% to 90% of all doctor's office visits are for stress related ailments and complaints. Stress can play a part in problems such as headaches, high blood pressure, heart problems, diabetes, skin conditions, asthma, arthritis, depression, and anxiety. Substance and Alcohol Abuse
What can go on in a substance abusing family? Fighting Neglect Fear Embarrassment Loneliness Anger Sadness/depression
Hero Responsible for well being of siblings/family Scapegoat Can take the blame (heat) Mascot defuses tension with comic relief Lost Child Stay out of dangers way Reality: Roles not mutually exclusive many people have multiple traits.
Survival Skills Adaptive response to the situation Self protection Family preservation Can create valuable strengths Can be maladaptive rigid
Family Rules Adult Children of Alcoholics ACOA/ACSA Intimacy issues Commitment Fear Isolation Hypervigilance Control issues Over responsible Conflict avoidance
The Impact of Trauma Trauma is cumulative Trauma affects the developing neurophysiological system Trauma increases likelihood of health risk behaviors (smoking, drinking, overeating) as means of coping Trauma is directly related to mental health symptoms, substance abuse, chronic physical illness, early mortality Has impact at the molecular, clinical and population level
Adverse Childhood Experiences Study The ACE study was a research collaboration between CDC and the Kaiser Permanente Health Appraisal Clinic in San Diego that took place from 1995 to 1997. The study examined health outcomes of over 17,000 Kaiser members in relation to events in their childhood. Each of the participants was asked a range of questions about Adverse Childhood Experiences (ACEs) and various health outcomes. The study found that adults who reported multiple adverse experiences in childhood were much more likely to suffer a range of negative health and social outcomes in adulthood including depression, substance use, alcoholism, smoking, suicide, heart disease, lung disease, injuries, HIV/sexually transmitted diseases, and impaired work performance.
Impact of Trauma Over the Life Span Effects of childhood adverse experiences: neurological biological psychological social (Felitti et al., 1998)
Aces and Negative Outcomes 60% 50% 40% ACEs and Negative Outcomes Depressed Mood for 2+ Weeks in Past Year Current Smoker 30% 20% 10% Ever Used Illicit Drugs Considers Self an Alcoholic 0% 0 1 2 3 4+ ACE Score Ever Attempted Suicide
ACES Underlie Chronic Depression in Adults % With a Lifetime History of Depression 80 70 60 50 40 30 20 10 0 0 1 2 3 >=4 ACE Score Women Men
Adverse Childhood Experiences and Current Smoking % 20 18 16 14 12 10 8 6 4 2 0 0 1 2 3 4-5 6 or more ACE Score
ACES and Adult Alcoholism 18 16 14 4+ % Alcoholic 12 10 8 6 3 4 2 0 0 1 ACE Score
PTSD Changes in Brain Structures/Function
Hyperaroused Amygdala Amygdala Role Alarm Center Fear Drive Center PTSD Hyperarousal Hypervigilant Difficulty discriminating threats Responds to memories Drive drug/pleasure seeking
Prefrontal Cortex Pre Frontal Cortex Role Complex thinking, Decision making Appropriate behavior PTSD Reduced Activity/Volume Dysfunctional thought processes and decision making; Inappropriate responses to situations Impaired extinction of fear responses
Reduced Hippocampus Hippocampus Role control of stress responses, declarative memory (knowing what) contextual aspects of fear conditioning. PTSD Reduced Size and Activity Altered Stress response hyperaousal Memory problem Difficulty with extinction of response
Hypothalamus/Pituitary Role Releases hormones like cortisol to help manage and direct efforts to stressor PTSD Overactive Imbalances in hormone levels increases stress and anxiety
Working with Trauma and Substance Abuse Substance Abuse Trauma
Post Traumatic Stress Disorder Patients experienced multiple traumas; hx of drug use has added traumatic exposure Patients may present as angry, anxious, dissociated or depressed and are fragile Develop plan for safety and teach how to de escalate intense emotion Trauma injures capacity for attachment and trust so go slow; give them control Traumatic experiences processed little by little, and after some sober time if possible; allow time to regroup; remember balance; set up longer term therapy
Trauma Informed Approach Realizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and Seeks to actively resist retraumatization."
SAMHSA s Six Key Principles of a Trauma Informed Approach A trauma informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting or sector specific: Safety Trustworthiness and Transparency Peer support Collaboration and mutuality Empowerment, voice and choice Cultural, Historical, and Gender Issues
Trauma Statistics Lifetime history of sexual abuse among women in childhood or adulthood ranges from 15% to 25%. The prevalence of domestic violence among women in the United States ranges from 9% to 44%, depending on definitions. The cost of intimate partner violence, which disproportionately affects women and girls, was estimated to be $8.3 billion in 2003. This total includes the costs of medical care, mental health services, and lost productivity. In a 2008 study by RAND, 18.5% of returning veterans reported symptoms consistent with post traumatic stress disorder (PTSD) or depression. In the United States, 18.9% of men and 15.2% of women reported a lifetime experience of a natural disaster.
SAMHSA s Concept of Trauma The 3 Es Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual s functioning and mental, physical, social, emotional, or spiritual well being. From SAMHSA s Concept Paper
A Trauma Informed Approach (Four R s) A trauma-informed program, organization, or system: Realizes Realizes widespread impact of trauma and understands potential paths for recovery Recognizes Recognizes signs and symptoms of trauma in clients, families, staff, and others involved with the system Responds Responds by fully integrating knowledge about trauma into policies, procedures, and practices Resists Seeks to actively resist re-traumatization. From SAMHSA s Concept Paper
Key Principles of a Trauma Informed Approach Safety Cultural, Historical, and Gender Issues Trustworthiness and Transparency Empowerment, Voice, and Choice Peer Support Collaboration and Mutuality
Evidence Based Practices Seeking Safety Cognitive Behavioral Popular in CJ settings Addiction and Trauma Recovery Integration Model (ATRIUM) 12 Session Used in CJ settings Trauma Recovery and Empowerment Model (TREM and M TREM) Trauma survivors (physical/sexual violence)
Traditional Approach vs. Trauma Theory Traditional approach You are sick You are bad You are sick and bad Trauma theory You are not sick or bad You are injured
What does TIC offer? Improves our desired outcomes Supports trauma recovery by Reducing re traumatization Providing corrective emotional experience Decreases our own vicarious trauma or compassion fatigue
Core Principles of TIC Awareness: Everyone knows the role of trauma Safety: Ensuring physical and emotional safety Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Choice: Respect and prioritize consumer choice and control Collaboration: Maximizing collaboration and sharing of power with consumers Empowerment: Prioritizing consumer empowerment and skill building
TIC Communication Style Transactional Focus on information exchange Transactional with Social Talk Mostly information exchange with some social talk (e.g. joking, comment on weather) Interactional Focus on rapport building and interpersonal relationship integrated with the information exchange https://nchdv.confex.com/nchdv/2012/webprogram/session2199.html
Tips for Practicing TIC Use language the person recognizes Has your partner messed with your birth control? Meet the survivor where they are If a person is not ready to talk, do not force the conversation. Rather keep the door open for a later time. Consider the person s cultural context Avoid making assumptions just ask!
Tips for Practicing TIC Recognize adaptive behaviors serve a purpose Why is a person chronically miss morning appointments? Is the morning the only time she can sleep? Does she have a traumatic brain injury that prevents her from remembering things? Make adjustments to help that person succeed. Set appointment times for the afternoon. Include everyone in your agency From receptionist to treatment staff Provide trauma training to every employee
How do we provide TIC? Listen What is the survivor saying to you? What is the survivor not saying? How is the survivor saying it? Inform What information do you have that may help her? What will happen next in the process? Why is the information important for her to have? How can your services can help her?
How do we provide TIC? To the best of your ability and within your given time constraints: Lose the labels Let her tell her story Give her time and space to tell her story Let the survivor lead Respect her voice and choice Recognize the survivor s comfort level Consider the survivor s perspective from her cultural context
Quick & Easy Offer support and validation Communicate care and concern Avoid passing judgement Ask questions of the survivor Find out if she is experiencing some kind of violence or coercion in her life Listen to what she has to say Resist interrupting her Make sure your body language is receptive Offer information and assistance Give her a resource card, a phone number, or a website Refer her to an advocate (warm hand off) Tell her you are available to her in the future
SECONDARY TRAUMA AND SELF CARE Norma Jaeger, M.S. National Association of Drug Court Professionals July 11, 2017
Overview and Introduction Secondary Trauma Vicarious Trauma Compassion Fatigue Burnout All represent a continuum of the impact of our work helping those who have experienced trauma
Secondary Trauma Secondary trauma refers to experiencing signs and symptoms mirroring those of persons, such as clients or friends, who have directly experienced a traumatic event or circumstance. Includes: hyperarousal (startle, heart rate, pulse) Intrusive thoughts Avoidance or numbing Anxiety and or depression
Vicarious Trauma Changes experienced by persons doing therapeutic or other helping work with trauma survivors, including: Relationship with meaning and hope Willpower Sense of humor Memory / Imagery Sense of connection to others
Compassion Fatigue A more severe example of cumulative the stress of working with those with many needs or trauma histories. Includes exhaustion and dysfunction, physically and emotionally
Burnout The cumulative psychological strain of working with many different stressors, including persons with many needs. Symptoms include: Depression Cynicism Boredom Loss of compassion Discouragement
Possible Behavior Changes Becoming judgmental of others Tuning out Disconnecting from colleagues and loved ones Becoming cynical or angry or hopeless Isolating Developing overly rigid, strict boundaries Developing rescue fantasies or over involved
Risk Factors Individual Personality and coping styles Current life circumstances Social supports Spiritual connection and resources Work style Personal History
Risk Factors Work Situation Role at work Work setting and exposure Work conditions Agency Support Client responses and reactions
Risk Factors Community Cultural factors Available resources Community environment
There is a plus side: Compassion Satisfaction We find purpose, meaning and satisfaction in helping others We may gain a sense of strength and confidence We gain respect for human resilience We may experience a heightened spiritual connection