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UnderstandingTraumaticStressupdateddsm-v
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- 2. What’s In Store? Part 1: Recognizing Trauma Definitions of Trauma Three Types of Trauma Short-term and long term impact Principles of Trauma Treatment Part 2: Responding to Traumatized People ARC (Attachment, self-Regulation, & Competency) Building safety, attachment, and attunement
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- 4. What Is “Trauma”? AmericanPsychological Association “ an emotional response to a terrible event like an accident, rape or natural disaster ” Merriam-Webster Dictionary “ a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury. an emotional upset ” Australian Psychological Society “ The word ‘trauma' is derived from the Greek term for ‘wound'. Very frightening or distressing events may result in a psychological wound or injury - a difficulty in coping or functioning normally following a particular event or experience. “
- 5. SAMHSA Definition Individual traumaresults from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being... In short, trauma is the sum of the event, the experience, and the effect.
- 6. Three Types ofTrauma Acute (isolated event) Trauma Chronic (repeated or prolonged) Trauma Complex (developmental) Trauma An isolated event such as being the victim of a crime, surviving a natural disaster, or a serious accident Living through an ongoing situation such as experiencing domestic violence, or a war Experiencing multi- layered traumatic circumstances such as caregiver abuse or neglect, or a combination of multiple trauma events, particularly in childhood.
- 7. Prevalence Adverse Childhood Experiences(ACE) reported by adults: 28% physical abuse, 21% sexual abuse, 15% emotional neglect 10% physical neglect, 13% domestic violence, 27% substance abuse in home
- 8. The Impact ofTrauma About 80% of 21 year olds who were abused as children met criteria for at least one psychological disorder (e.g. Depression, Anxiety) ACE in any category increased the risk of attempted suicide 2- to 5-fold Persons who have experienced 5 or more ACE events had a nearly threefold increase in rates use of psychotropic prescriptions.
- 9. The Brain Mid-Brain –Motor regulation, arousal, appetite, sleep Brain Stem – blood pressure, heart rate, body temperature Cortex – Abstract thought, concrete thought, language Limbic System – Attachment, sexual behavior, emotional reactivity
- 10. About The HumanBrain Develops in a use- dependent fashion Repeated activation of specific nerve connections develops those connections and the areas required to sustain those connections Areas that do not get consistent, repeated stimulation may not develop at all HHS Child Welfare Information Gateway
- 11. Acute Response ToTrauma In the reptilian and animal brain: Hyper or Hypo-arousal: Fight, Flight, Freeze, Submit. Information is processed directly for survival purposes. In the cortex: New information is not processed or retained. Rational thought is avoided in favor of survival-related activities.
- 12. About “Fight orFlight” Fight When a threat can be conquered Flight When a threat can be avoided Submit When a threat can be mitigated Freeze When there is no way to avoid harm Posturing Verbal outbursts or threats Confrontation Physical aggression Physically moving away Dissociation Hiding “shrinking” in posture, tone of voice “if you can’t beat them, join them” Self-harm Instigating Defending the attacker Complete helplessness Physical freezing Stupor Catatonia
- 13. Lasting Effects ofTrauma Attachment and attunement: Struggles to empathize with others Difficulty identifying others’ feelings through verbal or visual cues OR extreme sensitivity to others’ feelings perceived through these cues Isolation, or trouble developing safe, trusting relationships Unhealthy physical boundaries (touch aversion, sexual or social permissiveness)
- 14. Lasting Effects ofTrauma Physical challenges: Problems with balance (e.g. uneven gait) Movement coordination problems Lack of hand/eye coordination Delays in growth and development (e.g. “failure to thrive”) Unexplained physical pain Sleep disturbances, night terrors, or altered sleep pattern
- 15. Effects of Trauma Emotion and Mood: Difficulty describing feelings Feelings are experienced as overwhelming, with limited ability to modulate Depression, anxiety, and numbness are common Lack of affect
- 16. Effects of Trauma Arousal modulation: Dissociative states (black outs, out-of-body experiences, a “blank stare”) Abrupt outbursts of anger and/or aggression Hyperactivity or “mania”-like presentation Behavioral control: Difficulties in impulse control Self-destructive behavior
- 17. Lasting Effects ofTrauma Cognition: Problems with attention and concentration Difficulty retaining new information Short term memory problems Limited autobiographical memory Poor self-image and self-esteem Persistent intrusive thoughts and images, sometimes resembling hallucinations “Arrested development”
- 18. Trauma Treatment &Recovery In order to foster change, people’s reparative experiences must be Predictable Consistent Repetitive Appropriate for developmental stage of the person in the specific area of activity, rather than their chronological age or the usual performance of non-traumatized peers Inclusive of any and all unoffending caregivers
- 19. Trauma Treatment &Recovery The case of Robert and Mama P. (Excerpt From the book, “The boy who was raised as a dog”, by Dr. Bruce Perry) Questions for discussion: What themes are common to the case of Robert and the people with whom we work? What feelings/thoughts arise as we consider these common themes? What can we learn from this case?
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- 21. ARC Framework ARC:Attachment, Self-Regulation, Competency In order to be effective, treatment of complex trauma must be responsive to the specific developmental needs of the person, recognizing and addressing factors that have derailed normative development.
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- 23. Attachment Attachment isa relational (two-way) process, without which people do not develop the capacity to regulate their own emotions. People with complex trauma histories often have problematic attachment styles due to repeated disruptions in attachment
- 24. The Still FaceExperiment
- 25. Attachment Styles Attachment Style Behavior Underlying beliefs Previous caregiver’s behavior Avoidant Emotionally distant, doesnot connect with others “I can’t rely on others to meet my needs.” Never emotionally or physically available Ambivalent “push/pull”: fluctuates between connecting and rejecting “There is no way to predict whether my needs would be met.” Inconsistent in availability or response Disorganized No pattern: sometimes Avoidant, other times Ambivalent. Often dissociative. “Those who meet my needs are also likely to hurt me.” Intermittently aggressive and/or abusive
- 26. Level 1: Attachment Goal: work with caregiver system to crate a safe environment to support the client in meeting own needs Who is considered a caregiver? Anyone who has regular and consistent responsibility to support the client. Four tasks: Build caregiver capacity to manage affect Build caregiver-client attunement Build consistency in caregiver response to client behavior Build routines and rituals
- 27. Caregiver Affect Management Caregivers can support clients in developing healthy self-regulation skills through modeling the response they’d like the client to develop. E.g. child falls down. Mother’s response determines whether the child will cry. Challenges to caregiver affect management Client vigilance to caregiver cues Intensity of client affect Caregiver’s own history and situation Relational reenactments
- 28. Addressing The Challenges Encouraging self-awareness and self-monitoring Building capacity for self-care Developing a built-in support system Practicing teamwork Recognizing and addressing Secondary Traumatic Stress (STS), compassion fatigue, and burnout. Supporting knowledge sharing activities Identifying successes and failures and using them as teaching moments
- 29. Integrating Who YouAre Into Your Work Your personality, communication style, and background will inevitably find their way into your interactions with clients. Past hurts, traumas, and fears are bound to influence these interactions- sometimes in unpredictable ways. YOU can be a powerful catalyst for client growth and change: Identify what you bring into different interactions Recognize the impact of your life experiences on your work Consciously choose which parts of YOU enter the interaction with the client
- 30. Attunement Traumatized clientsoften have difficulty communicating effectively. Behavior is an attempt to communicate Unmet needs Unregulated affect These difficulties may be global, or situation- specific Caregivers often respond to the most distressing symptom or behavior, rather than the underlying emotion or need.
- 31. Value of Attunement Helps clients develop trust in caregiver system Clients experience being understood Demonstrates true compassion, caring Allows clients to learn that their needs and feelings will be addressed Facilitates prevention and rapid de- escalation of high-intensity situations Increases client engagement Supports client behavior change
- 32. How Attunement Happens Become a “feelings detective” When the client acts, consider what he/she might need or feel Consider basic needs: hot, cold, tired, hungry, thirsty... Consider the fight/flight response Consider the client’s attachment style and possible triggers Use reflective listening skills Practice responding to feelings/needs and not to behavior
- 33. Consistent Response Predictabilityin caregiver response helps clients feel safe, and reduces their need to exert control Limit-setting and praise are common triggers: they are often associated with powerlessness and vulnerability. Where possible, reduce the need for limits Adapt response to the individual needs of the client Build on successes
- 34. Routines and Rituals Trauma is often associated with chaos and unpredictability Routines enable clients to feel safe, anticipate and evaluate their experience, and learn reliability It is important to be selective in developing routines/rituals, build-in flexibility Routines/rituals are often subtle
- 35. Core Principles Safety How do we know whether a situation is safe? How do we know if a person is safe? How does our personal definition of safety impact our interactions with clients? Does our idea of safety translate into our work environment? Why? Why not? What are the challenges in creating / maintaining safety in our environment and interactions? How do we overcome them?
- 36. Core Principles Consistency What are some challenges to consistency that we encounter in our day-to-day? What can you do to create consistency? What support do you need, and from whom? Repetition Why is repetition important? Why is it good? How much is too much repetition? How much is not enough? How do we feel about repetition? How do we manage any potentially negative feelings?
- 37. Thank You! Questions, Comments,and Feedback welcome!
Editor's Notes
- #5 Substance abuse and mental health services administration (SAMHSA)
- #19 “Mama P.* was a large, powerful woman. She moved with confidence and strength. She wore a large, brightly colored muumuu and had a scarf around her neck. She’d come for a consultation about Robert, a seven-year-old child she was fostering. Three years before our visit, this boy had been removed from his mother’s custody. Robert’s mom was a prostitute who’d been addicted to cocaine and alcohol for her son’s whole life. She had neglected and beaten him; the boy had also seen her beaten by customers and pimps and had himself been terrorized and abused by her partners. Since being removed from his home Robert had been in six foster homes and in three shelters. He had been hospitalized for out-of-control behaviors three times. He had been given a dozen diagnoses including ADHD, ODD, Bipolar disorder, Schizoaffective disorder, and various learning disorders. He was often a loving and affectionate child, but he had episodic “rages” and aggression that scared peers, teachers and foster parents enough for them to reject him and have him removed from whatever setting he was in after he went on one of his rampages. Mama P. had brought him to us because once again, his inattentiveness and aggression had gotten him into trouble at school and the school had demanded that something be done. He reminded me of many of the boys I had worked with in Chicago at the residential treatment center. As I began talking I tried to engage Mama and make her feel comfortable. I knew that people can “hear” and process information much more effectively if they feel calm. I wanted her to feel safe and respected. Thinking back now, I must have seemed very patronizing to her. I was too confident; I thought I knew what was going on with her foster child and the implicit message was “I understand this child, and you don’t”. She looked at me defiantly, her face unsmiling, her arms folded. I went into long-winded and likely unintelligible explanation of the biology of the stress response and how it could account for the boy’s aggression and hyper-vigilance symptoms. I had not yet learned how to clearly explain the impact of trauma on a child. “so what can you do to help my baby?” she asked. He language struck me: why was she calling a seven-year-old child a baby? I wasn’t sure what to make of it. I suggested Clonidine, the medication I’d used with Sandy, and the boys at the center. She interrupted quietly but firmly, “you will not use drugs on my baby.” I tried to explain that we were quite conservative with medications, but she wouldn’t hear it. “No doctor is going to drug up my baby,” she said. At this point the child psychiatry fellow, Robert’s primary clinician, who was sitting next to me, started to fidget. This was awkward. Mr. Bigshot Vice-Chairman and Chief of Psychiatry was making an ass of himself. I was alienating this mother and getting nowhere. I again tried to explain the biology of the stress response system, but she cut me off. “Explain what you just told me to the school,” she said pointy. “My baby does not need drugs. He needs people to be loving and kind to him. That school and all those teachers don’t understand him.” “OK. We can talk to the school.” I retreated. And then I surrendered. “Mama P., how do you help him?” I asked, curious about why she didn’t have the problems with his “rages” that had gotten him expelled from prior foster homes and schools. “ I just hold him and rock him. I just love him. At night when he wakes up scared and wanders the house, I just put him to bed next to me, rub his back and sing a little and he falls asleep.” The fellow was now stealing looks at me, clearly concerned: seven-year-olds should not be sleeping in bed with their caregivers. But I was intrigued and continued to listen. “what seems to calm him down when he gets upset during the day?” I asked. “Same thing. I just put everything down and hold him and rock in the chair. Doesn’t take too long, poor thing.” As she said this I recalled a recurring pattern in Robert’s records. In every one of them, including the latest referral from the school, angry staff reported frustration with the boy’s noncompliance and immature “baby-like” behaviors, and complained about his neediness and clinginess. I asked Mama P., “So when he acts like that, you don’t ever get frustrated and angry?” “Do you get angry with a baby when a baby fusses?” she asked. “No. That is what babies do. Babies do the best they can and we always forgive them if they mess, if they cry, if they spit up on us.” “And Robert is your baby?” “They are all my babies. It’s just that Robert has been a baby for seven years.” We ended the session and made another appointment for a week later. I promised to call the school. Mama P. looked at me as I walked with Robert down the clinic hall. I joked that Robert needed to come back to teach us more. At that, she finally smiled. Over the years Mama P. continued to bring her foster children to our clinic. And we continued to learn from her. Mama P. discovered, long before we did, that many young victims of abuse and neglect need physical stimulation, like being rocked and gently held, comfort seemingly appropriate for far younger children. She knew that you don’t interact with these children based on their age, but based on what they need, what they may have missed during “sensitive periods” of development. Almost all the children sent to her had a tremendous need to be held and touched. Whenever my staff saw her in the waiting room holding and rocking these children, they expressed concern that she was infantilizing them. But I came to understand why her overwhelmingly affectionate, physically nurturing style, which I'd initially worried might be stifling for older children, was often just what the doctor should order. These children had never received the repeated, patterned physical nurturing needed to develop a well-regulated and responsive stress response system. They had never learned that they were loved and safe; they didn’t have the internal security needed to safely explore the world and grow without fear. They were starving for touch- and Mama P. gave it to them. “