Trauma Sensitive Care

Trauma Sensitive Care

What it isWhy it matters

How we can achieve it

Howard BathThomas Wright Institute

Perspectives on YP in Care

Dependent Abuse/neglect Attachment High Risk Strength-Based Trauma

Research Foundations

GENEROSITY INDEPENDENCE

BELONGINGMASTERY

The Circle of Courage

BelongingOpportunity to establish trusting

connections

MasteryOpportunity to solve problems

and meet goals

IndependenceOpportunity to build self control

and responsibility

GenerosityOpportunity to show respect and

concern

Self-Worth Research

SignificanceThe individual believes

“I am appreciated.”

CompetenceThe individual believes

“I can solve problems.”

PowerThe individual believes

“I set my life pathway.”

VirtueThe individual believes

“My life has purpose.”

Resilience Research

AttachmentMotivation to affiliate and form

social bonds

AchievementMotivation to work hard and

attain excellence

AutonomyMotivation to manage self and

exert influence

AltruismMotivation to help and be of

service to others

Circle of Courage

Triune Brain

Logical Brain(Neocortex)

Emotional Brain (Limbic System)

Survival Brain(Brain Stem)

The Triune Brain in language

Words that reflect the emotional/logical brain distinction:

thoughtless, inconsiderate, mindless, impulsive, crime of passion, without malice aforethought vs calculating, deliberate, premeditated murder

Descriptors of reptilian brain behaviours:animal, cold-blooded, predatory

The ‘Therapeutic’ Task

Psychotherapy is fundamentally a process “through which our neocortex learns to exercise control over evolutionary old systems” (LeDoux,

1996, p. 21)

“We want to raise children whose reasoning brain can triumph over the impulsive one” (Stein and Kendall, 2004, p. 12)

Hemispheric Specialization

“we are born to form attachments…our brains are physically wired to develop in tandem with another’s, through emotional communication beginning before words are spoken”

“The organisation of the developing brain occurs in the context of a relationship with another self, another brain. This relational context can be growth-facilitating or growth inhibiting, and so it imprints into the developing right brain either a resilience…or a vulnerability” (Shore, 2003, p. xv)

Which of the two faces appears happier?

Threat and Trauma

The Stress response

Amygdala (the ‘danger detector’) activates the ‘HPA axis’ by initiating the release CRT from the hypothalamus which stimulates the pituitary in brain stem

Glucocorticoids trigger the locus coeruleus to release norepinephrine which communicates with the amygdala

Adrenal glands release epinephrine (adrenalin) and, in prolonged stress, glucocorticoids

Brain stem releases ACTH which activates the sympathetic nervous system via the spinal cord stimulating the adrenal glands

Corticotrophin releasing hormone, CRH Adrenalcorticotrophic hormone, ACTH Epinephrine (Adrenalin) Norepinephrine Glucocorticoids (Cortisol)

The Stress/Fear Response (adapted from Sapolsky, 2004)

Amygdala

Brain stem pituitary

Locus coeruleus

Adrenal glands

Direct sympathetic nervous system activation

Blood pressure increases Heart rate increases Senses/reactivity are heightened Peripheral vision narrows Pupils dilate to take in more information

Hypothalamus

The Stress/Fear Response

Our stress mechanisms operate far more quickly than do our conscious, reflective capacities – this helps to keep us safe.

It has been estimated that our safety/stress reactions activate in around 6/1000 of a second

Problematic Effects of Stress

Living in a state on prolonged stress and anxiety can lead to the stress mechanisms becoming “sensitized” i.e. developing lower thresholds for activation (Sapolsky, Bremner) – researchers have used the term “kindling” to describe the effect of chronic stress on the amygdala.

Stress and Memory

‘Explicit’ (or ‘declarative’) memories are those memories which we can ‘recall’ and reflect on

‘Implicit’ memories involve the myriad sensations (sounds, smells, feelings, emotions, etc) associated with events. They also include what is called ‘procedural’ memory

The Danger Detector

Amygdala

The amygdala appears to have a critical ‘gate keeping’ role determining ‘friend or foe’

It asses for ‘emotional salience’ - the ‘danger detector’ – triggers the stress and ‘fight or flight’ responses

Fear Conditioning

Fear conditioning which underlies many anxiety-related conditions (e.g. PTSD and phobias) mainly involves the amygdala and ‘implicit’ memories

Anxiety, fear, or terror are triggered by cues (reminders) of the original frightening experiences. The cues can be internal (feelings, emotions, sensations) or external (sounds, smells, sights, certain people etc). The amygdala has ‘tagged’ these as being associated with danger – this is a largely unconscious process

Hippocampus

Memories are usually stored in parts of the cortex but the hippocampus has a key role in ‘organising’ and linking the various memory components. It has a key role in the storage and recall of explicit memories

The ‘keyboard’ vs ‘hard disk’ analogy

Stress and Memory

We tend to remember events that are associated with stress and emotion far more readily than those that do not (except if the events are overwhelmingly stressful or long-lasting)

Our brain remembers sensations and feelings) associated with events (‘implicit’ memory) even when we cannot recall the event consciously (‘explicitly’)

Stress and Memory

An infant or small child does not have ‘explicit’ memory capacities - we usually cannot remember anything ‘explicitly’ prior to around 4 years of age.

However, the infant/small child does have ‘implicit’ capacities - traumatizing events can only be recalled ‘implicitly’ (physiologically and emotionally)

Memory Overload

Hippocampal structures linked with ‘explicit’ memory may atrophy or even die with very high and/or sustained ‘flooding’ by cortisol – ‘implicit’ memory does not appear to be affected this way (Sapolsky)

Dissociation & Memory

Memories may be impaired by ‘dissociative’ responses e.g. ‘tuning out’, ‘floating above’, fainting, during frightening events (Perry)

Dissociative memories are fragmented, condensed, and conflated (Stein & Kendall)

Dissociating from traumatic events can lead to a faulty appraisal of the event’s significance and dangerousness

Stress, Memory & Trauma

Types of Trauma

Type 1 (simple) – from one overwhelming traumatic event

Type 2 (complex) – from ongoing exposure to fear/helplessness

Trauma and Children

‘Fight or flight’ responses are usually not available to children – therefore ‘freeze’ and other dissociative responses are common (Perry)

The ‘freeze’ response has been linked with the ‘learned helplessness’ models in animal studies – it appears to involve both sympathetic arousal and parasympathetic counter-effects or stepping on the ‘gas and the brake’ at the same time

Differential Effects of Trauma

“Interpersonal traumas are likely to have more profound effects than impersonal ones” – especially ‘betrayal of trust’ by attachment figures and figures of esteem(van der Kolk)

Outcomes of Trauma – Formal diagnosed conditions

Post traumatic symptomology including PTSD (re-experiencing, hyperarousal, hypervigilence, avoidance)

‘borderline’ symptoms as seen in ‘borderline personality disorder’ (acute abandonment anxiety, rapid mood swings, identity instability, suicidal ideation/gestures, complaints of boredom, capricious and reactive aggression, addictive behaviours etc)

Some sub-types of Oppositional Defiant Disorder and Conduct Disorder

Outcomes of Trauma

Language and other cognitive impairments inc. short term memory; rigid thinking styles; executive functions such as planning, weighing options, considering outcomes, controlling impulses; misinterpretation of social cues (Perry: only 2% of abused children have verbal>performance scores - 39% have the opposite pattern)

Outcomes of Trauma The process of reflection, labelling and

making meaning of events requires language – language functions are often impaired by trauma. This is reflected in words and phrases that are used:

Speechless unspeakable dumbfounded mute terror indescribable dumbstruck words can’t describe words fail me words cannot express

Outcomes of Trauma

Very constricted play, impairments of imagination Impairments of empathy – chronically aroused

lower brains gear the child for facing threat do not allow the time or energy for the higher brain functions involved in empathy

A range of somatic and psychiatric problems including infections, headaches, stomach aches, hyperactivity, depression, phobias

Emotional numbing and analgesia associated with dissociation and the endogenous opioids

Eating disorders are common Substance abuse – often self-medicating

Outcomes of Trauma

The apparently counterintuitive process in which children/YP appear to instigate traumatic incidents

Traumatic re-enactment or compulsive re-exposure - an effort to integrate the experience and/or to gain control of the traumatic triggers (Terr). Understanding compulsive re-exposure and doing something about it is one of the “great challenges of psychiatry” (van der Kolk)

‘Addiction’ to the post-crisis state of quiescence involving endogenous opioids – some generate crises and put themselves in dangerous situations to experience this physical and emotional “state of calm”

Outcomes of Trauma

Loss of trust, hope and sense of agency Loss of “thought as experimental action” Social avoidance with loss of attachments Lack of future orientation and involvement in

preparation for the future (van der Kolk, 1996)

Outcomes of Trauma

The process of ‘making meaning’ from exposure to extreme and prolonged threat

Bowlby’s notion of the maladaptive ‘working models’ of self and others – people are dangerous, they can’t be trusted, I’m not worthy of love, I’m bad

Sullivan’s description of ‘malevolent transformation’

The Primary Impact of Trauma

“The lack of or loss of self-regulation is possibly the most far-reaching effect of psychological trauma in both children and adults”

“The younger the age at which the trauma occurred, and the longer its duration, the more likely people (are) to have long-term problems with the regulation of anger, anxiety and sexual impulses” (van der Kolk et al., 1993)

Trauma, Dysregulation & Out-of-Home Care

Executive Deficits (BRIEF) – YP attending OOHC Psychiatric clinic (Redoblado-Hodge, 2004)

0 10 20 30 40 50 60 70

Impulsive

Working Memory

Inflexible

Disorganised

Self Monitoring

Emotional Regulation

Some UK data on prevalence of psychiatric symptoms of young people in care

“Total weighted prevalence rate of psychiatric disorders in adolescents in the Oxfordshire care system was 67%...with 96% of adolescents in residential units and 57% in foster care having psychiatric disorders” (McCann, James, Wilson & Dunn, BMJ, 1996)

Most common MH problems experienced by adolescents in care

Conduct disorder 28%Overanxious disorder

26%Major depressive episode 23%ADHD

14%Other depression types 12%Avoidant disorder 8%Functional psychosis 8%Panic disorder 4%Bipolar disorder 4%

Others: substance abuse; bulimia/anorexia nervosa; OCD; phobias; separation anxiety disorder

Disruptive Behaviour Disorders

Most young people come into residential care

or transition in (any kind of ) care because of

‘externalising’ behaviours such as aggression

and rule breaking.

This is the most common MH diagnosis

“Problems of chronic reactive violence have their origins in early life experiences (such as early traumas of parental rejection, exposure to family violence, and family instability) and/or constitutional abnormalities, whereas problems of proactive violence have their origins in social learning during school years” (Dodge et al., 1997)

Pain and Pain-based Behaviour

Challenging behaviours often reflect psychoemotional pain … “grief at losses and abandonment; persistent anxiety about themselves and their situation; fear of or even terror about a disintegrating present and a hopeless future; depression and dispiritedness at a lack of meaning or sense of purpose in their lives; and what could be termed ‘psycho-emotional paralysis’, or a state of numbness and withdrawal from the people and world around them”

(Anglin, 2003, p. 109-110)

Pain-Based Behaviours

Responding to Pain with Pain

“Seldom did careworkers acknowledge or respond sensitively to the inner world of the child. (They would react to difficult) behaviour by making demands of a controlling nature (e.g. get a grip on yourself!”, or “Watch your language now!”) or giving a warning of possible consequences in terms of lost points, time out, or withdrawal of privileges…” Anglin, 2003

The Biggest Challenge

“more than any other dimension of carework, the ongoing challenge of dealing with such primary pain without unnecessarily inflicting secondary pain experiences on the residents through punitive or controlling reactions can be seen to be the central problem for carework staff” (Anglin, 2003, 55)

The Parallel Process

“traumatized people are frequently misdiagnosed and mistreated in the …system… Because of their characteristic difficulties with close relationships, they are vulnerable to become re-victimized by caregivers. They may become engaged in ongoing, destructive interactions, in which the…system replicates the behaviour of the abusive family” (Herman 1992)

Four pillars of trauma-sensitivity

Safety – physical and emotional, sanctuary, consistency, predictability, honesty, transparency, reliability, availability, continuity

Emotion management – tools to assist with reflection, awareness, labelling of emotion, negotiation - to promote a more rational/cognitive style of problem solving

Loss – empathy and support around the ‘pain’ of multiple losses (family, home, friends, community etc)

Future – generation of hope, belief, competence

Safety

The Fundamental Human Need

SAFETY is the fundamental motivational drive Bowlby – safety is the function of attachment

behaviours Maslow – safety is the most fundamental of human

needs Erickson – trust based on safety and comfort is the

first psychosocial stage of development

A lack of physical and emotional safety (anxiety, fear) is the defining experience of people who have experienced complex trauma

Emotion management

The Primary Function

“The primary function of parents can be thought of as helping children modulate their own arousal by attuned and well-timed provision of playing, feeding, comforting, touching, looking, cleaning, and resting – in short, by teaching them skills that will gradually help them modulate their own arousal” (van der Kolk)

What then is the primary function of teachers, care workers, programs for troubled kids?

The Primary Function

How we experience the world, relate to others, and find meaning in life are dependent on how we have come to regulate our emotions (Siegel, 1999, p. 245)

The Foundation of Therapeutic Change

The Foundation of Change

We’ve always heard that positive connections and relationships are important – the difference is that there is now hard science confirming it

The results are the same whether its mental health, education, youth work, psychotherapy

Connecting for Change

40% - Extra-therapeutic, client factors 15% - Placebo, expectancy 15% - Technique 30% - Nature of the connection (warmth,

acceptance, empathy, expectancy)

‘The Heart and Soul of Change’ (Hubble et al., APA, 1999)

Trauma Sensitivity involves

Understanding the impact on the child of overwhelming experiences of fear and helplessness

Understanding how the child’s emotions and behavioural responses can become re-activated here and now

Understanding the behavioural sequelae of complex trauma including ‘defense’ mechanisms and the development of maladaptive behaviour patterns

Responding therapeutically to support and heal and to teach adaptive ways of coping with stress and anxiety

Trauma-Sensitivity Checklist

Are all contact staff members familiar with basic trauma theory?

Are all clients assessed for developmental trauma?

Are program and intervention models audited for trauma sensitivity?

Does the issue of physical and emotional safety guide placement and co-placement decisions?

Do behaviour management tools focus on external behaviour manipulation or on understanding motivation (the outer or inner child)?

Trauma-Sensitivity Checklist

Is the focus of behaviour management on teaching for change or the infliction of ‘pain’?

Is co-regulation with the young person the guiding principal for crisis management?

Is there formal emphasis on post-crisis de-briefing to stimulate thinking, promote insight and teach new skills?

Is the relational basis of therapeutic change given priority in staff training, supervision, and intervention planning? hbath@twi.org.au

ACWA – Aug17, 2006

It is worth any sacrifice,

however great or costly

To see eyes that were listless light up again;

To see someone smile who seemed to have forgotten

How to smile;

To see trust reborn in someone

Who no longer believed in anything

Or AnyoneDom Helder Camara