What is Trauma and Why Must We Address It? (Part I: Implications for Clinical Practice)

Provide feedback and earn CE Credit with one link:

We will provide this link at the end of the webinar

Welcome to the Military Families Learning Network Webinar:

What is Trauma and Why Must We Address It?

(Part I: Implications for Clinical Practice) "

This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.

Welcome to the Military Families Learning Network


Research and evidenced-based professional development

through engaged online communi7es eXtension.org/militaryfamilies

POLL

How would you best describe your current employer?


https://www.facebook.com/MilitaryFamilyAdvocate https://twitter.com/MilFamAdvocate https://www.youtube.com/user/MIlFamLN #eXfamdev https://www.linkedin.com/groups/Military-Families-Learning-Network-6617392\

To receive no7ca7ons of future webinars and other learning opportuni7es from the Military Families Learning Network, sign up for the Email Mailing list at: h6p://bit.ly/MFLNlist

Webinar participants who want to get 2.0 NASW CE Credits (or just want proof of participation in this training) need to take the post-test provided at the end of the webinar#

CE Certificates of completion will be automatically emailed to participants upon completion of the post-test. #

Questions/concerns surrounding the National Association of Social Workers (NASW) CE credit certificates can be emailed to this address: [email protected]#

Sometimes state/professional licensure boards for fields other than social work recognize NASW CE Credits, however, you would have to check with your state and/or professional boards if you need CE Credits for your field. #

" To learn more about obtaining CE Credits, please visit this website:

http://blogs.extension.org/militaryfamilies/family-development/professional-development/nasw-ce-credits/#

CE Credit Information#

INSERT PHOTO

Todays Presenters:

Dr. Joan B. Gillece, Ph.D. has thirty years of experience working in the behavioral health field with seventeen dedicated to trauma and seven in prevention of seclusion and restraint. Working across agencies, Dr. Gillece promotes the use of trauma informed care in multiple settings including mental health, substance abuse, adult and juvenile justice and homeless services. As project director for SAMHSAs National Center for Trauma-Informed Care (NCTIC), Dr. Gillece has championed the cause of full consumer integration and development of Culturally Competent programs. Utilizing survivors in all aspects of trauma work, Dr. Gillece has coordinated technical assistance, conference presentations, and consultations with experts in the field. Commitment to strength-based support by implementing trauma informed values with the overreaching theme of recovery has been her focus.

INSERT PHOTO

Brian R. Sims, M.D. is a Forensic Psychiatrist currently working in several positions. He is a Staff Psychiatrist with Correctional Mental Health Services, the Senior Medical Advisor for the National Association of State Mental Health Program Directors based in Alexandria, Virginia and a National and International Consultant on the Fundamentals of Trauma Informed Care. Dr. Sims routinely provides lectures and trainings for Staff, consumers and Administration in the US, Guam, and recently Australia and New Zealand on the practice of Trauma - Informed Care; its applications, as well as the Neurobiology of Trauma. Dr. Sims has also served with the State Mental Health System for 25 years, as well as private practice.

What is Trauma and Why Must We Address It? (Part I: Implications for Clinical Practice)

Presented By: Joan Gillece, Ph.D.,

Director of SAMHSAs National Center for Trauma Informed Care &

Brian Sims, M.D., NASMHPSs Senior Medical Provider

Important Things to Remember

Not whats wrong with you but what happened to you.

Symptoms are adaptations. Violence causes trauma andtrauma

causes violence.

What is Trauma?

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and emo;onally harmful or threatening and that has las;ng adverse eects on the individuals physical, social, emo;onal, or spiritual well-being.

Draft Definition (SAMSHA, 2012)

The Three Es

Events and Circumstances The individuals experience of these events or circumstances helps to determine whether it is a trauma7c event.

The long-las7ng adverse eects on an individual are the result of the individuals experience of the event or circumstance.

Grin, 2012

Six Key Principles Fundamental to a Trauma-Informed Approach

1. Safety: Throughout the organiza7on, sta and the people they serve, whether children or adults, feel physically and psychologically safe; the physical seYng is safe and interpersonal interac7ons promote a sense of safety. Understanding safety as dened by those served is a high priority.

2. Trustworthiness and Transparency: Organiza7onal opera7ons and decisions are conducted with transparency with the goal of building and maintaining trust with clients and family members, and among sta, and others involved in the organiza7on.

3. Peer Support: Peer support and mutual self-help are key vehicles for establishing safety and hope, building trust, enhancing collabora7on, and u7lizing their stories and lived experience to promote recovery and healing. The term Peers refers to individuals with lived experiences of trauma, or in the case of children this may be family members of children who have experienced trauma7c events and are key caregivers in their recovery. Peers have also been referred to as trauma survivors.


4. CollaboraCon and mutuality: Importance is placed on partnering and the leveling of power dierences between sta and clients and among organiza7onal -sta from clerical and housekeeping personnel, to direct care professional sta to administrators, demonstra7ng that healing happens in rela7onships and in the meaningful sharing of power and decision-making. The organiza7on recognizes that everyone has a role to play in a trauma-informed approach. As one expert stated: one does not have to be a therapist to be therapeu7c


5. Empowerment, Voice and Choice: Throughout the organiza7on and among the clients served, individuals strengths and experiences are recognized and built upon. The organiza7on fosters a belief in the primacy of the people served, in resilience, and in the ability of individuals, organiza7ons, and communi7es to heal and promote recovery from trauma. The organiza7on understands that the experience of trauma may be a unifying aspect in the lives of those who run the organiza7on, who provide the services, and/ or who come to the organiza7on for assistance and support. As such, opera7ons, workforce development and services are organized to foster empowerment for sta and clients alike. Organiza7ons understand the importance of power dieren7als and ways in which clients, historically, have been diminished in voice and choice and are o`en recipients of coercive treatment. Clients have are supported in shared decision-making, choice, and goal seYng a leadership role into determining the plan of ac7on they need to heal and move forward. They are supported in cul7va7ng self-advocacy skills. Sta are facilitators of recovery rather than controllers of recovery .


6. Cultural, Historical, and Gender Issues: The organiza7on ac7vely moves past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orienta7on, age, religion, gender-iden7ty, geography, etc.); oers, either directly or through referral, access to gender responsive services; leverages the healing value of tradi7onal cultural connec7ons; incorporates policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma.


Symptoms as Adapta7ons

Self Inflicted Injuries

People use self-harm because it helps them manage what feels unbearable in the moment. There is a great deal of intensity behind the acts of self-injury.

Feeling states such as profound despair, anguish,

rage or terror, or a fear of losing oneself or being swallowed by traumatic flashbacks or re-enactments are just some of the stressors leading to self-inflicted violence (SIV).

(Mazelis, n.d.)

Dissociation

A mental process which produces a lack of connection in a persons thoughts, memories, feelings, actions, or sense identity.

During dissociation certain information is not associated with other

information as it normally would be. For example: during a traumatic experience, a person may

dissociate the memory of the place and circumstances of the trauma from his ongoing memory, resulting in a temporary mental escape from the fear and pain of the trauma and, in some cases, a memory gap surrounds the experience.

(Sidran Institute, 1999 )

Post-Traumatic Stress Disorder (PTSD)

Symptoms of PTSD Intrusive Re-experiencing Avoidance Arousal

(Sidran Institute, 2000)

ACE Questions:

20

While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often Swear at

you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you?

4. Did you often or very often feel that No one in your family loved you or thought you were important or special? Or Your family didnt look out for each other, feel close to each other, or support each other?

ACE Questions: Cont

5. Did you often or very often feel that You didnt have enough to eat, had to wear dirty clothes, and had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced? 7. Was your mother or stepmother: Often or very often pushed, grabbed,

slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

10. Did a household member go to prison?

ACE Study

Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might heroin be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find?

(Felitti et al, 1998)

22

ACE Study

Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?

(Felitti, et al, 1998)

23

Peer Engagement Guide

Link to Document: http://www.nasmhpd.org/docs/publications/EngagingWomen/PeerEngagementGuide_Color_REVISED_10_2012.pdf

I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.

~ Maya Angelou

Contact Information Joan Gillece, PhD

SAMHSA National Center for Trauma Informed Care

[email protected]

703-682-5195

Module created by Saxe, 2002

Brian R. Sims, M.D.

Senior Medical Advisor National Association of State Mental Health

Program Directors

Time Period

PTSD

-RI S

core

Acute Assessment 3 Month Assessment 0

Longitudinal Course of PTSD Symptoms in Children with Burns

5

10

15

20

25

30

35

40

45

50

4

Text

Text

Prevalence of Trauma in the General Population

Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a

Healthy, Non-Maltreated Matched Control

(De Bellis et al., 1999)

6

Hippocampus Volume Reduction in PTSD

Effective Treatment Must Account For:

1) A dysregulated nervous system

2) A social environment that cannot contain this dysregulation

Core Concepts of Development

The development of children unfolds along individual pathways whose trajectories are characterized by continuities and discontinuities, as well as by a series of significant transitions.

(Shonkoff & Phillips, 2000)

PTSD Rates

8-14% of PTSD rates in the general population and among certain disadvantaged groups may even be higher.

(Kaplan et al., 1994; Kessler et al., 1995)

Trauma victimizations studies show prevalence between 51-98% among persons with serious mental illness (SMI) in the public sector.

(Goodman et al., 1997; Muesar et al., 1998)

309.81 PTSD Definition

The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons experience of:

Actual or threatened death Actual or threatened serious injury Threat to physical integrity

Post Traumatic Stress Disorder

Characterized by: Re-experiencing the event

Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories

Avoidance and emotional numbing Flattening of affect, detachment from others,

loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience

Core Concepts of Development

2) The growth of self regulation is a cornerstone of early development that cuts across all behavioral domains.

(Shonkoff & Phillips, 2000)

State Change

Aggression

Fear

Dissociation

Calm/ Continuous/

Engaged

22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained.

State Change

Shame

Fear

Dissociation Self Mutilation

Calm/ Continuous/

Engaged

12 year-old sexually abused girl in school when provoked by older male peer.

Parameters that change between state

Affect Thought Behavior Sense-of-self Consciousness

Goal of Treatment

Maintain Calm/Continuous/

Engaged State

Prevent Discontinuous States Build Cognitive Structures

that allow choices

Between Stimulus and Response

Response

Stimulus


Response

Stimulus Traumatic Reminder

Trigger

Intervention

Social- environmental intervention

Neuro- regulatory

Intervention


Response Stimulus

Traumatic Reminder

Trigger

Intervention

Social- environmental Intervention

Neuro- regulatory

Intervention

COGNITION!!!

Emotional Brain

(Restak, 1988)


Stimulus (LeDoux, 1996)


Stimulus

Sensory Thalamus

(LeDoux, 1996)


Stimulus

Sensory Thalamus Amygdala

Very Fast

(LeDoux, 1996)


Stimulus


Cortex

Very Fast

Slower Hippocampus

(LeDoux, 1996)


Stimulus


Cortex

Very Fast

Slower Hippocampus

Response

(LeDoux, 1996)


Stimulus

Sensory Thalamus Amygdala Very Fast

Slower Hippocampus

Response

Cortex

(LeDoux, 1996)


Stimulus


Slower

Response

Cortex

Hippocampus

(LeDoux, 1996)


Stimulus


Slower

Response

Cortex

Hippocampus

Neuroregulatory Intervention Psychotherapy

Psychopharmacology

Social Environmental Intervention

(LeDoux, 1996)

Rauch Brain scans

Play

(Panksepp, 1998)

Play and Fear

(Panksepp, 1998)

Traumatic Mastery

Many children have primarily experienced abusive and neglectful relationships Extreme behaviors within relationships can be seen as defensive or self-protective Traumatized children respond to their trauma history in the present. They are not able to discern that the context has changed This behavior must be seen as an attempt to master extremely difficult environments In this way, traumatized children are doing the best that they can

TAKE HOME IDEAS

Set up calm and nurturing environments

Teach staff to meticulously observe for triggers when someone is beginning to move from a calm, continuous state to a discreet state of emergency

Train to caring and compassion

Meticulously interview for triggers

Adjust the environment Adjust what we do (i.e., look at ourselves and our behaviors and actions as the key

for success)

CONCLUSIONS Response to traumatic stress is learned behavior, mediated by the

brain & the social environment

Traumatic stress brings the past to the present

The survival response impacts the mind, body, behavior & speech the amygdala leads a hostile takeover of consciousness by emotion. (LeDoux, 2002 )

To change the response, create new learning & skills: Analyze & adapt Buffer & bolster Teach, support, & build that cognitive wedge

Webinar participants who want to get 2.0 NASW CE Credits (or just want proof of participation in this training) need to take the post-test provided here: https://vte.co1.qualtrics.com/SE/?SID=SV_0CFNxTOpNhjM5Zr#

CE Certificates of completion will be automatically emailed to participants upon completion of the post-test. #

Questions/concerns surrounding the National Association of Social Workers (NASW) CE credit certificates can be emailed to this address: [email protected]#

Sometimes state/professional licensure boards for fields other than social work recognize NASW CE Credits, however, you would have to check with your state and/or professional boards if you need CE Credits for your field. #

" To learn more about obtaining CE Credits, please visit this website:

http://blogs.extension.org/militaryfamilies/family-development/professional-development/nasw-ce-credits/#

CE Credit Information#


Next Webinar:

Thursday, October 30, 2014 @ 11:00 am EST

What Is Trauma & Why Must We Address It? (Part 2: Implications for Work With Children)

https://learn.extension.org/events/1571

Military Families Learning Network"


Find all upcoming and recorded webinars covering: #

Family DevelopmentMilitary Caregiving #Personal Finance #Network Literacy#

#http://www.extension.org/62581

#

Education

What is Trauma and Why Must We Address It? (Part I: Implications for Clinical Practice)