trauma informed care stephanie sundborg, ms [email protected] 503-931-0536 mandy a. davis, lcsw, phd...
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TRAUMA INFORMED CARE
Stephanie Sundborg, [email protected]
Mandy A. Davis, LCSW, PhD [email protected]
TIC101- RECOGNIZING
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Trauma Informed Care“A program, organization, or system that is trauma-
informed:1. Realizes the widespread impact of trauma and
understands potential paths for recovery;2. Recognizes the signs and symptoms of trauma in
clients, families, staff, and other involved with the system;
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
4. Seeks to actively resist re-traumatization” (SAMHSA, 2014)
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Trauma Informed Care“A program, organization, or system that is trauma-
informed:1. Realizes the widespread impact of trauma and
understands potential paths for recovery;2. Recognizes the signs and symptoms of trauma in
clients, families, staff, and other involved with the system;
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
4. Seeks to actively resist re-traumatization” (SAMHSA, 2014)
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Environment Brain Behavior
Input from the environment• vision, hearing, smell, taste, touch
“In-between” stuff – mental activities• Perception, attention, memory, learning
Output in the environment• Running, yelling, fighting, eating, listening, speaking,
WHY
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Sensory Perception – Bottom Up
Visual• Least accurate of all
senses• Does not reach full
adult functioning until age four
Touch• First of five senses to
develop and most prominent at birth
• Critical part of growth and nurturing
Taste• 2,000-5,000 taste
buds• Four types of
taste:
Auditory• Can be powerful triggers• Studies show trauma survivors
are more aware of oddball sounds earlier
Olfactory (Smell) Can detect around 10,000
smells Only sensory input that is
directly connected to limbic system (memory & emotion)
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Sensory / Perception… and the Trauma brain
• More sensitive to incoming sensory information – sounds are louder, smells are stronger.
• Sensory information act as triggers
• Top down input may be distorted – not available
Connecting to behavior: Do you notice survivors are more aware or bothered by sensory input?
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Attention… and the Trauma brain
• Selective attention is worse in general but better for threatening stimuli
• Divided attention – hyper vigilance – not wanting to inhibit distractors
Connecting to behavior: Do you notice survivors have a harder time focusing attention? Are they easily distracted?
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Memory… and the Trauma brain
• Short term (Working memory) isn’t very good – frontal lobe activation is decreased
• LT Declarative memory is usually impaired – damage to hippocampus and problems with working memory
• HOWEVER – LT - Implicit memory is strong for threatening stimuli
Connecting to behavior: Do survivors forget appointments, treatment plans, what was discussed last time? But, is their memory for threat situations or details good?
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Executive Function… and the Trauma brain
• Frontal lobe function is impaired – affecting judgment, decision making, planning, reasoning
• Impulse control is more difficult
• Needed regulation is not online - attention and emotion can get out of wack • Anxiety related, perseverative loops - OCD
Connecting to behavior: Do survivors perseverate, fixate? Do they show problems with impulse control? Struggle with making decisions or planning?
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Top Down Processing
• Pre-existing knowledge is used to rapidly organize features into a meaningful whole
• Past experiences, motives, contexts, or suggestions prepare us to perceive in a certain way (Perceptual Expectancy)
“We don’t see things as they are. We see them as we are”
Anais Nin
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• Long-term memory
• Learning• Judgment• Problem solving• Decision making
Upstairs Brain
• Incoming sensory
• Orienting attention
• Reflexive Perception (e.g. startle)
• Perception• Selective
attention• Working
Memory
Downstairs Brain
Response
Mezzanine
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Opportunity to help navigate, control, filter sensory input
What to expect
“We know the noise in the waiting area can be overwhelming – perhaps bringing headphones…”
Opportunity to make sure attention is focused? Perception isn’t distorted? Info is getting into short term memory?
“With so much going on in this room, I know it can be difficult to stay focused on me, but if you could give me your attention for just a few minutes…”
“I know I just gave you a lot of information, can you tell me your understanding of next steps”
Draw on context, experience, and LT memory to shape incoming info. If needed, create new stories / memories to replace old ones… “Remember last time this happened, you were able to XYZ”
Stress Response
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Stress Response….
Considers sensory info for real or perceived danger
Offers rational thinking, planning, decision making, sense making
Memory formation – checks memories for context
If stress response warranted – HPA axis initiates
Incoming sensory information
Illustration: Hallorie Walker Sands
Selective Attention and working memory
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• Dominant at birth
• Sensory experiences – no language
• Emotional Processing
• Relational hemisphere – focused on attachment
• Developing slower ~ 18-24 months• More logical,
analytical, and sequential• Focuses on details –
construct narratives
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Cortisol and other Brain Chemicals
• Norepiniphrine (NE)• Alertness / arousal / attention• fight/flight (SAM sys chemical)• Solidifying threat memories
• Cortisol • fight/flight (HPA axis chemical)• Damages hippocampus (memory)• Needed to shut off stress response – neg feedback loop• Lower levels in PTSD
• Serotonin (5HT)• Dampen NE firing• Reduces sensory stimulation in amygdala – only in presence of cortisol• Reduced levels in PTSD, depression
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Cortisol and other Brain Chemicals
• GABA (benzodiazepine)• Inhibitory NT – reduces excitatory activity• Reduces re-experiencing / hyperarousal• Frontal lobe “squirts” GABA into amygdala• Impaired in PTSD
• Endogenous Opiates• Analgesia• Related to dissociative symptoms• Acute stress response elevates secretion of opioids• Chronic stress response may lead to lower concentration of
opioids
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When Trauma Happens….• Freeze, Flight, Fight, Fright
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When Trauma Happens….• Chronic Trauma, Complex trauma overtime
• Central Nervous system becomes unbalanced
Parasympathetic Nervous Sys:Rest and Digest Sympathetic
NS:Arousal system Fight or Flight
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Neurobiology Take Aways
• Simple to complex – Survival mechanisms act first and faster than the thinking brain.
• When we are threatened – brain moves resources away from thinking toward survival.
• Our brain learns patterns. Fire-together-wire-together.
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Neurobiology Take Aways• Attention can be a problem:
• Amygdala in survivors is hyper-vigilant – scanning for real or perceived threat; attentional control from frontal lobe is decreased
• Communication is challenging: dominance of RH • Decreased verbal (left hemisphere) – hypersensitive to
nonverbal (right hemisphere) – prone to misinterpret.
• Memory is impaired – damage to hippocampus due to excess cortisol: • Explicit memory (hippocampus) – facts, stories, pictures –
impaired • Implicit memory (amygdala – acute trauma) often clear and
sharp
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Stretch
TRAUMA INFORMED CARE 201
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Principles of PracticeWith a foundation of awareness and understanding, organizations can strive to reflect three central principles of TIC, by creating policies, procedures, and practices that:
• create safe context,• restore power, and• value the individual.
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Trauma Informed Care (TIC) recognizes that traumatic experiences terrify, overwhelm, and violate the individual. TIC is a commitment not to repeat these experiences and, in whatever way possible, to restore a sense of safety, power,
and worth
Commitment to Trauma Awareness
Understanding the Impact of Historical Trauma
Create Safe Contextthrough:Physical safetyTrustworthinessClear and consistent boundariesTransparencyPredictabilityChoice
Restore Power through:ChoiceEmpowermentStrengths perspectiveSkill building
Value the Individual through:CollaborationRespectCompassionMutualityEngagement andRelationship Acceptance and Non-judgment
Agencies demonstrate Trauma Informed Care with
Policies, Procedures and Practices that
Trauma Informed Care
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What is required to Provide TIC?• Secure, healthy adults;• Good emotional management skills;• Intellectual and emotional intelligence;• Able to actively teach and be role model;• Consistently empathetic and patient;• Able to endure intense emotional labor;• Self-disciplined, self-controlled, and never likely to abuse power.
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The Reality• We have a workforce that is under stress.• We have a workforce that absorbs the trauma of the consumers.
• We have a workforce populated by trauma survivors.
• We have organizations that can be oppressive.• All of this has an impact
• We have organizations that come to resemble the behavior we’re trying to help.
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SafetyEmotional ManagementDissociationSystematic ErrorAuthoritarianismImpaired CognitionImpoverished relationshipDisempowered –HelplessnessIncreased AggressionUnresolved GriefLoss of Meaning
Adapted from Sandra Bloom’s Sanctuary Model