trauma informed environments...•trauma-informed services take into account an understanding of...
TRANSCRIPT
Trauma Informed Environments
M. Bennington-Davis, M.D., M.M.M.
October 2014
Y|Üáà? WÉ aÉ [tÜÅY|Üáà? WÉ aÉ [tÜÅY|Üáà? WÉ aÉ [tÜÅY|Üáà? WÉ aÉ [tÜÅ• Sometimes our systems disenfranchise the very
people we hope to serve
• This is borne out in missed appts, dropped
medications, therapies that don’t seem to work
• When this happens, we often blame the patient
• If we change our view, everything else changes
too
• Engagement in treatment increases dramatically
• Job satisfaction increases
• Health improves
When you
change the
way you
look at
things, the
things you
look at
change
Let’s
reconsider
how we
view our
services,
our clients,
and
ourselves
…
• Trauma-informed services take into account an understanding of trauma in
all aspects of service delivery and place priority on the individual’s safety,
choice, and control. Such services create a treatment culture of
nonviolence, learning, and collaboration.
• Utilizing a trauma-informed approach does not require disclosure of
trauma. Rather, services are provided in ways that recognize the need for
physical and emotional safety, as well as choice and control in decisions
affecting one’s treatment. TIP is more about the overall essence of the
approach, or way of being in the relationship, than a specific treatment
strategy or method.
Trauma informed practice guide
BC Provincial Use Planning
Council
WHAT DO WE MEAN BY WHAT DO WE MEAN BY WHAT DO WE MEAN BY WHAT DO WE MEAN BY TRAUMA?TRAUMA?TRAUMA?TRAUMA?
.
“Traumatization occurs when both internal
and external resources are inadequate to cope with the external threat.” Van der Kolk
Those we seek to serveThose we seek to serveThose we seek to serveThose we seek to serveMore than ¾ of Medicaid
recipients have had experiences
of trauma and violence during
their childhoods.
TRAUMA SHATTERS OUR EXPERIENCE OF REALITY AND
SHATTERS THE SENSE THAT WE CAN UNDERSTAND,
MANAGE, AND FIND MEANING IN OUR WORLD
We serve people exposed to trauma, violence, and
overwhelming chronic stress, particularly as
children, affecting neural development.
These experiences call forth a range of responses,
including the easy triggering of fight/flight/freeze,
intense feelings of fear, loss of trust in others,
chronic hypervigilance, a decreased sense of
personal safety, feelings of guilt and shame, and
difficulty engaging in traditionally administered
healthcare services.
What have we used the brain for?
100,000 years:
Homo Sapiens
Hunter/Gatherer
5,000 years:
Recorded history
Building civilization
250 years:
“Modern” civilization
Here’s How the Brain Develops
• The brain needs safe experiences to thrive
• It grows,
is “pruned”
and learns
• It forms
connectomes
Life and coping can affect genes
Events in the environment can turn genes on or off
This may mean that environmental events may impact subsequent generations through epigenetic markers.
EPIGENETICS
The Adverse Childhood Experiences Study The Adverse Childhood Experiences Study The Adverse Childhood Experiences Study The Adverse Childhood Experiences Study (ACES)(ACES)(ACES)(ACES)
� Largest study ever done examining effects of adverse childhood experiences over one’s lifespan (>17,000 people)
� Majority were >50 yo, white, and attended college
� Original study done in California
� www.acestudy.org
ACES ResultsACES ResultsACES ResultsACES ResultsAbuse:
� Emotional 10%
� Physical 26%
� Sexual 21%
Neglect:
� Emotional 15%
� Physical 10%
� Two-thirds had at least one ACE
� ACEs tend to occur in clumps
Household Dysfunction
� Mother treated violently 13%
� Mental illness 20%
� Substance abuse 28%
� Parental separation or
� divorce 24%
� Household member
� imprisoned 6%
ACES Deadly OutcomesACES Deadly OutcomesACES Deadly OutcomesACES Deadly Outcomes� ACEs influence the likelihood of the 10 most common
causes of death in the U.S.
� With an ACE score of “0”, the majority of adults have few, often none, of the risk factors for these diseases
� With an ACE score of 4 or more, the majority of adults have multiple risk factors for these diseases or the diseases themselves
Top Ten…
�Heart disease
�Cancer
�Chronic respiratory
disease
�Stroke
�Unintentional
injuries
�Alzheimer’s
disease
�Diabetes
�Nephritis
�Influenza and
pneumonia
�Suicide
Positive, linear correlation between ACEs Positive, linear correlation between ACEs Positive, linear correlation between ACEs Positive, linear correlation between ACEs and health problemsand health problemsand health problemsand health problems
� Smoking
� COPD
� Hepatitis
� Cardiac disease
� Diabetes
� Fractures
� Obesity
� Alcoholism
� Other substance abuse
� Depression
� Attempted suicide
� Teen pregnancy and teen paternity
� Sexually transmitted diseases
� Occupational health
� Poor job performance
Health
problems
# ACEs
Twice as likely to smoke
Seven times more like to be alcoholics
Six times more likely to have had sex before the age of 15
Twice as likely to have been diagnosed with cancer
Twice as likely to have heart disease
Four times as likely to suffer from emphysema or chronic bronchitis
Twelve times as likely to have attempted suicide
Five times more likely to be involved in IPV or get raped
Ten times more likely to have injected street drugs
ACEs score of 8 gives four co-occurring problems
Epinephrine (adrenalin)
Cortisol
Beta-endorphins
Hypervigilance
Action, not thought
Cognitive diminishment
Increased aggression
Loss of impulse control
Speechless terror
• Reset CNS
• Traumatic re-enactment
• Aggression become chronic
• Dissociation is common
• Chronic hyperarousal interferes with
cognitive clarity
• Loss of (or failure to develop) affect
modulation
Stress Response to
RECURRENT THREAT
The wear-and-tear on the body and brain resulting from chronic over-activity or inactivity of physiological systems that are normally involved in adaptation to environmental challenge
Extreme poverty, repeated abuse or neglect,
Growing up in families facing economic hardship can produce elevated cortisol levels that may stay elevated even after conditions have improved.
Even infants and young children are affected by significant stresses that negatively affect their family and caregiving environments
Emotional Brain
(Restak, 1988)
Between Stimulus and Response
S Stimulus
Sensory Thalamus Amygdala
Very Fast
(LeDoux, 1996)
Between Stimulus and Response
S Stimulus
Sensory Thalamus Amygdala
Cortex
Very Fast
SlowerHippocampus
Response
(LeDoux, 1996)
Between Stimulus and Response
S Stimulus
Sensory Thalamus Amygdala
Cortex
Very Fast
SlowerHippocampus
Response
(LeDoux,
1996)
Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
SlowerHippocampus
Response
Cortex
(LeDoux,
1996)
Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
Slower
Response
Cortex
Hippocampus
(LeDoux,
1996)
Play
In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and
Animal Emotions, Oxford, New York
Play and Fear
In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions,
Oxford, New York
Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
Slower
Response
Cortex
Hippocampus
Neuroregulatory
Intervention
Cognitive engagement
Psychopharmacology
Social
Environmental
Intervention
(LeDoux,
1996)
HYPERVIGILANCE…
• Changes the way you view the world - literally Hypervigilance is an enhanced
state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats.
Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other sx include: abnormally increased arousal, a high responsiveness to stimuli, and a constant scanning of the environment for threats
Physically Abused Children See AngerWhere Others See Fear
Pollack, 2005, courtesy PNAS
The behavioral and emotional adaptations
that maltreated children and adults make in order to survive are brilliant, creative solutions, and are personally costly.
Jennifer Wilgocki, MS, LCSW
What we see
• Aggression and low impulse control in new situations or with new people
• Power struggles and fear in the context of rule enforcement
• Disengagement• Interpretation of safety
enforcement as predatory• “Minor” events
precipitating catastrophic reactions
Changing gears a little…Changing gears a little…Changing gears a little…Changing gears a little…
• Physiologic changes during F/F/F…
– Increased heart rate
– Increased BP
– Increased respiration
• Do you run because you are afraid or are you
afraid because you run… (Kohut)
Stress Research from Stress Research from Stress Research from Stress Research from JerusalemJerusalemJerusalemJerusalem
• Ariah Shalev at Hadassah Medical School
– Survivors of suicide bombers
• Following ER treatment
– Those that do not develop stress symptoms are able
to decrease heart rate, calm, quiet their bodies
– Those that do develop stress symptoms still have
hyperarousal, high heart rates, high blood pressure
• Regulated states appear to be correlated with
decreased likelihood to develop stress syndromes
How do you “center”
yourself?
• Deep, slow
breaths
• Concentrate
• Meditate
Goals of the Treatment setting
•Maintain Regulating State
•Prevent Re-experiencing States
•Build Cognitive Structures that allow choices
Saxe, 2001
A responsive environment will
• Facilitate physiologic
calm
• Avoid triggering the
fight/flight/freeze
response
• Encourage thinking,
problem-solving,
decision-making,
collaboration
What does YOUR environment do?
• Welcoming atmosphere?
• Pleasant physical environment?
• Kind, respectful people?
• Listening skills?
• Choices and individualized treatment?
• Clear communication on many levels?
• Hopeful staff members?
Physical EnvironmentsPhysical EnvironmentsPhysical EnvironmentsPhysical Environments� Have an impact on attitude, mood, and behavior
� Physical environment is the program as much as groups, routines, and therapy
� Its manipulation by skilled staff becomes an essential aspect of the educational process
� Strong link between physiologic state, emotional state, and the physical environment
What does YOUR environment say?What does YOUR environment say?What does YOUR environment say?What does YOUR environment say?
Language and VocabularyLanguage and VocabularyLanguage and VocabularyLanguage and Vocabulary
claims
denies
refuses
noncompliant
alleges
failed
Coercion… overt and covertCoercion… overt and covertCoercion… overt and covertCoercion… overt and covertMicroaggressionsMicroaggressionsMicroaggressionsMicroaggressions
� Rigid or confrontativeapproaches
� Rules, rules, rules
� Confusing information
� Secrets/lack of transparency
� Loss of control
� Punitive attitude when something goes wrong
� Directive staff language
� Judgmental aura
On Stage: On Stage: On Stage: On Stage: Treating each other wellTreating each other wellTreating each other wellTreating each other well
� How staff treat each other is not a secret
� How staff treat each other has an impact on those they serve
� How staff treat each other sets the cultural norm
� Respect is contagious
Healthy Provider Response to Healthy Provider Response to Healthy Provider Response to Healthy Provider Response to upset behaviorupset behaviorupset behaviorupset behavior
• Reinterpret through the lens of trauma exposure
• Avoid over-reacting
• Avoid power struggles
• Lean into service
• Find the distress
• Open up communication
This sometimes feels counter-intuitive…
Parallel ProcessParallel ProcessParallel ProcessParallel Process� Collective disturbance
� We do unto others as is done to us� Coercion is infectious
� So is respect
� Response to organizational trauma� Hypervigilance
� Easily triggered
� Sense of community� Cultural norms
� Deep democracy: having a voice
Bloom and Farragher 2011
Bloom and Farragher 2011
Five SquirrelsFive SquirrelsFive SquirrelsFive Squirrels� Donald Geisler 2005. “Meaning from Media: the Power
of Organizational Culture”. Organization Development Journal 23 (1): 81-83.
SAFE!• Control
• Respect
• Influence
• Information
• Reassurance
• Hopefulness
"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
You never know when You never know when You never know when You never know when you’re making a you’re making a you’re making a you’re making a
memory…memory…memory…memory…
--------Rickie Lee JonesRickie Lee JonesRickie Lee JonesRickie Lee Jones
Feel free to contact me!