Trauma Sensitive Care

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Trauma Sensitive Care

• What it is
• Why it matters
• How we can achieve it
• Howard Bath
• Thomas Wright Institute

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Perspectives on YP in Care

• Dependent
• Abuse/neglect
• Attachment
• High Risk
• Strength-Based
• Trauma

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Circle of Courage
GENEROSITY INDEPENDENCE BELONGING MASTERY
Research Foundations

• The Circle of Courage
• Belonging
• Opportunity to establish trusting connections
• Mastery
• Opportunity to solve problems and meet goals
• Independence
• Opportunity to build self control and
  responsibility
• Generosity
• Opportunity to show respect and concern

Self-Worth Research Significance The individual
believes I am appreciated. Competence The
individual believes I can solve
problems. Power The individual believes I set
my life pathway. Virtue The individual believes
My life has purpose.
Resilience Research Attachment Motivation to
affiliate and form social bonds Achievement Motiv
ation to work hard and attain excellence Autonomy
Motivation to manage self and exert
influence Altruism Motivation to help and be of
service to others
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Triune Brain
Logical Brain (Neocortex)
Emotional Brain (Limbic System)
Survival Brain (Brain Stem)
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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

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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)

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Hemispheric Specialization
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• we are born to form attachmentsour
• brains are physically wired to develop in tandem
  with anothers, 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 resilienceor a vulnerability (Shore,
  2003, p. xv)

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Which of the two faces appears happier?
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Threat and Trauma

• The Stress response

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The Stress/Fear Response (adapted from Sapolsky,
2004)
Glucocorticoids trigger the locus coeruleus to
release norepinephrine which communicates with
the amygdala
Amygdala
Locus coeruleus
Amygdala (the danger detector) activates the
HPA axis by initiating the release CRT from the
hypothalamus which stimulates the pituitary in
brain stem
Hypothalamus
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
Brain stem pituitary
Brain stem releases ACTH which activates the
sympathetic nervous system via the spinal cord
stimulating the adrenal glands
Adrenal glands
Corticotrophin releasing hormone, CRH
Adrenalcorticotrophic hormone, ACTH
Epinephrine (Adrenalin)
Norepinephrine

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

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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.

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Stress and Memory
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• 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

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The Danger Detector
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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

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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

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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

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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)

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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)

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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)

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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 events significance and
  dangerousness

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Stress, Memory Trauma
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Types of Trauma

• Type 1 (simple) from one overwhelming traumatic
  event
• Type 2 (complex) from ongoing exposure to
  fear/helplessness

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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

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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)

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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

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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
  verbalgtperformance scores - 39 have the opposite
  pattern)

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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 cant
  describe words fail me
• words cannot express

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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

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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

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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)

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Outcomes of Trauma

• The process of making meaning from exposure to
  extreme and prolonged threat
• Bowlbys notion of the maladaptive working
  models of self and others people are
  dangerous, they cant be trusted, Im not worthy
  of love, Im bad
• Sullivans description of malevolent
  transformation

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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)

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Trauma, Dysregulation Out-of-Home Care
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Executive Deficits (BRIEF) YP attending OOHC
Psychiatric clinic (Redoblado-Hodge, 2004)
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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)

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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

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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

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• 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)

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Pain and Pain-based Behaviour
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Pain-Based Behaviours

• 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)

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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

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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)

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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 thesystem replicates the behaviour of the
  abusive family (Herman 1992)

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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

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Safety
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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

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Emotion management
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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?

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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)

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The Foundation of Therapeutic Change
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The Foundation of Change

• Weve 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

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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)

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Trauma Sensitivity involves

• Understanding the impact on the child of
  overwhelming experiences of fear and helplessness
• Understanding how the childs 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

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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)?

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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_at_twi.org.au
• 
  ACWA Aug17, 2006

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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
Anyone Dom Helder Camara