TRAUMA 101
TRAUMA INFORMED PRACTICE
Feb. 11, 2013
Kathy Savicki, LCSW,
Mid-Valley Behavioral Care Network
WHAT DO WE MEAN BY TRAUMA?
.
“Traumatization occurs when both internal
and external resources are inadequate to
cope with the external threat.” Van der Kolk



Critical role of environmental support
Link with abuse and neglect – toxic stress
for children
Fear + disrupted attachment
2
Limitations of the Diagnostic System


Acute Stress Disorder – 1st month after event
PTSD




1st described Vietnam vets and rape victims
Poor fit for children and youth
DSM V will change criteria
Proposed but rejected by APA:


Developmental Trauma Disorder
Complex Trauma/Disorders of Extreme Stress
3
Generational Trauma
Parental trauma responses affect their children
 Parental problems and crises impact kids
 Parental coping tools and relational styles
are passed down
 Children can learn a ‘trauma response’ to
life
4
Trauma in Our Lives

Up to 70% of American adults experience
at least one traumatic event
At any time 5% of Americans have active PTSD
 8% of us will experience PTSD in our lifetime


Approx. 25% experience multiple traumas

Prevalence in women is 2x that in men
5
Ability to Cope with Trauma
Depends on:





Single vs. repeated trauma
Age when trauma occurred or began
Agent – natural vs. human
Nature of the trauma – accidental vs.
purposeful
Innate resilience
6
ul
t
en
t/I
nj
ur
y
As
sa
Be
at
in
g
Un
ex
p
Sh
oo
tin
g/
ec
St
te
ab
d
bl
De
in
at
g
h
Ch
o
fL
ild
ov
's
Lif
ed
e-T
On
hr
e
ea
te
ni
ng
Illn
W
es
itn
s
es
sK
illi
ng
/In
ju
fy
Na
tu
ra
lD
isa
st
er
cc
id
ua
l
er
e
rS
ex
Se
rio
us
A
Ot
he
Se
v
55
50
45
40
35
30
25
20
15
10
5
0
Ra
pe
Select Traumatic Events and Risk
for PTSD
Risk of PTSD (%)
49
31.9
23.7
16.8
15.4
14.3
10.4
7.3
3.8
Source: Breslau, 1996 Detroit
Area Survey of Trauma
7
Neurobiology of Trauma
What happens in our brains?
These slides are available on the BCN website at
http://www.mvbcn.org/home/mv1/smartlist_176
/trauma-sensitive_services.html
9
Trauma and the Brain




Thalamus (temporal lobe) receives sensory
signals
Amygdala sorts for immediate danger
- Shuts down ‘thinking brain’
- Diverts energy to physical response
Hippocampus stores episodic long term
memory
Reactivation of this pathway strengthens it
10
In the Traumatized Brain
In the Traumatized Brain
Intervention Strategies
Memory & Perception
A memory includes:
 Narrative, verbal

Visual imagery

Sensory, somatic

Affective, feeling

Interpersonal, behavioral
Traumatic memories are encoded or “remembered”
in a different way from normal, everyday events.
19
Traumatic Memory
Sensory
 Linked with intense arousal
 Fragmented
 ‘Body’ rather than verbal memory
Role of psychotherapy is to develop the use
of the frontal cortex to make sense of
and manage reactivity

20
PTSD Symptom Clusters (DSM IV)
Re-Living the
Event
Avoiding
Reminders
Hyper-Arousal
 Recurring
nightmares,
flashbacks
 Avoid places, people,  Overly alert, easily
thoughts or other
startled, “on guard” at
associated activities
all times
 Intrusive images
“pop” into head
 Emotional numbing,
Loss of interest in
everyday activities
 Irritability or sudden
anger
 Extreme emotional or
 Difficulty sleeping,
physical reactions to  Withdrawal from
Lack of concentration
reminders (shaking,
family, friends
chills, panic, racing
heartbeat)
 “Avoid awareness”
that trauma occurred
1 + symptoms present 3 + symptoms present 2 + symptoms present
21
Developmental Trauma Disorder
Exposed to over a year of interpersonal violence,
with significant disruptions of protective caregiving
 Affective and Physiological Dysregulation
 Attentional and Behavioral Dysregulation
 Self and Relational Dysregulation
 PTSD Symptoms
 Functional Impairment
22
Complex PTSD, also called
Disorders of Extreme Stress



Proposed for DSM-IVR by trauma treatment
experts, but not adopted
Superb clinical description of adults who
experienced on-going child abuse and
neglect and multiple or pro-longed trauma
Better way of understanding many people
otherwise labeled with personality disorders
23
Generational Trauma
Parental trauma responses affect their children
 Parental problems and crises impact kids
 Parental coping tools and relational styles
are passed down
 Children can learn a ‘trauma response’ to
life
24
Systems Trauma

Simply put, systems trauma is the trauma
that people experience or re-experience as
a direct result of their interaction with a
powerful system

Although it may be connected to a single
trauma, more often it is part of complex
trauma
25
Systems Trauma




The experience of powerlessness is key to
retraumatization, especially when people have
experienced authority figures as cruel.
People are often retraumatized when they
experience being treated in a way that is similar
to past traumas.
The more trauma a person has experienced, the
more vulnerable they are to retraumatization
If you have a negative sense of self, feeling
judged can be powerfully retraumatizing
26
When Under Stress……….




We all tend to use our more primitive defensive
brain
Use of that part of the brain curtails the use of the
more-highly organized, intelligent part of the
brain
We become more tuned in to immediate survival,
and less tuned in to the abstract future
We opt for simple and swift as opposed to
complex and thoughtful reactions
27
Retraumatization: Feeling States
Being retraumatized often invokes intense feelings








Hopelessness
Helplessness
Extreme vulnerability
Intense desires to die, disappear or run
Pervasive shame
Anger or rage
Terror
Self-hatred/condemnation
28
Retraumatization: Common responses





Strong negative emotions that may be difficult for
the person to explain, and expressed in ways that
we might not understand (or appreciate)
Defensive or angry verbalizations/avoidance
Withdrawing emotionally/shutting down/selfsabotage
Telling people “in authority” what they think the
person wants to hear/overly “compliant”
Disengaging from services/leaving
29
SYSTEMS WHICH FREQUENTLY
RE-TRAUMATIZE






Law Enforcement
Criminal Justice
Child Welfare
Hospitals and related medical systems
Mental Health
Substance Abuse Treatment
30
Many Parents Encountering Child Welfare





Have experienced abuse as children
Have experienced multiple life traumas and
developmental interruptions
Have not had the natural and therapeutic
supports needed to initiate their own recovery
Have had little or no experience, training or
support in being a parent
Have multiple life stressors and limited
resources
31
CHILD WELFARE




Parents experience Child Welfare staff as
extremely powerful
Parents who encountered the Child Welfare
System as children know that power
What’s at stake is the primary attachment
to one’s child
Actual and perceived negative experiences
create difficulties in building a relationship
32
CHILD WELFARE

The Child Protective Services System
works with a legal system that can feel
adversarial

Fact-based reports can feel accusatory,
triggering intense feelings of guilt

Parents often experience this process as
frightening, unfair, humiliating and painful
33
Potentially traumatizing experiences




Not being informed of or understanding the plan
for the children when they have been taken into
custody, not knowing the process
Having – or feeling that - important decisions are
made about them or their children without their
knowledge, participation or consent
Multiple conflicting priorities without the
resources or support to accomplish them
Negative evaluations of their character or value as
parents
34
Potentially traumatizing experiences




Judgments and stereotypes related to the
parent’s addiction, mental health, or family
history
Being treated as hopeless or as if their past
history dooms them to failure
Fear of their children having negative
experiences (big or little) in foster care
Loss of contact with child or termination of
rights
35
Basic Skills: Trust and Respect






Kindness, courtesy, politeness
Reliability
Attentive listening – open ended questions
Emphasize choice
Owning our mistakes
Assume symptoms (including lies) have a
positive intent and an adaptive function
36
Reconsidering Our Words

Frequent flyer


Manipulation


Reflects a primary need not met in other ways
Attention Seeking


An indirect method of achieving a goal when being direct
isn’t see as an option or likely to succeed
Secondary Gain


Perjorative label reflecting our helplessness/frustration
Why do people have to work so hard to get our attention?
Borderline

Person with an attachment disorder
37
We Have to Believe in Recovery
Stay strengths-based and respectful
 Remember that change is terrifying
 Know that the person is doing their best to
survive in the moment
 If they rage at you, assume you’ve reactivated
previous traumatic relationships and don’t overreact yourself
 Peer supports are invaluable to help people feel
truly understood and hopeful about change
38
We Have to Believe in Recovery
Stay grounded in Recovery Principles
 Recovery is not linear, but marked by growth,
setbacks and learning from experience


Honoring attempts that don’t work
Moving from destructive to healthy coping
involves daily choices for health and safety




The process can be laborious
Small steps need to be recognized and valued
Beware when you feel “Here we go again”
Holding on to hope
39