BUILDING RESILIENCE E Szabo C., KelemanO., & Keri S. (2013) Bol Psychiatry Lauren Ashbaugh, Ph.D.,...

BUILDING RESILIENCE

• February 21st, 2019

Lauren Ashbaugh, Ph.D., NCSP

AGENDA

8:35-8:45 Setting the stage

8:45-9:00 Defining resilience

9:00-9:20 ACEs, trauma, & toxic stress

9:20-9:30 Trauma & the body

9:30-10:00 Building resilienceContinua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP

REFLECTION PAGE

• Find the numbers on the slides:

• Match the numbers to the questions on the reflection sheet.

• Voluntary and entirely for you.

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YOUR RIGHTS

• You have the right to take all the space you need. Please do. Some content is distressing.

• You have the right to choose how you prefer to participate.

• You have the right to use humor and laughter.

• You have the right to speak and be heard.

• You are invited to talk to me about any and all of this.

Continua Consulting Group, LLCLauren Ashbaugh, Ph.D., NCSP

• Do your best to be present.

• Do no harm.

• Be kind to yourself.

• Remember that vulnerability often leads to growth.

MY REQUESTS


Chapter: SUDS: The Subjective Units of Distress Scale

From: Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): Patient Workbook

www.anxietybc.com

TENDING TO MY INTROVERTS .

Optional means optional

Feel free to choose to focus on empathy, listening, & reflection.


EMPATHY: CLIMBING IN THE HOLE

https://brenebrown.com/

BUILDING RESILIENCE

WHAT IS RESILIENCE?


AMAZING TACOMA KIDS2

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RESILIENCE

(1) the ability to face and cope with challenges;

(2) adapt to the changes created by these challenges; and

(3) recover and even grow from these setbacks.

Seelig et al. (2016) Sleep and health resilience metrics in a large military cohort.


RESILIENT TO WHAT?

ACEs, Trauma, & Toxic Stress


What are Adverse Childhood Experiences (ACEs)?

Source: Robert Wood Johnson Foundation


HOW DID THE "ACES" STUDY ARISE?

Original question arose in 1985 in obesity clinic

Vincent Felitti, M.D.


http://www.apbspeakers.com/speaker/vincent-felitti

When he finished, one of the experts stood up and blasted him. “He told me I was naïve to believe my patients, that it was commonly understood by those more familiar with such matters that these patient statements were fabrications to provide a cover explanation for failed lives!”

Dr. Felitti at the North American Association for the Study of Obesity conference in 1990:

Continua Consulting Group, LLC

Source: J.E. Stevens, Huffington Post, 10/2012


THE ORIGINAL CDC/KAISER ACES STUDY*:

• Original question arose in 1985 in obesity clinic

• CDC partnered study spanned 1995-1997

• Kaiser Permanente in San Diego, CA

• 17,421 participants

Vincent Felitti, M.D.

Robert Anda, M.D., M.S.

Almost 2/3 had at least 1 ACE

40% had 2 or more ACEs

One in five had >3 ACEs

*Felitti & Anda et al, American Journal of Preventative Medicine, 1998



Without intervention, 20 year difference in life expectancy with 4+ ACEs

Source: CDC


CDC/KAISER ACES STUDY: WHAT’S MISSING?

• Peer victimization/bullying

• Deportation of family member

• Racism/institutional oppression

• Multiple deployments/military

• Caretaking an elderly or ill parent

• Acute health issue

• Car accident, health aftermath

• Natural disaster

• Multiple moves

• Losing a home/homelessness

• Loss of a colleague or teacher

• Poverty

• Disability

• Exposure to community violence

• Exposure to school violence

• Death of a family member


ACEs in WASHINGTON SCHOOLS – SOPHOMORES AND SENIORS(2010)

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• Behavioral Risk Factor Surveillance System (BRFSS)

• Over 23 states, 200,000+ participants

• Higher frequency of ACEs reported in:

• Women, young adults vs. men, older adults

• Less than high school diploma vs. HS graduate

• Multiracial, Hispanic, black vs. white

• Bisexual, LGBTQ vs. heterosexual

THE 2018 JAMA PEDIATRICS* ACES STUDY:

Merreck et al, 2019 JAMA Pediatrics. Graphic: CDC


ACES AND INTERSECTIONALITY

• Race

• Gender identity

• Sexual orientation

• Nationality

• Disability

• Available resources and support

Source: YW Boston


Intersectionality, n.

The interconnected nature of social categorizations such as race, class,

and gender, regarded as creating overlapping and interdependent

systems of discrimination or disadvantage; a theoretical approach based

on such a premise.

(Oxford Dictionary)


CHRONIC EXPOSURES

Rejection

Exclusion

Oppression

Threat

Neglect


REVISIT THE ORIGINAL CDC/KAISER ACES STUDY:

• Original question arose in 1985 in obesity clinic

• CDC partnered study spanned 1995-1997

• Kaiser Permanente in San Diego, CA

• 17,421 mostly middle-class adult participants

• 80% white, 10% black, 10% Asian

• 74% college-educated

• Average age: 57

Vincent Feletti, M.D.

Robert Anda, M.D., M.S.

Almost 2/3 had at least 1 ACE

40% had 2 or more ACEs

One in five had >3 ACEs



WHAT DOES THIS MEAN ABOUT OUR STAFF? OURSELVES?

ASSUME ACES

Are we walking the talk?

With ourselves?

With each other?

ASSUME SECONDARY TRAUMATIZATION/COMPASSION FATIGUE


LANGUAGE

Toxic Stress

Adversity, Challenges, Setbacks

Chronic Trauma

Are we supporting a deficit model?

Are we underemphasizing resilience?


WHY WAS THE ACES STUDY REVOLUTIONARY?WE DON’T LIKE TO SIT WITH TRAUMA

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EVIDENCE-BASEDTREATMENTS

FOR PTSD

Heal the wound

Enhance strengths



HISTORICAL CONSEQUENCE OF AVOIDANCE

• Missed opportunities for intervention

• Misdiagnosis and misuse of funds

• Neglect of impact on society, community, individuals

• Erasing history to avoid responsibility, accountability

• Perpetuate shame, guilt, overresponsibility in survivors


WE ARE ALONE WITH IT.

WE LEAVE OTHERS ALONE WITH IT.


Toxic Stress & the Brain

• Overactive ”Fight, Flight, or Freeze” – amygdala changes

• Changes to reward system functioning and pleasure centers (VTA)

• Structural changes to executive functioning/prefrontal cortex

• Memory center: hippocampal neurotoxicity; reduced volume

Ulrich-Lai 2009, Roth 1988, Iperato1991, Charmandari2005, McEwen 2010, McEwen 2007, Bierhauset al. 2003; Kiecolt-Glaser et al. 2003


Can result in:


• inflammation

• Infection

• cardiovascular problems

• chronic diseases

Toxic Stress & the Body

Ulrich-Lai 2009, Roth 1988, Iperato1991, Charmandari2005, McEwen 2010, McEwen 2007, Bierhauset al. 2003; Kiecolt-Glaser et al. 2003


• HPA axis & cortisol response

• Adrenaline

• Growth hormone/thyroid

• Pubertal hormones

• Levels of leptin and ghrelin

• satiety & appetite

Miller 2007

Increased risk of changes to:Increased risk of:


• Epigenetic changes & impact

• Biological mechanisms that turn genes on and off

• Affected by what you eat, where you live, how you

sleep, exercise, aging, and by your experiences


Su 2014



Childhood

Learning difficulties

Behavioral difficulties

Asthma & allergies

Infections

Atopic diseases

Pneumonia

Early Childhood

Developmental delay

Growth delay

Failure to thrive

Sleep disruption

Behavioral disruption

Adolescence

Learning difficulties

Behavioral difficulties

Obesity

Diabetes

Headache & abdominal pain

Hyperthyroidism

Pubertal changes

Adapted from: Burke-Harris 2018; Oh et al., in press, Matheson, 2016; Kerker 2015, Shen 2016, Ryan 2015, Giordano 2014, Rhodes 2012, Thompson 2017, Bjorkenstam 2015


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What does trauma look like in a classroom?

Arousal & Reactivity

Avoidance

Distorted thinking

Reexperiencing

Sleep disturbanceProblems concentrating

It’s not safe. I’m not safe. Gotta watch my back.

No way will I stay in that class.

(I could be embarrassed or fail again.)

I will fail if I try.

It happened because of me.

He sounds just like my stepdad.

I hate being yelled at.

I’m so tired. I can’t stay awake. I – I’m confused. Did we do this

yesterday?

I don’t know why I blew up like that


Symptom PTSD Depression ADHD Anxiety ODD (Oppositional)

Anger/Irritability X X X

Difficulty concentrating X X X X

Recklessness/impulsivity X X X

Trouble sleeping X X X

Social problems X X X X X

Lack of interest X X

Difficulty relaxing X X

Agitation/Restlessness X X X X

Youth Mental Health and Symptom Overlap:

Is it really ADHD?


TRIGGERS:

• Can be external (environment) reminders or internal (eg., thoughts)

• Can be reminders of the feelings related to the event(s)

• Guilt, shame, worthlessness, powerlessness

• Embarrassment, humiliation, rage

If the response seems to be much bigger than the situation

seems to call for, there is likely powerful historical context.


We know that toxic stress changes the body.

Positive experiences do too.


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• General definition: The quality of being shaped or molded.

• Biology: The adaptability of an organism to changes in its environment or

differences between its various habitats.

• Neuroscience: The brain’s ability to change – for better or for worse

What is plasticity?


Changing thoughts, changing body

12 week course of CBT for PTSD

• Statistical increase in hippocampal volume

• Significant increase in gene expression of FKBP5

• Significant improvement in PTSD symptoms

Levi-Gigi, E Szabo C., Keleman O., & Keri S. (2013) Bol Psychiatry


NOW THAT WE KNOW, WHAT DO WE NEED?


Between stimulus and response, there is a space.

In that space lies our freedom and our power to choose our response.

In our response lies our growth and our happiness.

-Steven R. Covey, summarizing Viktor Frankl’s work

RESEARCH ON RESILIENCE

1st wave: Inherent characteristics of the children that fared better than others

2nd wave: How resilience factors of children led to better outcomes

3rd wave:

How do we promote resilience through prevention, intervention, and policy change?

1. Traub, F & Boynton-Jarrett, R. 2017


RESILIENCE

“Far from being inherent to the child, resilience

results from a complex interplay between the

child’s genetics, natural temperament, knowledge

and skills, past experiences, social supports, and

cultural and societal resources.‍”

- Traub, F & Boynton-Jarrett, R. 2017, emphasis mine


TWO-PRONGS, SAME IDEA

Prevention

Reduce harm/exposures

Increase regulation & adaptive coping

Enhance positive identity formation, tenacity, competence

Increase connection and deepen meaningful relationships


Prevention

Reduce harm/exposures

Increase regulation & adaptive coping

Enhance positive identity formation, tenacity, competence

Increase connection and deepen meaningful relationships

Sleep Mindfulness

Exercise Healthy Relationships

Nutrition Mental Health

EVIDENCE-BASED RESILIENCE BUILDING


ANY DATA ON THOSE?

• Sleep: Rosenbaum, Vancamfort, & Steel et al (2015) Psychiatry Research

• Exercise: Ho, Chan, & Tang (2016). Psychiatry Research

Talbot, Maguen, & Metzler et al (2014) Sleep

• Nutrition: Clay (2017) Monitor on Psychology

• Mindfulness: Ortiz & Siibinga (2017) Children

• Healthy Relationships: Jaffe et al (2013) J of Adolescent Health

• Mental Health: Rolfsnes & Idsoe (2011) J of Traumatic Stress;

Kowalick et al (2011) J of Behavior Therapy and Experimental Psychiatry


INCREASING SAFETY, REGULATION, CONNECTION

• Diet, exercise, sleep

education, access, advocacy, opportunity, parent engagement, health care

• Family health & engagement

connecting resources, increasing engagement, collaboration

• Social competence & belonging

SEL, culturally responsive, restorative practices, activities, leadership opportunities

• Executive functioning, locus of control, growth mindset, grit, optimism

PBIS; clear, consistent, predictable, rigorous content, high expectations

• Facing fears, reappraising experiences

counseling, mental health, cognitive therapy, graduated exposure, mindfulness

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Predictability

Consistent expectations

High expectations

Welcoming and warm

Engaging content and approach

Opportunities to start over

Avoiding power struggles

Opportunities for leadership

Co-Constructed Norms

Classroom community

Tier I: T-MTSS Principles

Arousal

Avoidance

Sudden, intense anger

Distorted thoughts

Concentration problems

Reexperiencing

Sleep problems

I can be safe here

I am valued here

I can be successful here

I am worth something

I matter to other people

Mistakes are learning

People believe in me.

Symptoms of trauma

I can trust other people

Why T-MTSS?

How does T-MTSS relate to a trauma-responsive school?


MECHANISM: HEALTHY RELATIONSHIPS


A SECURE, SUPPORTIVE RELATIONSHIP WITH AN ADULT

Dr. Emmy Werner

Hawaii: 700 people over 40 years – all the babies born on the island of Kauai in 1955 —from infancy through

adolescence and adulthood.

Werner found that one-third of the high-risk children grew into adults who were caring and successful.

“Having a secure, supportive relationship in early childhood is one of best predictors of whether you’d be resilient later in

childhood and into adulthood. If you had at least one relationship where people were able to do that soothing,

protecting…or help you build strength, if you had at least that one relationship at least that could protect you from many

other stress exposures.”


https://en.wikipedia.org/wiki/Emmy_Werner

A trauma-informed practice requires us to respond neutrally or constructively.

How do we increase reflection, compassion, and curiosity?

A SECURE, SUPPORTIVE RELATIONSHIP WITH AN ADULT


WORKING TOWARDS A TRAUMA-INFORMED SYSTEM

Key principles of a trauma-informed approach:

1. Safety (physical and emotional)

2. Trustworthiness and transparency

3. Peer support

4. Collaboration and mutuality

5. Empowerment, voice, and choice

6. Recognition of historical and ongoing systematic traumatization

Source: SAMHSA, 2018Lauren Ashbaugh, Ph.D., NCSP

Anticipate needs and create safe environments

Maintain composure in the face of fear and uncertainty

Respond to crises without personalizing, becoming defensive, or panicking

Perform to the best of our ability when we are needed most

Lean on and build the strengths of others; empower and support

What do we need from our pilot and flight crew?


“We all carry within us places of exile, our crimes, our

ravages. Our task is not to unleash them on the world;

it is to transform them in ourselves and others.”

― Albert Camus


https://www.goodreads.com/author/show/957894.Albert_Camus

https://www.goodreads.com/author/show/957894.Albert_Camus

ATTENDING TO YOURSELF IS TAKING CARE OF THEM.

• Kids respond to our emotions and reactions.

• Kids know when adults are lying or are inauthentic.

• We need to model what we want to see in them.

• We need to be able to problem-solve with peers for their benefit.

What are you most afraid of in your building/office/classroom?

Who do you go to for help? How safe does it feel to ask for help?


IT’S A MINDSET, AND PRACTICES ARISE FROM MINDSET

• Students (and staff) want to do well.

• Something (skills deficit, crisis) may be getting in their way.

• Students and staff have tremendous potential and strengths. Build up both.

• Behavior has meaning and function. Look for both.

• Value the person, address the behavior

• Asking for help is a sign of strength and reflectiveness.

• Everyone needs help and connection.


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UNIQUE

https://changingmindsnow.org/

INSPIRATIONS

Laura van Dernoot Lipsky, MSW Rachel Lloyd, MA

Mary Oliver , Ph.D. Viktor Frankl, MD, Ph.D.

Jackson Katz, Ph.D. Patricia Resick, Ph.D.

Nadine Burke-Harris, MD, MPH

Robert Waldinger, MD Audre Lorde, MLS

Documentary: The Mask You Live In Documentary: Miss Representation


https://brenebrown.com/

BUILDING RESILIENCE E Szabo C., KelemanO., & Keri S. (2013) Bol Psychiatry Lauren Ashbaugh, Ph.D.,...

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