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!

maggie.bennington-davis@cascadiabhc.org