Trauma Informed Relationships:

A Pathway to Understanding and Resilience

Cyndi Vrabel, MD

“People will forget what you said,

People will forget what you did,

But people will never forget how you

made them feel.”

Maya Angelou

Trauma Informed Engagement

• Acknowledges the significant prevalence of trauma in the world.

• Recognizes the profound effects of trauma on the thoughts, feelings, and behavior of survivors.

• Affirms the strengths and resilience of survivors.

Trauma: The Hidden Epidemic

• More than 50% of people in the United States are survivors of trauma.

• Many have experienced multiple traumatic events, often beginning in childhood.

• Rates of trauma increase with: poverty, homelessness, mental illness, substance abuse and developmental disability.

Public Mental Health and Trauma

• More than 90% of clients served in the public mental health system are survivors of trauma.

• It is reasonable to assume that trauma is a universal experience of the people we serve and adopt “universal precautions”.

Trauma: the Three E’s

• EVENT: Overwhelms ability to cope.

• EXPERIENCE: “In the eye of the beholder”.

• EFFECT: Attempts to cope and survive.

Traumatic Events Include:

• Neglect

• Witnessing Violence

• Physical, Sexual and Psychological Abuse

• Foster Care

• Absence of a Parent

• Familial: Mental Illness, Substance Abuse Incarceration

Traumatic Events Include:

• Poverty

• Bullying

• Incarceration

• Combat

• Disaster

• Accidents

• Traumatic Loss……………..ETC!!

ACES: Adverse Childhood Experiences Study

• Vincent Felitti, MD (Kaiser Permanente) and Robert Anda, MD (CDC) 1995

• Understanding the effect of childhood trauma on lifelong health and wellbeing.

• Initial study involved 17,000 middle class, insured individuals

ACES: Adverse Childhood Experiences Study

• Adverse Experience Categories: Abuse, Neglect, Family Dysfunction

• ACE Score: number of categories of adverse experiences in first 18 years of life.

ACES

• 2/3 of the participants had a score of 1 or higher.

• 12% of the participants had a score of 4 or higher

• The higher the ACE score the higher the risk of serious health issues as an adult.

Health Risks with High ACE Score

• Depression and suicide• Smoking and substance abuse• Teen parenthood• Impaired work performance• Heart disease, obesity and diabetes• Liver disease, lung disease and cancer• An ACE score of 6 or higher decreases life

expectancy by 20 years.

ACES in a Nutshell

• The greater the exposure to adverse experiences in childhood…

• The greater the neurobiological impacts and health risks…

• The greater the lifelong consequences for health and well-being.

The Experience of Surviving Trauma

• Trauma is a core life event around which subsequent development organizes.

• Trauma profoundly changes the experience of “being in the world”.

• Trauma changes how a person thinks, how they experience emotion and how they behave in the world.

Traumatic Events

• Disrupt the experience of CONTROL

• Disrupt the experience of CONNECTION

• Disrupt the process of MEANING MAKING

World View After Trauma

• The world is not a safe place.

• People cannot be trusted.

• Those I care about will hurt me the most.

• I have to defend myself.

• I am powerless.

• I am worthless.

• I am crazy.

Emotions after Trauma

• Fear and Anxiety

• Depression

• Numbing

• Anger and Rage

• Grief

• Guilt and Shame

• Rapid shifts in emotion

Behavior After Trauma

• Hyper-vigilance

• Avoidance and Isolation

• Aggression: “Hurt People Hurt People”

• Exhaustion

• Poor Sleep

• Difficulty with Boundaries

• Re-experiencing and Flashbacks

Trauma Triggers

• Symbols of past trauma which make us think we are in danger when we are not.

• Triggers can be : sounds, smells, sights, anniversaries, objects or movements.

• Triggers re-create the Trauma Dynamic.

• Fight-Flight-Freeze Response.

Neurobiology of Triggers

• Prefrontal Cortex: diminished activity to ensure instinctual response

• Thalamus: diminished ability to perceive new information

• Diencephalon and Brainstem: Fight, Flight, Freeze

An Important Differentiation

• Normal emotional states: Cognitive Processing is intact.

• Triggers: Cognitive Processing is disrupted.

• Provides a framework for effective intervention.

Healing and Recovery

• Survivors of Trauma do Recover and Thrive.

• Creating a “New Normal”

• Healing Happens in The Context of Relationships.

Trauma Informed Relationships

• Trauma Lens

• A shift from: What is wrong with you???

• A focus on: What has happened to you and how can I support you?

• “If you don’t get what happened to me you’re not going to get how I am happening to the rest of the world.”

Trauma Informed Relationships

• The concept of Re-Traumatization.

• Recreating the devastating dynamics involved in trauma.

• “One does not have to act with great malice to do great harm. The absence of empathy and understanding are sufficient.”

Trauma Informed Relationships

• SAFETY

• EMPOWERMENT

• CONNECTION

Trauma Informed Relationships

• We all have stories.

• Our stories provide the meaning underlying our behavior.

• In trauma survivors, behavior is often an adaption which has allowed them to cope and survive.

• Trauma is an Explanation…not an Excuse.

Principles of a Trauma Informed Culture SAMHSA

• Safety

• Trustworthiness and Transparency

• Collaboration and Mutuality

• Voice and Choice

• Peer Support and Mutual Self-Help

• Resilience and Strength Based

• Intentional and Ongoing Change Process

“TI” TIPS

• You have great power and importance in the lives of the children and clients that you serve.

• You are planting seeds and creating experiences that will literally change the future.

“TI” TIPS

• Assume that people are doing the best that they can in the moment.

• When you see suffering…Lean In.

• When a client is struggling…Comfort First…Instruct Later.

• “I see that you are having a tough time…I want to help…How can I support you?

“TI” TIPS

• When you see anger, avoidance or apathy…Think Fear.

• Look at your workplace through a trauma lens: When I come in do I feel safe?...Do I feel hopeful?... Do I feel calm?

• Is there a space for clients to regroup and regain control?

• Consider a Comfort Kit.

“TI” TIPS

• Consistency and good boundaries promote trust and safety.

• Flexibility promotes empowerment and connection.

• Communicating with compassion, respect and honesty promotes growth.

• Your greatest tool is the exquisite gift of your presence.

“TI” TIPS

• Do not walk this path alone…this is a daily practice…not a destination.

• Come together for creative problem solving in working with clients.

• Come together for support.

• Come together for fun.

SELF CARE IS NOT SELFISH

• Put on your own oxygen mask before you assist the vulnerable person beside you.

• Working with trauma survivors can be tremendously gratifying but we must be aware of the “Cost of Caring”.

• What do we need to do to maintain our own resilience???

RESILIENCE

• Awareness of personal triggers, stressors and how the work is affecting us.

• Balance: Time and space for self care both DURING and after the workday.

• Connection and Healthy Coping.

• “Finish each day and be done with it…you have done what you could”

Thank You.

“Courage does not always roar. Sometimes courage is the quiet voice at the end of the day saying…I will try again tomorrow”

cynthia.vrabel@frontlineservice.org