understanding traumatic stress a brief overview. what’s in store? part 1: recognizing trauma...
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Understanding Traumatic Stress
A Brief Overview
What’s In Store? Part 1: Recognizing Trauma
Definitions of Trauma Three Types of Trauma Short-term and long term impact Principles of Trauma Treatment
Part 2: Responding to Traumatized People ARC (Attachment, self-Regulation, &
Competency) Building safety, attachment, and attunement
Recognizing Trauma
Part 1
What Is “Trauma”?American Psychological Association
“ an emotional response to a terrible event like an accident, rape or natural
disaster ” Merriam-Webster Dictionary
“ a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury. an
emotional upset ”
Australian Psychological Society
“ The word ‘trauma' is derived from the Greek term for ‘wound'. Very frightening or distressing events may result in a psychological wound or injury - a difficulty in coping or functioning normally following a
particular event or experience. “
SAMHSA DefinitionIndividual trauma results from an event, series of
events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being...
In short, trauma is the sum of the event, the experience, and the effect.
Three Types of TraumaAcute
(isolated event) Trauma
Chronic (repeated or prolonged)
Trauma
Complex (developmental)
Trauma
An isolated event such as being the victim of a crime, surviving a natural disaster, or a serious accident
Living through an ongoing situation such as experiencing domestic violence, or a war
Experiencing multi-layered traumatic circumstances such as caregiver abuse or neglect, or a combination of multiple trauma events, particularly in childhood.
PrevalenceAdverse Childhood Experiences (ACE)
reported by adults: 28% physical abuse, 21% sexual abuse,
15% emotional neglect 10% physical neglect, 13% domestic
violence, 27% substance abuse in home
The Impact of Trauma About 80% of 21 year olds who were
abused as children met criteria for at least one psychological disorder (e.g. Depression, Anxiety)
ACE in any category increased the risk of attempted suicide 2- to 5-fold
Persons who have experienced 5 or more ACE events had a nearly threefold increase in rates use of psychotropic prescriptions.
The Brain
Mid-Brain – Motor regulation, arousal, appetite, sleep
Brain Stem – blood pressure, heart rate, body temperature
Cortex – Abstract thought, concrete thought, language
Limbic System – Attachment, sexual behavior, emotional reactivity
About The Human Brain Develops in a use-
dependent fashion Repeated activation of
specific nerve connections develops those connections and the areas required to sustain those connections
Areas that do not get consistent, repeated stimulation may not develop at all HHS Child Welfare Information
Gateway
Acute Response To Trauma In the reptilian and animal brain:
Hyper or Hypo-arousal: Fight, Flight, Freeze, Submit.
Information is processed directly for survival purposes.
In the cortex: New information is not processed or retained. Rational thought is avoided in favor of survival-
related activities.
About “Fight or Flight”Fight
When a threat can be
conquered
FlightWhen a
threat can be avoided
SubmitWhen a threat
can be mitigated
FreezeWhen there is
no way to avoid harm
PosturingVerbal outbursts or threatsConfrontationPhysical aggression
Physically moving awayDissociationHiding“shrinking” in posture, tone of voice
“if you can’t beat them, join them”Self-harmInstigatingDefending the attacker
Complete helplessnessPhysical freezingStuporCatatonia
Lasting Effects of Trauma Attachment and attunement:
Struggles to empathize with others Difficulty identifying others’ feelings through
verbal or visual cues OR extreme sensitivity to others’ feelings perceived through these cues
Isolation, or trouble developing safe, trusting relationships
Unhealthy physical boundaries (touch aversion, sexual or social permissiveness)
Lasting Effects of Trauma Physical challenges:
Problems with balance (e.g. uneven gait) Movement coordination problems Lack of hand/eye coordination Delays in growth and development (e.g.
“failure to thrive”) Unexplained physical pain Sleep disturbances, night terrors, or altered
sleep pattern
Effects of Trauma Emotion and Mood:
Difficulty describing feelings Feelings are experienced as overwhelming,
with limited ability to modulate Depression, anxiety, and numbness are
common Lack of affect
Effects of Trauma Arousal modulation:
Dissociative states (black outs, out-of-body experiences, a “blank stare”)
Abrupt outbursts of anger and/or aggression Hyperactivity or “mania”-like presentation
Behavioral control: Difficulties in impulse control Self-destructive behavior
Lasting Effects of Trauma Cognition:
Problems with attention and concentration Difficulty retaining new information Short term memory problems Limited autobiographical memory Poor self-image and self-esteem Persistent intrusive thoughts and images,
sometimes resembling hallucinations “Arrested development”
Trauma Treatment & Recovery
In order to foster change, people’s reparative experiences must be
Predictable Consistent Repetitive Appropriate for developmental stage of the
person in the specific area of activity, rather than their chronological age or the usual performance of non-traumatized peers
Inclusive of any and all unoffending caregivers
Trauma Treatment & Recovery The case of Robert and Mama P. (Excerpt
From the book, “The boy who was raised as a dog”, by Dr. Bruce Perry)
Questions for discussion: What themes are common to the case of
Robert and the people with whom we work? What feelings/thoughts arise as we consider
these common themes? What can we learn from this case?
Responding to Traumatized People
Part 2
ARC Framework ARC: Attachment, Self-Regulation,
Competency In order to be effective, treatment of
complex trauma must be responsive to the specific developmental needs of the person, recognizing and addressing factors that have derailed normative development.
ARC Building Blocks
CaregiverAffect Mgmt
AttunementConsistent Response
Routines&
Rituals
Affect Identifi-cation
Affect Modulation
AffectExpression
Executivefunctions
Self-Dev’t& Identity
Dev’tal tasks
Attachment Attachment is a relational (two-way)
process, without which people do not develop the capacity to regulate their own emotions.
People with complex trauma histories often have problematic attachment styles due to repeated disruptions in attachment
The Still Face Experiment
Attachment StylesAttachment
StyleBehavior
Underlying beliefs
Previous caregiver’s behavior
AvoidantEmotionally distant, does not connect with others
“I can’t rely on others to meet my needs.”
Never emotionally or physically available
Ambivalent
“push/pull”: fluctuates between connecting and rejecting
“There is no way to predict whether my needs would be met.”
Inconsistent in availability or response
Disorganized
No pattern: sometimes Avoidant, other times Ambivalent. Often dissociative.
“Those who meet my needs are also likely to hurt me.”
Intermittently aggressive and/or abusive
Level 1: Attachment Goal: work with caregiver system to crate a safe
environment to support the client in meeting own needs
Who is considered a caregiver? Anyone who has regular and consistent responsibility to
support the client. Four tasks:
Build caregiver capacity to manage affect Build caregiver-client attunement Build consistency in caregiver response to client
behavior Build routines and rituals
Caregiver Affect Management Caregivers can support clients in developing
healthy self-regulation skills through modeling the response they’d like the client to develop. E.g. child falls down. Mother’s response determines
whether the child will cry. Challenges to caregiver affect management
Client vigilance to caregiver cues Intensity of client affect Caregiver’s own history and situation Relational reenactments
Addressing The Challenges
Encouraging self-awareness and self-monitoring Building capacity for self-care Developing a built-in support system Practicing teamwork Recognizing and addressing Secondary Traumatic
Stress (STS), compassion fatigue, and burnout. Supporting knowledge sharing activities Identifying successes and failures and using them
as teaching moments
Integrating Who You Are Into Your Work Your personality, communication style, and
background will inevitably find their way into your interactions with clients. Past hurts, traumas, and fears are bound to influence
these interactions- sometimes in unpredictable ways. YOU can be a powerful catalyst for client growth
and change: Identify what you bring into different interactions Recognize the impact of your life experiences on your
work Consciously choose which parts of YOU enter the
interaction with the client
Attunement Traumatized clients often have difficulty
communicating effectively. Behavior is an attempt to communicate
Unmet needs Unregulated affect
These difficulties may be global, or situation-specific
Caregivers often respond to the most distressing symptom or behavior, rather than the underlying emotion or need.
Value of Attunement Helps clients develop trust in caregiver
system Clients experience being understood Demonstrates true compassion, caring Allows clients to learn that their needs and
feelings will be addressed Facilitates prevention and rapid de-
escalation of high-intensity situations Increases client engagement Supports client behavior change
How Attunement Happens Become a “feelings detective”
When the client acts, consider what he/she might need or feel
Consider basic needs: hot, cold, tired, hungry, thirsty...
Consider the fight/flight response Consider the client’s attachment style and possible
triggers
Use reflective listening skills Practice responding to feelings/needs and
not to behavior
Consistent Response Predictability in caregiver response helps
clients feel safe, and reduces their need to exert control
Limit-setting and praise are common triggers: they are often associated with powerlessness and vulnerability. Where possible, reduce the need for limits Adapt response to the individual needs of the
client Build on successes
Routines and Rituals Trauma is often associated with chaos and
unpredictability Routines enable clients to feel safe,
anticipate and evaluate their experience, and learn reliability
It is important to be selective in developing routines/rituals, build-in flexibility
Routines/rituals are often subtle
Core Principles Safety
How do we know whether a situation is safe? How do we know if a person is safe? How does our personal definition of safety
impact our interactions with clients? Does our idea of safety translate into our work
environment? Why? Why not? What are the challenges in creating /
maintaining safety in our environment and interactions? How do we overcome them?
Core Principles Consistency
What are some challenges to consistency that we encounter in our day-to-day?
What can you do to create consistency? What support do you need, and from whom?
Repetition Why is repetition important? Why is it good? How much is too much repetition? How much is not
enough? How do we feel about repetition? How do we manage
any potentially negative feelings?
Thank You!
Questions, Comments, and Feedback welcome!
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