Trauma Informed Care

Steven Davidson, LCSW, CST www.nashvillepsychotherapy.com

Objectives
Define trauma (including examples)

Learn how trauma influences the human brain

Learn how trauma influences behavior

Discover the correlation between trauma and addiction

Identify common interventions for treating trauma

Defining Trauma
any event that has a lasting negative effect (Shapiro & Forest, 2004) an emotional shock with a lasting effect (Allen, 2005)

something happened, it is experienced as emotionally disturbing, it continues to have negative consequences for the individual long after the event is over

Examples of Traumatic Events

Natural Disasters: (earthquakes, floods, tornados).

Technological Disasters: (dam breaks, plane crashes)

Attachment Trauma: (domestic violence, child abuse or neglect) Human-Made Disasters: (terrorist attacks, war) Criminal Violence: (robbery, rape, assault)

Betrayal Trauma: (abuse of trust by a perceived authority)

Symptoms of trauma
Too much emotion (rage, panic, despair) Too little emotion (blunted, numb, empty) Compulsions (sex, food, substances)

Eating disorders
Memory deficits or intrusive memories

Shame (belief that one is defective)

Two Aspects of Trauma

Objective: The facts about the event; (A tornado destroyed the house, but no one was killed.)

Subjective: The individuals personal experience of the event; (I could feel the debris hitting my body. I could hear my children screaming. I saw the roof lift off the house. I thought I was going to die. I believed I would never see my family again.)

Single-Blow Trauma VS. Repeated Trauma

Single-Blow: The individual personally experiences the traumatic event one time only (hurricane, robbery)

Repeated: The individual is exposed to the trauma repeatedly over a period of time (war, domestic violence, bullying)

Impersonal vs. Interpersonal Trauma

Impersonal: not about you, could have happened to anyone (tornado, auto accident)

Interpersonal: you are the intended target (bullying, rape, assault)

Physical vs. Conceptual Threat

Physical Threat: Perceived potential for injury to the body, including death, either by direct assault or absence of vital resources such as food and water.
Conceptual Threat: Perceived attack on the individuals belief system (religion, politics, self-esteem).

Attachment Trauma
Humans need to feel attached to other humans Many traumas occur in the context of attachment relationships (abuse, bullying) Trauma may impair your ability to form attachment relationships (abused children are more likely to become abusers) Attachment trauma early in life makes you more vulnerable to additional attachment trauma throughout the lifespan (abused children are more likely to enter and maintain relationships with abusive partners). Attachment can help heal the effects of trauma.

Effects of trauma on behavior

Anger outbursts and aggression (verbal and physical) Isolation (social withdrawal)

Avoidance (intentional avoiding people, places, situations that might trigger uncomfortable feelings)

Anger as a Response to Trauma

Fear and anger are instinctive self-protecting emotions. Humans will fight to protect our bodies and our beliefs. A perceived threat mobilizes an automatic physiological response. Self-preservation is the goal.

Emotions trigger thoughts and thoughts trigger emotions.

The emotion of anger is a call to action. The intense physiological response readies the body to fight or run (fight or flight) from the perceived threat.

The Physiological Effects of Anger

Perspiration (cools the body for optimal performance, rids the body of excess fluid weight)

Racing heart (delivers blood quickly throughout the body carrying the brains natural secretions of stimulants) Nausea/Diarrhea, Urination (rids the body of unnecessary weight which may impair the ability to run from the attacker) Tense face and body (non verbal communication to the perceived attacker to back off)

Acute Stress Disorder

Exposure to a traumatic event in which the individual experienced fear or helplessness Presence of dissociative symptoms (numbing, depersonalization, dissociative amnesia) Re-experiencing (dreams, flashbacks)

Avoidance of arousing stimuli

Anxiety

Impaired functioning (socially, occupationally)

Last from 2 days to 4 weeks

Post Traumatic Stress Disorder (PTSD)

DSM classification as a form of anxiety disorder A mental disorder in which the individual experiences ongoing symptoms of anxiety at least one month after a traumatic event and can last a lifetime Symptoms include 1. Re-experiencing (flashbacks, nightmares, intrusive memories), 2. Avoidance (withdrawal, staying away from anything that reminds you of the event, numbing, trouble consciously remembering the event, 3. Hyper-arousal (easily startled, poor sleep, chronic anxiety, panic attacks) Not everyone who is exposed to a traumatic event will develop PTSD

Childhood Sexual abuse

Perpetrators are usually someone known by the child or childs family What happens after the abuse may be equally or more traumatizing than the abuse itself

Some adults who were sexually abused as children do not identify the event as abuse
Children can also be sexually traumatized by the messages they receive about their bodies or their sexuality even if penetration never occurs

Trauma and the Brain

Amygdala (detects danger, triggers fear response)
Associative memory network Genetics (mood disorders, anxiety disorders, chemical dependency) Excessive levels of cortisol can damage the hippocampus, impairing the individuals ability to regulate arousal (hyper-responsiveness) Decreased activation of prefrontal cortex impairs ability to think and feel simultaneously, emotion overrides thought

The Correlation between trauma and substance abuse Self-Medicating symptoms of PTSD (substance abuse is a coping mechanism) Many anti-anxiety medications are addictive Some individuals experience trauma resulting from their chemical dependency

Interventions
Cognitive Behavioral Therapy

Exposure Therapy
EMDR Hypnosis

Medication

Cognitive Behavioral Therapy

emotions and behaviors are triggered by thoughts
changing your thoughts about the situation will change your feelings and behavior, even if the situation does not change specific and goal driven learn a new way to behave when the thought occurs

Modifying the thoughts, modifies the emotions and the behavior

Practice techniques out of therapy setting

Exposure Therapy
Education about trauma

Repeated reliving of trauma through imagination, writing

In-vivo exposure (imagine self in everyday situations where the stress might occur, real exposure to experiences that raise arousal ) Approximately 10 sessions (slow exposure in safe setting with reprocessing and concluding with cognitive restructure)

EMDR (Eye Movement Desensitization & Reprocessing

A psychotherapeutic intervention developed in 1980s APA recommended for treatment of PTSD Targets brains natural information processing ability Bilateral stimulation of left and right hemispheres of the brain (thinking & feeling), while focusing on the event Systematic measurement of the arousal response over the course of treatment

Facilitates resolution of the trauma with an adaptive conclusion

Hypnosis

Targets unconscious mind Good for increasing control of physiological symptoms (breathing, heart rate, relaxation, pain control) Can be paired with systematic desensitization

The legacy of Trauma

Oppression
Inherited trauma Witnessed trauma Hate Crimes Terrorism

Recommendations
Be aware, mindful

Be respectful
Avoid judgment and criticism of others

Engage in acts of kindness

Dont assume others understand your system

References

Allen, J. (2005). Coping with Trauma; Help Through Understanding. Arlington: American Psychiatric Publishing Shapiro, F. & Forrest, M. (2004). EMDR. New York: Basic Books