Trauma Informed Environments
M. Bennington-Davis, M.D., M.M.M.
October 2014
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• 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
TRAUMA?
.
“Traumatization occurs when both internal
and external resources are inadequate to cope
with the external threat.” Van der Kolk
Those we seek to serve
More than ¾ of Medicaid
recipients have had experiences
of trauma and violence during
their childhoods.
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.
TRAUMA SHATTERS OUR EXPERIENCE OF REALITY AND
SHATTERS THE SENSE THAT WE CAN UNDERSTAND,
MANAGE, AND FIND MEANING IN OUR WORLD
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
(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 Results
Abuse:
Emotional 10%
Physical 26%
Sexual 21%
Neglect:
Emotional 15%
Physical 10%
Household Dysfunction
Mother treated
violently 13%
Mental illness 20%
Substance abuse 28%
Parental separation or
divorce 24%
Household member
imprisoned 6%
Two-thirds had at least one ACE
ACEs tend to occur in clumps
ACES 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
Alzheimer’s
disease
Chronic respiratory Diabetes
disease
Nephritis
Stroke
Influenza and
pneumonia
Unintentional
injuries
Suicide
Cancer
Positive, linear correlation between ACEs
and health problems
Smoking
COPD
Hepatitis
Depression
Attempted suicide
Health
problems
Teen pregnancy and teen
Cardiac disease
Diabetes
Fractures
Obesity
Alcoholism
Other substance abuse
# ACEs
paternity
Sexually transmitted
diseases
Occupational health
Poor job performance
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
Hypervigilance
Epinephrine (adrenalin) Action, not thought
Cognitive diminishment
Cortisol
Increased aggression
Loss of impulse control
Beta-endorphins
Speechless terror
Stress Response to
RECURRENT THREAT
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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
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
Very Fast
Sensory Thalamus
Amygdala
S Stimulus
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(LeDoux,
1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(LeDoux,
1996)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(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
Cognitive engagement
Social
Environmental
Intervention
Hippocampus
Sensory Thalamus
Neuroregulatory
Intervention
Cortex
Very Fast
Psychopharmacology
Slower
Amygdala
S Stimulus
Response
(LeDoux,
1996)
HYPERVIGILANCE…
• Changes the way you view the world
Hypervigilance is an enhanced
- literally
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 Anger
Where 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…
• 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
Jerusalem
• 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?
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Welcoming atmosphere?
Pleasant physical environment?
Kind, respectful people?
Listening skills?
Choices and individualized treatment?
Clear communication on many levels?
Hopeful staff members?
Physical 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?
Language and Vocabulary
failed
refuses
alleges
denies
noncompliant
claims
Coercion… overt and covert
Microaggressions
Rigid or confrontative
approaches
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:
Treating 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
upset 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 counterintuitive…
Parallel 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 Squirrels
Donald Geisler 2005. “Meaning from Media: the Power
of Organizational Culture”. Organization
Development Journal 23 (1): 81-83.
SAFE!
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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’re making a
memory…
--Rickie
-Rickie Lee Jones
Feel free to contact me!
[email protected]