Trauma Sensitive Care

1. Trauma Sensitive Care What it is Why it matters How we can achieve it Howard Bath Thomas Wright Institute

2. Perspectives on YP in Care • Dependent • Abuse/neglect • Attachment • High Risk • Strength-Based • Trauma

3. The Circle of Courage Belonging Opportunity to establish trusting connections Mastery Opportunity to solve problems and meet goals Independence Opportunity to build self control and responsibility Generosity Opportunity to show respect and concern Circle of Courage GENEROSITY INDEPENDENCE BELONGING MASTERY Research Foundations Resilience Research Attachment Motivation to affiliate and form social bonds Achievement Motivation to work hard and attain excellence Autonomy Motivation to manage self and exert influence Altruism Motivation to help and be of service to others Self-Worth Research Significance The individual believes “I am appreciated.” Competence The individual believes “I can solve problems.” Power The individual believes “I set my life pathway.” Virtue The individual believes “My life has purpose.”

4. Triune Brain Logical Brain (Neocortex) Emotional Brain (Limbic System) Survival Brain (Brain Stem)

5. The Triune Brain in language Words that reflect the emotional/logical brain distinction: thoughtless, inconsiderate, mindless, impulsive, crime of passion, without malice aforethought vs calculating, deliberate, premeditated murder Descriptors of reptilian brain behaviours: animal, cold-blooded, predatory

6. The ‘Therapeutic’ Task Psychotherapy is fundamentally a process “through which our neocortex learns to exercise control over evolutionary old systems”(LeDoux, 1996, p. 21) “We want to raise children whose reasoning brain can triumph over the impulsive one”(Stein and Kendall, 2004, p. 12)

7. Hemispheric Specialization

8. “we are born to form attachments…our brains are physically wired to develop in tandem with another’s, through emotional communication beginning before words are spoken” “The organisation of the developing brain occurs in the context of a relationship with another self, another brain. This relational context can be growth-facilitating or growth inhibiting, and so it imprints into the developing right brain either a resilience…or a vulnerability”(Shore, 2003, p. xv)

10. Which of the two faces appears happier?

11. Threat and Trauma The Stress response

12. The Stress/Fear Response(adapted from Sapolsky, 2004) Glucocorticoids trigger the locus coeruleus to release norepinephrine which communicates with the amygdala Amygdala Locus coeruleus Amygdala (the ‘danger detector’) activates the ‘HPA axis’ by initiating the release CRT from the hypothalamus which stimulates the pituitary in brain stem Hypothalamus Direct sympathetic nervous system activation Blood pressure increases Heart rate increases Senses/reactivity are heightened Peripheral vision narrows Pupils dilate to take in more information Brain stem pituitary Brain stem releases ACTH which activates the sympathetic nervous system via the spinal cord stimulating the adrenal glands Adrenal glands Corticotrophin releasing hormone, CRH Adrenalcorticotrophic hormone, ACTHEpinephrine (Adrenalin) Norepinephrine Glucocorticoids (Cortisol) Adrenal glands release epinephrine (adrenalin) and, in prolonged stress, glucocorticoids

13. The Stress/Fear Response Our stress mechanisms operate far more quickly than do our conscious, reflective capacities – this helps to keep us safe. It has been estimated that our safety/stress reactions activate in around 6/1000 of a second

14. Problematic Effects of Stress Living in a state on prolonged stress and anxiety can lead to the stress mechanisms becoming “sensitized” i.e. developing lower thresholds for activation (Sapolsky, Bremner) – researchers have used the term “kindling” to describe the effect of chronic stress on the amygdala.

15. Stress and Memory

16. ‘Explicit’ (or ‘declarative’) memories are those memories which we can ‘recall’ and reflect on • ‘Implicit’ memories involve the myriad sensations (sounds, smells, feelings, emotions, etc) associated with events. They also include what is called ‘procedural’ memory

17. The Danger Detector

18. Amygdala The amygdala appears to have a critical ‘gate keeping’ role determining ‘friend or foe’ It asses for ‘emotional salience’ - the ‘danger detector’ – triggers the stress and ‘fight or flight’ responses

19. Fear Conditioning • Fear conditioning which underlies many anxiety-related conditions (e.g. PTSD and phobias) mainly involves the amygdala and ‘implicit’ memories • Anxiety, fear, or terror are triggered by cues (reminders) of the original frightening experiences. The cues can be internal (feelings, emotions, sensations) or external (sounds, smells, sights, certain people etc). The amygdala has ‘tagged’ these as being associated with danger – this is a largely unconscious process

20. Hippocampus Memories are usually stored in parts of the cortex but the hippocampus has a key role in ‘organising’ and linking the various memory components. It has a key role in the storage and recall of explicit memories The ‘keyboard’ vs ‘hard disk’ analogy

21. Stress and Memory • We tend to remember events that are associated with stress and emotion far more readily than those that do not (except if the events are overwhelmingly stressful or long-lasting) • Our brain remembers sensations and feelings) associated with events (‘implicit’ memory) even when we cannot recall the event consciously (‘explicitly’)

22. Stress and Memory An infant or small child does not have ‘explicit’ memory capacities - we usually cannot remember anything ‘explicitly’ prior to around 4 years of age. However, the infant/small child does have ‘implicit’ capacities - traumatizing events can only be recalled ‘implicitly’ (physiologically and emotionally)

23. Memory Overload Hippocampal structures linked with ‘explicit’ memory may atrophy or even die with very high and/or sustained ‘flooding’ by cortisol – ‘implicit’ memory does not appear to be affected this way (Sapolsky)

24. Dissociation & Memory • Memories may be impaired by ‘dissociative’ responses e.g. ‘tuning out’, ‘floating above’, fainting, during frightening events (Perry) • Dissociative memories are fragmented, condensed, and conflated (Stein & Kendall) • Dissociating from traumatic events can lead to a faulty appraisal of the event’s significance and dangerousness

25. Stress, Memory & Trauma

26. Types of Trauma • Type 1 (simple) – from one overwhelming traumatic event • Type 2 (complex) – from ongoing exposure to fear/helplessness

27. Trauma and Children ‘Fight or flight’ responses are usually not available to children – therefore ‘freeze’ and other dissociative responses are common (Perry) The ‘freeze’ response has been linked with the ‘learned helplessness’ models in animal studies – it appears to involve both sympathetic arousal and parasympathetic counter-effects or stepping on the ‘gas and the brake’ at the same time

28. Differential Effects of Trauma “Interpersonal traumas are likely to have more profound effects than impersonal ones” – especially ‘betrayal of trust’ by attachment figures and figures of esteem (van der Kolk)

29. Outcomes of Trauma – Formal diagnosed conditions • Post traumatic symptomology including PTSD (re-experiencing, hyperarousal, hypervigilence, avoidance) • ‘borderline’ symptoms as seen in ‘borderline personality disorder’ (acute abandonment anxiety, rapid mood swings, identity instability, suicidal ideation/gestures, complaints of boredom, capricious and reactive aggression, addictive behaviours etc) • Some sub-types of Oppositional Defiant Disorder and Conduct Disorder

30. Outcomes of Trauma Language and other cognitive impairments inc. short term memory; rigid thinking styles; executive functions such as planning, weighing options, considering outcomes, controlling impulses; misinterpretation of social cues (Perry: only 2% of abused children have verbal>performance scores - 39% have the opposite pattern)

31. Outcomes of Trauma • The process of reflection, labelling and making meaning of events requires language – language functions are often impaired by trauma. This is reflected in words and phrases that are used: • Speechless unspeakable dumbfounded mute terror indescribable dumbstruck words can’t describe words fail me words cannot express

32. Outcomes of Trauma • Very constricted play, impairments of imagination • Impairments of empathy – chronically aroused lower brains gear the child for facing threat do not allow the time or energy for the higher brain functions involved in empathy • A range of somatic and psychiatric problems including infections, headaches, stomach aches, hyperactivity, depression, phobias • Emotional numbing and analgesia associated with dissociation and the endogenous opioids • Eating disorders are common • Substance abuse – often self-medicating

33. Outcomes of Trauma • The apparently counterintuitive process in which children/YP appear to instigate traumatic incidents • Traumatic re-enactment or compulsive re-exposure - an effort to integrate the experience and/or to gain control of the traumatic triggers (Terr). Understanding compulsive re-exposure and doing something about it is one of the “great challenges of psychiatry” (van der Kolk) • ‘Addiction’ to the post-crisis state of quiescence involving endogenous opioids – some generate crises and put themselves in dangerous situations to experience this physical and emotional “state of calm”

34. Outcomes of Trauma • Loss of trust, hope and sense of agency • Loss of “thought as experimental action” • Social avoidance with loss of attachments • Lack of future orientation and involvement in preparation for the future (van der Kolk, 1996)

35. Outcomes of Trauma • The process of ‘making meaning’ from exposure to extreme and prolonged threat • Bowlby’s notion of the maladaptive ‘working models’ of self and others – people are dangerous, they can’t be trusted, I’m not worthy of love, I’m bad • Sullivan’s description of ‘malevolent transformation’

36. The Primary Impact of Trauma • “The lack of or loss of self-regulation is possibly the most far-reaching effect of psychological trauma in both children and adults” • “The younger the age at which the trauma occurred, and the longer its duration, the more likely people (are) to have long-term problems with the regulation of anger, anxiety and sexual impulses” (van der Kolk et al., 1993)

39. Trauma, Dysregulation & Out-of-Home Care

40. Executive Deficits (BRIEF) – YP attending OOHC Psychiatric clinic (Redoblado-Hodge, 2004)

41. Some UK data on prevalence of psychiatric symptoms of young people in care “Total weighted prevalence rate of psychiatric disorders in adolescents in the Oxfordshire care system was 67%...with 96% of adolescents in residential units and 57% in foster care having psychiatric disorders” (McCann, James, Wilson & Dunn, BMJ, 1996)

42. Most common MH problems experienced by adolescents in care Conduct disorder 28% Overanxious disorder 26% Major depressive episode 23% ADHD 14% Other depression types 12% Avoidant disorder 8% Functional psychosis 8% Panic disorder 4% Bipolar disorder 4% Others: substance abuse; bulimia/anorexia nervosa; OCD; phobias; separation anxiety disorder

43. Disruptive Behaviour Disorders • Most young people come into residential care or transition in (any kind of ) care because of ‘externalising’ behaviours such as aggression and rule breaking. • This is the most common MH diagnosis

44. “Problems of chronic reactive violence have their origins in early life experiences (such as early traumas of parental rejection, exposure to family violence, and family instability) and/or constitutional abnormalities, whereas problems of proactive violence have their origins in social learning during school years” (Dodge et al., 1997)

45. Pain and Pain-based Behaviour

46. Pain-Based Behaviours Challenging behaviours often reflect psychoemotional pain … “grief at losses and abandonment; persistent anxiety about themselves and their situation; fear of or even terror about a disintegrating present and a hopeless future; depression and dispiritedness at a lack of meaning or sense of purpose in their lives; and what could be termed ‘psycho-emotional paralysis’, or a state of numbness and withdrawal from the people and world around them” (Anglin, 2003, p. 109-110)

47. Responding to Pain with Pain “Seldom did careworkers acknowledge or respond sensitively to the inner world of the child. (They would react to difficult) behaviour by making demands of a controlling nature (e.g. get a grip on yourself!”, or “Watch your language now!”) or giving a warning of possible consequences in terms of lost points, time out, or withdrawal of privileges…” Anglin, 2003

48. The Biggest Challenge “more than any other dimension of carework, the ongoing challenge of dealing with such primary pain without unnecessarily inflicting secondary pain experiences on the residents through punitive or controlling reactions can be seen to be the central problem for carework staff”(Anglin, 2003, 55)

49. The Parallel Process “traumatized people are frequently misdiagnosed and mistreated in the …system… Because of their characteristic difficulties with close relationships, they are vulnerable to become re-victimized by caregivers. They may become engaged in ongoing, destructive interactions, in which the…system replicates the behaviour of the abusive family” (Herman 1992)

50. Four pillars of trauma-sensitivity • Safety – physical and emotional, sanctuary, consistency, predictability, honesty, transparency, reliability, availability, continuity • Emotion management – tools to assist with reflection, awareness, labelling of emotion, negotiation - to promote a more rational/cognitive style of problem solving • Loss – empathy and support around the ‘pain’ of multiple losses (family, home, friends, community etc) • Future – generation of hope, belief, competence