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Trauma Informed Care
An Over-view
Nurse Educator
MHAID Service Southern DHB
Over-view
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Definitions
Prevalence
Impact of Trauma
Trauma Informed Care
Resiliency
References
Resources
What is trauma
A traumatic event is one in which a person
experiences (witnesses or is confronted
with):
• Actual or threatened death
• Serious injury
• Threat to the physical integrity of self or
another
What is trauma
“Prolonged exposure to repetitive or severe events
such as child abuse, is likely to cause the most
severe and lasting effects.”
“Traumatisation can also occur from neglect, which
is the absence of essential physical or emotional
care, soothing and restorative experiences from
significant others, particularly in children.”
(International society for the study of Trauma and Dissociation, 2009)
Responses to a traumatic event
may include
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Intense fear
Helplessness
Horror
Attachment
Interpersonal trauma?
• Interpersonal violence tends to be more
traumatic than natural disasters because it
is more disruptive to our fundamental
sense of trust and attachment, and is
typically experienced as intentional rather
than as “an accident of nature.”
(International society for the study of trauma and
dissociation, 2009)
Attachment
• Genes have little to do with Attachment
• Temperament and attachment are
independent!
• Attachment patterns are solely built by
experience
L. Alan Sroufe, et al “The Development of the
Person,” 2005.
• In every culture, healthy relationships are
contingent on relational interactions
ACE Study (Adverse Childhood
Events) 2010
• CDC and Kaiser Permanente
Collaboration (USA).
• Over a decade long. 17,000 people
involved.
• Looked at effects of adverse childhood
experiences over the lifespan.
• Largest study ever done on this subject
HMO Members in ACE Study
• 80% White,
including Hispanic
• About 50% men, 50%
women
• 10% Black
• 74% had attended
college
• 10% Asian
• 62% age 50 or older
Adverse Childhood Experience*
ACE Categories (Birth to 18)
Abuse of Child
Impact of Trauma and Health
Risk Behaviors to Ease the Pain
Neurobiologic Effects of Trauma
Long-Term Consequences of
Unaddressed Trauma (ACEs)
Disease and Disability
• Emotional abuse
• Physical abuse
• Contact Sexual abuse
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Trauma in Child’s Household
Environment
• Alcohol and/or Drug User
• Chronically depressed, emotionally
disturbed or suicidal household
member
• Mother treated violently
• Imprisoned household member
• Not raised by both biological
parents
(Loss of parent – best by death
unless suicide, - Worst by
abandonment)
Neglect of Child
• Physical neglect
• Emotional neglect
* Above types of ACEs are the
“heavy
end” of abuse. *1 type =
Disrupted neuro-development
Difficulty controlling anger-rage
Hallucinations
Depression - other MH Disorders
Panic reactions
Anxiety
Multiple (6+) somatic problems
Sleep problems
Impaired memory
Flashbacks
Dissociation
Health Risk Behaviors
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Smoking
Severe obesity
Physical inactivity
Suicide attempts
Alcoholism
Drug abuse
50+ sex partners
Repetition of original trauma
Self Injury
Eating disorders
Perpetrate interpersonal violence
Ischemic heart disease
Cancer
Chronic lung disease
Chronic emphysema
Asthma
Liver disease
Skeletal fractures
Poor self rated health
Sexually transmitted disease
HIV/AIDS
Serious Social Problems
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Homelessness
Prostitution
Delinquency, violence, criminal
Inability to sustain employment
Re-victimization: rape, DV, bullying
Compromised ability to parent
Negative alterations in self perceptions and relationships with others
• Altered systems of meaning
• Intergenerational trauma
• Long-term use of multiple human
service systems
Adverse Childhood Experiences
ACE Categories (Birth – 18)
Abuse of Child
• Emotional Abuse
• Physical Abuse
• Contact Sexual Abuse
Neglect of Child
• Physical Neglect
• Emotional Neglect
Trauma in Child’s
Household/Environment
• Alcohol and/or Drug user
• Chronically depressed,
emotionally disturbed or
suicidal household member
• Mother treated violently
• Not raised by both biological
parents. (Loss of parent – best
by death, unless suicide. –
Worst by abandonment)
Adverse Childhood
Experiences are Common
Of the 17,000 HMO Members:
• 1 in 4 exposed to 2 categories of ACEs
• 1 in 16 was exposed to 4 categories.
• 22% were sexually abused as
children.
• 66% of the women experienced
abuse, violence or family strife in
childhood.
• Women were 50% more likely than
men to have experienced 5 or more
ACEs
ACE Study Findings
• Childhood experiences are powerful
determinants of who we become as adults.
Impact of Trauma and Health Risk
Behaviours to Ease the Pain
Neurobiologic Effects of Trauma
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Disrupted neuro-development
Difficulty controlling anger-rage
Hallucinations
Depression – other MH
disorders
Panic reactions
Anxiety
Multiple (6 +) somatic
problems
Sleep problems
Impaired memory Flashbacks
Dissociation
Health Risk Behaviours
• Smoking
• Severe obesity
• Physical inactivity
• Suicide attempts
• Alcoholism
• Drug abuse
• 50 + sex partners
• Repetition of original trauma
• Self injury
Long-term Consequences of
Unaddressed Trauma (ACEs)_
Disease and disability
• Ischemic heart disease
• Cancer
• Chronic lung disease
• Chronic emphysema
• Asthma
• Liver disease
• Skeletal Fracture
• Poor self rated health
• Sexually transmitted disease
• HIV/AIDS
Serious Social Problems
• Homelessness
• Prostitution
• Delinquency, violence, criminal
• Inability to sustain employment
• Re-victimisation: rape,
violence
• Compromised ability to parent
• Negative alterations in self
perceptions and relationships
with others
• Altered systems of meaning
The higher the ACE Score, the
greater the likelihood of :
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Severe and persistent emotional problems
Health risk behaviors
Serious social problems
Adult disease and disability
High health, behavioral health, correctional
and social service costs
• Poor life expectancy
Health Consequences of Early
Life Trauma
Vincent Felitti, M.D.,
• Health in all domains is related to
childhood experience
• Health risks:
– Stroke
– Heart disease
– Depression and suicide
– Substance abuse
– Smoking
Childhood Experiences vs.
Adult Alcoholism
18
16
4+
% Alcoholic
14
12
3
10
2
8
6
1
4
2
0
0
ACE Score
% With a Lifetime History of
Depression
Childhood Experiences
Underlie Chronic Depression
80
70
60
50
40
30
20
Women
Men
10
0
0
1
2
ACE Score
3
>=4
25
Childhood Experiences
Underlie Suicide
4+
% Attempting Suicide
20
15
3
10
2
5
0
1
0
ACE Score
Emotional Problems
• Childhood experiences underlie Chronic
depression
• Childhood experiences underlie suicide
 2/3rd (67%) of all suicide attempts
 64% of adult suicide attempts
 80% of child/adolescent suicide attempts
Are attributable to Childhood Adverse
Experiences
Positive Stress
• Moderate, short-lived physiological response
– Increased heart rate, higher blood pressure
– Mild elevation of stress hormone, cortisol ,
levels
• Activated by:
– Dealing with frustration, meeting new people
(National Scientific Council on the Developing Brain, Harvard University 2006)
Tolerable Stress
• Physiological responses large enough to disrupt brain
architecture
• Relieved by supportive relationships:
– that facilitate coping,
– restore heart rate and stress hormone levels
– reduce child’s sense of being overwhelmed
Activated by:
– Death of loved one, divorce, natural disasters
(National Scientific Council on the Developing Brain, Harvard University 2006)
Toxic Stress
• Strong & prolonged activation of stress response
systems in the absence of buffering protection
of adult support
– Recurrent abuse, neglect, severe maternal
depression, substance abuse, family violence
– Increased susceptibility to cardiovascular disease,
hypertension, obesity, diabetes and mental health
problems
Institutionalization and Neglect of Young
Children Disrupts Their Body Chemistry
35%
Percent of
Children
with
Abnormal
Stress
Hormone
Levels
30%
25%
20%
15%
10%
5%
Middle Class US Toddlers
in Birth Families
Source: Gunnar & Fisher
(2006)
Neglected/Maltreated Toddlers
Arriving from Orphanages Overseas
PTSD
• PTSD is the only diagnostic category in the DSM
that is based on etiology.
• In order for a person to be diagnosed with
PTSD, there had to be a traumatic event.
• Because most diagnoses are descriptive and not
explanatory they focus on symptoms or
behaviours without a context: they do not explain
how or why a person may have developed those
behaviours (e.g. to COPE with traumatic stress).
TRAUMA
For the purposes of identifying trauma and
its adaptive symptoms, it is much more
useful to ask “What HAPPENED to this
person” rather than “What is WRONG with
this person”.
Types of Trauma: Acute Trauma
• Acute trauma is a single traumatic event that is limited in
time. Examples include:
• Serious accidents
• Community violence
• Natural disasters (earthquakes, wildfires, floods)
• Sudden or violent loss of a loved one
• Physical or sexual assault (e.g., being shot or raped)
• During an acute event, people go through a variety of
feelings, thoughts, and physical reactions that are
frightening in and of themselves and contribute to a sense
of being overwhelmed.
Acute Response To Trauma
Terror
Normal
with
supports
Fear
Vulnerable “with
supports”
Alarm
Vigilance
Vulnerable
few
supports
Dissociation
or
Resilient
Calm
Traumatic Event
Types of Trauma: Chronic
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Chronic trauma refers to the experience of multiple traumatic events.
•
These may be multiple and varied events—such as a child who is
exposed to domestic violence, is involved in a serious car accident, and
then becomes a victim of community violence—or longstanding trauma
such as physical abuse, neglect, or war.
•
The effects of chronic trauma are often cumulative, as each event
serves to remind the child of prior trauma and reinforce its negative
impact.
Types of Trauma: Complex
• Complex trauma describes both exposure to chronic
trauma—usually caused by adults entrusted with the
child’s care—and the impact of such exposure on the
child.
• Children who experienced complex trauma have
endured multiple interpersonal traumatic events from a
very young age.
• Complex trauma has profound effects on nearly every
aspect of a child’s development and functioning.
Additional Sources of Stress
• Children in the child welfare system frequently face
other sources of ongoing stress that can challenge
workers’ ability to intervene. Some of these sources
of stress include:
• Poverty
• Discrimination
• Separations from parent/siblings
• Frequent moves
• School problems
• Traumatic grief and loss
• Refugee or immigrant experiences
The impact of a potentially traumatic event
depends on several factors, including:
– The child’s age and developmental stage
– The child’s perception of the danger faced
– Whether the child was the victim or a witness
– The child’s relationship to the victim or perpetrator
– The child’s past experience with trauma
– The adversities the child faces following the trauma
– The presence/availability of adults who can offer help
and protection
Impact of Trauma on Child
Development
• Physical and Neurodevelopment
• Psychosocial and Relational Development
Developmental Factors
• Chronic early trauma – starting when the
individual’s personality is forming – shapes
a child’s (and later adult’s) perceptions and
beliefs about everything.
• Severe trauma can have major impacts on
the course of life.
• Childhood trauma can cause the
disruption of basic developmental tasks.
Disruption of Developmental Tasks
Survivors of childhood trauma can
have mild – several deficits in
abilities such as:
• Self soothing
• Seeing the world as a safe
place
• Trusting others
• Organised thinking for decision
making
• Avoiding exploitation
Disruption of these tasks in
childhood can result in adapted
behaviour, which may be
interpreted as “symptoms:”
• Disrupted self-soothing can be
labelled as agitation
• The disrupted ability to see the
world as a safe place looks like
paranoia
• Distrust of others can be
interpreted as paranoia (even
when based on experience)
• Disruptions' in organised
thinking for decision making
appears as psychosis
• Avoiding pre-empting
exploitation is called selfsabotage.
Exposure to Trauma – General
Population
• Until fairly recently, trauma exposure was
thought to be unilaterally rare (combat violence,
disaster trauma)
(Kessler et al, 1995)
• More recent research has changed this and
studies completed indicate that trauma exposure
is common across all demographics
• 56% of a general population adult sample
reported at least one event (National Executive Training Institute NETI 2005)
Prevalence of Trauma – Mental
Health Population
• 90% of mental health clients have been
exposed
(Muesar et al., 1998)
• Most have multiple experiences of trauma
• 34 – 53% report childhood sexual or
physical abuse
(kessler et al., 1995)
• 43 – 81% report some form of victimisation
Prevalence of Trauma – Mental
Health Population
• 97% of homeless women with SMI have
experienced severe physical and sexual abuse –
87% experience this abuse both as child and
adult
(Goodman et al., 1997)
• Current rates of PTSD in people with SMI range
from 29 – 43% (Jennings & Ralph, 1997)
• Whilst research needs to continue, studies are
increasingly showing that trauma appears to be
epidemic among the population in mental health
services
Prevalence of Trauma
What this means…….
• A majority of adult and children in inpatient
psychiatric treatment settings present with
trauma histories (Lipschitz et. Al., 1999)
“ Many providers may assume that abuse
experiences are additional problems for
the person, rather than the central
problem….”
(Hodas 2004)
Impact of Trauma
• Hyperarousal: nervousness', jumpiness,
quickness to startle
• Re-experiencing: intrusive images, sensations,
dreams, memories
• Avoidance and withdrawal; feeling numb,
shutdown or separated from normal life, pulling
away from relationships and/or activities
• Avoiding things that trigger memories of
trauma/s
Definition of Trauma Informed Care
• Mental Health Treatment that is directed
by:
A thorough understanding of the profound
neurological, biological, psychological and
social effects of trauma and violence on
the individual and,
An appreciation for the high prevalence of
traumatic experiences in persons who
receive mental health services.
(Jennings 2004)
Symptoms as Adaptations
• The traumatic event is over, but the person’s
reaction to it is not.
• The intrusion of the past into the present is one
of the main problems confronting the trauma
survivor.
• Often referred to as re-experiencing, this is the
key to many psychological symptoms and
psychiatric disorders that RESULT from
traumatic experiences.
• This intrusion may present as distressing
intrusive memories, flashbacks, nightmares, or
overwhelming emotional states.
Trauma “symptoms” as adaptations
It is useful to think of all trauma “symptoms” as adaptations.
• Symptoms represent the clients’ attempt to cope the best
way they can with overwhelming feelings.
• When we see “symptoms” in a trauma survivor, it is
always significant to ask ourselves: what purpose does
this behaviour serve?
• Every symptom helped the survivor cope at some point
in the past and is still in the present – in some way.
• As humans we are incredibly adaptive creatures. If we
help the survivor explore how behaviours are an
adaptation, we can help them learn to substitute a less
problematic behaviour.
The use of Adaptive Coping
Strategies
• Survivors of repetitive early trauma are likely to
instinctively continue to use the same selfprotective coping strategies that they employed
to shield themselves from psychic harm at the
time of the traumatic experience.
• Hypervigilance, dissociation, avoidance and
numbing are examples of coping strategies that
may have been effective at some time, but later
interfere with the persons' ability to live the life
s/he wants
A model of treatment
• Safety and stabilization
• Processing of traumatic material
• Reconnection and reintegration
Phase one; Safety and stabilization
• Attention to basic needs including;
connection to resources, self care,
identification of support system
• Focus on regulation of emotion and
develop capacity to self soothe.
• Education on trauma and treatment
process
Phase two: Processing and
Grieving of Traumatic Memories
• “The primary goal of this phase is to have
the patient acknowledge, experience and
normalise the emotions and cognitions
associated with the trauma at a pace that
is safe and manageable.”
(Luxenberg, Spinazzola, Hildago, Hunt and van der Kolk,
2001)
Phase Three- Reconnection
• Development of a firm or a new sense of
self
• Development of healthy and supportive:
 Friendships
 Intimacy
 Spirituality
Trauma informed Care
• Aims to avoid re-victimisation
• Appreciates many problem behaviours began as
understandable attempts to cope
• Strives to maximise choices for the survivor and
control over the healing process
• Seeks to be culturally competent
• Understands each survivor in the context of life
experiences and cultural background
(Alvarez and Sloan, 2010)
Resiliency
• “Resilience is the capability of individuals
to cope successfully in the face of
significant change, adversity, or risk. The
capacity changes over time and is
enhanced by protective factors in the
individual and environment.”
(Stewart et al., 1991 as cited by Greene and Conrad, 2002)
Protective Factors
• There are behaviours, characteristics and
qualities inherent in some personalities
that will assist in recovery after exposure
to a traumatic event, these are called
protective factors.
Environment
• A reliable support system (friends, family)
• Access to safe and stable housing
• Timely and appropriate care from first
responders
Behaviours
• Good self-care such as sleeping at least
eight hours a night
• Eating a well balanced diet
• Exercise
• Practising good boundaries
• Using positive coping mechanisms verses
negative coping mechanisms
Resiliency as a trait
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A vigorous approach to life
A sense of meaningfulness
An internal locus of control (vs. external)
A way to conceptualise this is the “ability of
a person to bounce back from challenges
through feelings of control, commitment
and the ability to see change as a
challenge.” Phelps et al., 2009)
Post-traumatic Growth
• “Resilient survivors continue therefore, to grow and even
thrive in spite of, and quite often because of their
histories.” (Armour 2007)
• Survivors of trauma who strengthen their abilities to find
wisdom that allow them emotional growth in relationship
with others are often referred to as experiencing posttraumatic growth.
• Post-traumatic growth is reflected in the following:
 Strengthening of relationships/sense of connection
 Increased sense of personal strengths
 Awareness of increased possibilities in life
References
• Centers for Disease control and prevention (CDC).
Adverse Childhood experiences (ACE) study. Available
at http://www.cdc.gov/ace/
• Alvarez, G. and Sloan, R., Trauma: Considering
Behaviour Through a Trauma Lens, (2012). Powerpoint
Presentation: Everly Ball – Westminster house, 1 – 49
• Armour, M. (2007). Violent Death. Journal of Human
Behaviour in the Social Environment, 14(4), 53 – 90.
• Child Welfare information Gateway (2006). Long term
Consequences of Child Abuse and Neglect. Retrieved
from: http://www.childwelfare.gov/pubs/factsheets/longterm-consequences.cfm
References
• Child Welfare Information Gateway (2012), The Risk and
Prevention of Maltreatment of Children with Disabilities.
Bulletins for Professionals, (1 – 20).
• Childhelp, National Child Abuse Statistics: Child Abuse in
America, (1), Available at
www.childhelp.org/pages/statistics
• Greene, R.R. (Ed), (2002). Resiliency: An Integrated
approach to practice, policy and research. Washington,
D.C.: NASW Press.
• International Society for the study of Trauma and
Dissociation, FAQs Trauma (1 – 8) Retrieved: http://isstd.org/education/faq-trauma.htm
References
• Marcenich, L., (2010) Trauma Informed Care,
Powerpoint Presentation, available at:
http://smhealth.org/sites/default/files/docs/LMarcenichPw
rpt/pdf
• James, R.K (2008). Crises intervention strategies (6th
ed.) Pacific Grove, CA: Brooks/Cole Pub.
• Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009).
Caring for Carers in the aftermath of Trauma. Journal of
Aggression, Maltreatment and trauma, 18(3), 313 -330.
Resources
• International Society for Traumatic Stress Studies
http://www.istss.org/Home.htm An international collection
of studies, research and education regarding trauma.
Also provides guidelines for treatment of trauma.
• National Child Traumatic Stress Network
http://www.nctsn.org/ Programme works to educate
professionals and non professionals about trauma and
evidence based practices for trauma interventions. Site
provides definitions of different types of trauma and
evidence based practice resources.
• Sidran Institute: Traumatic Stress Education and
Advocacy http://www.sidran.org/index.cfm