Download Introduction to Brain Structure, Function, & Development

Trauma Sensitive Care
What it is
Why it matters
How we can achieve it
Howard Bath
Thomas Wright Institute
Perspectives on YP in Care
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Dependent
Abuse/neglect
Attachment
High Risk
Strength-Based
Trauma
Circle of Courage
Research Foundations
GENEROSITY
INDEPENDENCE
BELONGING
MASTERY
Resilience Research
The Circle of Courage
Self-Worth Research
Attachment
Belonging
Significance
Motivation to affiliate and form
social bonds
Opportunity to establish trusting
connections
The individual believes
“I am appreciated.”
Achievement
Mastery
Competence
Motivation to work hard and
attain excellence
Opportunity to solve problems
and meet goals
The individual believes
“I can solve problems.”
Autonomy
Independence
Power
Motivation to manage self and
exert influence
Opportunity to build self control
and responsibility
The individual believes
“I set my life pathway.”
Altruism
Generosity
Virtue
Motivation to help and be of
service to others
Opportunity to show respect and
concern
The individual believes
“My life has purpose.”
Triune Brain
Logical Brain
(Neocortex)
Emotional Brain
(Limbic System)
Survival Brain
(Brain Stem)
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
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)
Hemispheric Specialization
Right Brain
Intuitive, creative logic.
Active in fear, anger,
pessimism and worry
Left Brain
Verbal, analytic logic.
Active in joy, empathy,
optimism and trust
“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)
Which of the two faces appears happier?
Threat and Trauma
The Stress response
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
Brain stem
pituitary
Brain stem releases ACTH
which activates the sympathetic
nervous system via the spinal
cord stimulating the adrenal
glands
Corticotrophin releasing hormone, CRH
Adrenalcorticotrophic hormone, ACTH
Epinephrine (Adrenalin)
Norepinephrine
Glucocorticoids (Cortisol)
Blood pressure increases
Heart rate increases
Senses/reactivity are heightened
Peripheral vision narrows
Pupils dilate to take in more
information
Adrenal glands
Adrenal glands release
epinephrine (adrenalin) and, in
prolonged stress, glucocorticoids
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
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.
Stress and Memory
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‘Explicit’ (or ‘declarative’) memories are those
memories which we can ‘recall’ and reflect on
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‘Implicit’ memories involve the myriad
sensations (sounds, smells, feelings,
emotions, etc) associated with events. They
also include what is called ‘procedural’
memory
The Danger Detector
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
Fear Conditioning
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Fear conditioning which underlies many anxietyrelated conditions (e.g. PTSD and phobias) mainly
involves the amygdala and ‘implicit’ memories
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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
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
Stress and Memory
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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 longlasting)
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Our brain remembers sensations and
feelings) associated with events (‘implicit’
memory) even when we cannot recall the
event consciously (‘explicitly’)
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)
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)
Dissociation & Memory
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Memories may be impaired by ‘dissociative’
responses e.g. ‘tuning out’, ‘floating above’,
fainting, during frightening events (Perry)
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Dissociative memories are fragmented,
condensed, and conflated (Stein & Kendall)
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Dissociating from traumatic events can lead to a
faulty appraisal of the event’s significance and
dangerousness
Stress, Memory
& Trauma
Types of Trauma
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Type 1 (simple) – from one overwhelming
traumatic event
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Type 2 (complex) – from ongoing exposure to
fear/helplessness
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
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)
Outcomes of Trauma – Formal
diagnosed conditions
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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
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)
Outcomes of Trauma
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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:
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Speechless unspeakable dumbfounded
mute terror indescribable dumbstruck
words can’t describe words fail me
words cannot express
Outcomes of Trauma
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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
Outcomes of Trauma
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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”
Outcomes of Trauma
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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)
Outcomes of Trauma
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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’
The Primary Impact of Trauma
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“The lack of or loss of self-regulation is
possibly the most far-reaching effect of
psychological trauma in both children and
adults”
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“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)
Trauma, Dysregulation &
Out-of-Home Care
Executive Deficits (BRIEF) – YP
attending OOHC Psychiatric clinic
(Redoblado-Hodge, 2004)
Emotional Regulation
Self Monitoring
Disorganised
Inflexible
Working Memory
Impulsive
0
10
20
30
40
50
60
70
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)
Most common MH problems
experienced by adolescents in care
Conduct disorder
Overanxious disorder
Major depressive episode
ADHD
Other depression types
Avoidant disorder
Functional psychosis
Panic disorder
Bipolar disorder
28%
26%
23%
14%
12%
8%
8%
4%
4%
Others: substance abuse; bulimia/anorexia nervosa; OCD; phobias;
separation anxiety disorder
Disruptive Behaviour Disorders
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Most young people come into residential care
or transition in (any kind of ) care because of
‘externalising’ behaviours such as aggression
and rule breaking.
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This is the most common MH diagnosis
“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)
Pain and Pain-based
Behaviour
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 ‘psychoemotional paralysis’, or a state of numbness
and withdrawal from the people and world
around them”
(Anglin, 2003, p. 109-110)
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
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)
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)
Four pillars of traumasensitivity
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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
Safety
The Fundamental Human Need
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SAFETY is the fundamental motivational drive
Bowlby – safety is the function of attachment
behaviours
Maslow – safety is the most fundamental of human
needs
Erickson – trust based on safety and comfort is the
first psychosocial stage of development
A lack of physical and emotional safety (anxiety,
fear) is the defining experience of people who have
experienced complex trauma
Emotion management
The Primary Function
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“The primary function of parents can be
thought of as helping children modulate their
own arousal by attuned and well-timed
provision of playing, feeding, comforting,
touching, looking, cleaning, and resting – in
short, by teaching them skills that will
gradually help them modulate their own
arousal” (van der Kolk)
What then is the primary function of teachers,
care workers, programs for troubled kids?
The Primary Function
How we experience the world, relate to
others, and find meaning in life are
dependent on how we have come to
regulate our emotions (Siegel, 1999, p. 245)
The Foundation of
Therapeutic Change
The Foundation of Change
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We’ve always heard that positive connections
and relationships are important – the
difference is that there is now hard science
confirming it
The results are the same whether its mental
health, education, youth work, psychotherapy
Connecting for Change
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40% - Extra-therapeutic, client factors
15% - Placebo, expectancy
15% - Technique
30% - Nature of the connection (warmth,
acceptance, empathy, expectancy)
‘The Heart and Soul of Change’ (Hubble et al., APA,
1999)
Trauma Sensitivity involves
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Understanding the impact on the child of
overwhelming experiences of fear and helplessness
Understanding how the child’s emotions and
behavioural responses can become re-activated
here and now
Understanding the behavioural sequelae of complex
trauma including ‘defense’ mechanisms and the
development of maladaptive behaviour patterns
Responding therapeutically to support and heal and
to teach adaptive ways of coping with stress and
anxiety
Trauma-Sensitivity Checklist
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Are all contact staff members familiar with basic
trauma theory?
Are all clients assessed for developmental
trauma?
Are program and intervention models audited
for trauma sensitivity?
Does the issue of physical and emotional safety
guide placement and co-placement decisions?
Do behaviour management tools focus on
external behaviour manipulation or on
understanding motivation (the outer or inner
child)?
Trauma-Sensitivity Checklist
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Is the focus of behaviour management on
teaching for change or the infliction of ‘pain’?
Is co-regulation with the young person the
guiding principal for crisis management?
Is there formal emphasis on post-crisis debriefing to stimulate thinking, promote insight
and teach new skills?
Is the relational basis of therapeutic change
given priority in staff training, supervision, and
intervention planning?
[email protected]
ACWA – Aug17, 2006
It is worth any sacrifice,
however great or costly
To see eyes that were listless light up again;
To see someone smile who seemed to have forgotten
How to smile;
To see trust reborn in someone
Who no longer believed in anything
Or Anyone
Dom Helder Camara