Transcript Neurobiology of Trauma Trauma Informed Care

TRAUMA INFORMED CARE
Mandy A. Davis, LCSW, PhD
[email protected]
503-725-9636
Stephanie Sundborg, MS
[email protected]
503-931-0536
TIC101- RECOGNIZING
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Trauma Informed Care
“A program, organization, or system that is traumainformed:
1. Realizes the widespread impact of trauma and
understands potential paths for recovery;
2. Recognizes the signs and symptoms of trauma in
clients, families, staff, and other involved with the
system;
3. Responds by fully integrating knowledge about trauma
into policies, procedures, and practices; and
4. Seeks to actively resist re-traumatization”
(SAMHSA, 2014)
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Trauma Informed Care
“A program, organization, or system that is traumainformed:
1. Realizes the widespread impact of trauma and
understands potential paths for recovery;
2. Recognizes the signs and symptoms of trauma in
clients, families, staff, and other involved with the
system;
3. Responds by fully integrating knowledge about trauma
into policies, procedures, and practices; and
4. Seeks to actively resist re-traumatization”
(SAMHSA, 2014)
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Environment  Brain  Behavior
Input from the environment
• vision, hearing, smell, taste, touch
“In-between” stuff – mental activities
• Perception, attention, memory, learning

WHY

Output in the environment
• Running, yelling, fighting, eating, listening, speaking,
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Sensory Perception – Bottom Up
Touch
• First of five senses to
develop and most prominent
at birth
• Critical part of growth and
nurturing
Auditory
• Can be powerful triggers
• Studies show trauma survivors are
more aware of oddball sounds earlier
Taste
• 2,000-5,000 taste buds
• Four types of taste:
Olfactory (Smell)
 Can detect around 10,000 smells
 Only sensory input that is
directly connected to limbic
system (memory & emotion)
Visual
• Least accurate of all
senses
• Does not reach full adult
functioning until age
four
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Sensory / Perception…
and the Trauma brain
• More sensitive to incoming sensory information – sounds are
louder, smells are stronger.
• Sensory information act as triggers
• Top down input may be distorted – not available
Connecting to behavior: Do you notice survivors are more aware or
bothered by sensory input?
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Attention…
and the Trauma brain
• Selective attention is worse in general but better for
threatening stimuli
• Divided attention – hyper vigilance – not wanting to inhibit
distractors
Connecting to behavior: Do you notice survivors have a
harder time focusing attention? Are they easily distracted?
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Memory…
and the Trauma brain
• Short term (Working memory) isn’t very good – frontal lobe
activation is decreased
• LT Declarative memory is usually impaired – damage to
hippocampus and problems with working memory
• HOWEVER – LT - Implicit memory is strong for threatening
stimuli
Connecting to behavior: Do survivors forget appointments,
treatment plans, what was discussed last time? But, is their memory
for threat situations or details good?
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Executive Function…
and the Trauma brain
• Frontal lobe function is impaired – affecting judgment, decision
making, planning, reasoning
• Impulse control is more difficult
• Needed regulation is not online - attention and emotion can get
out of wack
• Anxiety related, perseverative loops - OCD
Connecting to behavior: Do survivors perseverate, fixate? Do they
show problems with impulse control? Struggle with making
decisions or planning?
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Top Down Processing
• Pre-existing knowledge is used to rapidly organize features into a
meaningful whole
• Past experiences, motives, contexts, or suggestions prepare us
to perceive in a certain way (Perceptual Expectancy)
“We don’t see things as they are.
We see them as we are”
Anais Nin
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Downstairs Brain
• Incoming
sensory
• Orienting
attention
• Reflexive
Perception
(e.g. startle)
Mezzanine
• Perception
Upstairs Brain
• Long-term
• Selective
attention
• Working
Memory
•
•
•
•
memory
Learning
Judgment
Problem solving
Decision making
Response
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Opportunity to make sure attention is focused? Perception
isn’t distorted? Info is getting into short term memory?
“With so much going on in this room, I know it can be difficult to
stay focused on me, but if you could give me your attention for
just a few minutes…”
Opportunity to help
navigate, control,
filter sensory input
“I know I just gave you a lot of information, can you tell me your
understanding of next steps”
What to expect
“We know the noise in
the waiting area can be
overwhelming –
perhaps bringing
headphones…”
Stress
Response
Draw on context, experience, and LT memory to shape incoming
info. If needed, create new stories / memories to replace old ones…
“Remember last time this happened, you were able to XYZ”
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Stress Response….
Selective Attention
and working
memory
Offers rational
thinking, planning,
decision making,
sense making
If stress response
warranted – HPA
axis initiates
Illustration: Hallorie Walker Sands
Incoming sensory
information
Memory formation –
checks memories for
context
Considers sensory info for real or
perceived danger
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• Developing slower ~
• Dominant at birth
18-24 months
• More logical, analytical,
and sequential
• Focuses on details –
construct narratives
• Sensory experiences –
no language
• Emotional Processing
• Relational hemisphere –
focused on attachment
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Cortisol and other Brain Chemicals
• Norepiniphrine (NE)
• Alertness / arousal / attention
• fight/flight (SAM sys chemical)
• Solidifying threat memories
• Cortisol
• fight/flight (HPA axis chemical)
• Damages hippocampus (memory)
• Needed to shut off stress response – neg feedback loop
• Lower levels in PTSD
• Serotonin (5HT)
• Dampen NE firing
• Reduces sensory stimulation in amygdala – only in presence of cortisol
• Reduced levels in PTSD, depression
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Cortisol and other Brain Chemicals
• GABA (benzodiazepine)
• Inhibitory NT – reduces excitatory activity
• Reduces re-experiencing / hyperarousal
• Frontal lobe “squirts” GABA into amygdala
• Impaired in PTSD
• Endogenous Opiates
• Analgesia
• Related to dissociative symptoms
• Acute stress response elevates secretion of opioids
• Chronic stress response may lead to lower concentration of opioids
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When Trauma Happens….
• Freeze, Flight, Fight, Fright
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When Trauma Happens….
• Chronic Trauma, Complex trauma overtime
• Central Nervous system becomes unbalanced
Parasympathetic
Nervous Sys:
Rest and Digest
Sympathetic NS:
Arousal system
Fight or Flight
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Neurobiology Take Aways
• Simple to complex – Survival mechanisms act first and faster
than the thinking brain.
• When we are threatened – brain moves resources away from
thinking toward survival.
• Our brain learns patterns. Fire-together-wire-together.
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Neurobiology Take Aways
• Attention can be a problem:
• Amygdala in survivors is hyper-vigilant – scanning for real or perceived
threat; attentional control from frontal lobe is decreased
• Communication is challenging: dominance of RH
• Decreased verbal (left hemisphere) – hypersensitive to nonverbal (right
hemisphere) – prone to misinterpret.
• Memory is impaired – damage to hippocampus due to excess
cortisol:
• Explicit memory (hippocampus) – facts, stories, pictures – impaired
• Implicit memory (amygdala – acute trauma) often clear and sharp
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Stretch
TRAUMA INFORMED CARE
201
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Principles of Practice
With a foundation of awareness and understanding,
organizations can strive to reflect three central principles of
TIC, by creating policies, procedures, and practices that:
•
create safe context,
• restore power, and
• value the individual.
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Trauma Informed Care
Trauma Informed Care (TIC) recognizes that traumatic experiences terrify, overwhelm, and violate the
individual. TIC is a commitment not to repeat these experiences and, in whatever way possible, to
restore a sense of safety, power, and worth
Commitment to Trauma Awareness
Understanding the Impact of Historical Trauma
Agencies demonstrate Trauma Informed Care with
Policies, Procedures and Practices that
Create Safe Context
Restore Power
Value the Individual
through:
through:
through:
Physical safety
Trustworthiness
Clear and consistent
boundaries
Transparency
Predictability
Choice
Choice
Empowerment
Strengths perspective
Skill building
Collaboration
Respect
Compassion
Mutuality
Engagement and
Relationship
Acceptance and Nonjudgment
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What is required to Provide TIC?
• Secure, healthy adults;
• Good emotional management skills;
• Intellectual and emotional intelligence;
• Able to actively teach and be role model;
• Consistently empathetic and patient;
• Able to endure intense emotional labor;
• Self-disciplined, self-controlled, and never likely to abuse
power.
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The Reality
• We have a workforce that is under stress.
• We have a workforce that absorbs the trauma of the
consumers.
• We have a workforce populated by trauma survivors.
• We have organizations that can be oppressive.
• All of this has an impact
• We have organizations that come to resemble the behavior we’re trying
to help.
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Safety
Emotional Management
Dissociation
Systematic Error
Authoritarianism
Impaired Cognition
Impoverished relationship
Disempowered –Helplessness
Increased Aggression
Unresolved Grief
Loss of Meaning
Adapted from Sandra Bloom’s Sanctuary Model