Family engagement for sustainable recovery

Paul Krauss MA LPC is the Clinical Director of Health for Life Counseling Grand Rapids, home of The Trauma-Informed Counseling Center of Grand Rapids. Paul is also a Private Practice Psychotherapist, an Approved EMDRIA Consultant , host of the Intentional Clinician podcast, Behavioral Health Consultant, Clinical Trainer, and Counseling Supervisor. Paul is the creator of the National Violence Prevention Hotline (in progress) as well as the Intentional Clinician Training Program for Counselors. Paul has been quoted in the Washington Post and Wired Magazine.

Abstract

•  Description: This presentation covers how to engage with a family system that has lived through traumatic events or is dealing with current traumatic circumstances.
• To do this, first, trauma is defined through a scientific and sociological lens; a discussion of how trauma effects may affect a person takes place, and the differences between PTSD, trauma and stress are discussed.
• The Adverse Child Experiences (ACE) study is explored in how it links traumatic events to long-term negative health events in most people and in most family systems—and how these findings can help clinicians understand clients better.
• The presentation then focuses on the environment of the family home, the particular family’s behaviors, and the neighborhood in which they reside as important aspects in both understanding trauma, mental health, and working on preventing long-term trauma.
• The presentation concludes with methods to help families that have endured environmental trauma, how to work with individuals who have experienced trauma that impacts their mental health, and concludes with tips on how clinicians can help families on the road to a sustainable recovery from the after-effects of trauma.

Learning Objectives of this Presentation

1. For clinicians to have a working knowledge of environmental trauma, the effects of environmental trauma on the family, and how to promote a sustainable recovery within the family, along with post-traumatic growth.
2. For clinicians to understand the differences between trauma and stress, the correlations between trauma and Post Traumatic Stress Disorder, and the impacts of trauma on both individual and family mental health.
3. For clinicians to be able to take some knowledge of what trauma is and how it may affect a person and a family, and what trauma-informed counseling modalities can look like and be able to incorporate that information into their particular clinical setting.

Why is this important?

• The neurobiology studies and scientific research which launched the trauma-informed care initiative in the last 20 years, is one of the most important developments in understanding the human condition
  • the way in which symptoms originate;
  • how life experiences and “trauma” influence the spectrum of human adaptation, thoughts, behaviors, physical health and more;
  • and is the key to understanding the importance of the entire mind-body therapy paradigm as well as why integrated care is paramount for the prevention of and recovery from mental illness.
• This presentation outlines some of the copious amounts of research that have proven the trauma-informed care paradigm to be empirically valid, and how knowledge of trauma-informed counseling techniques can lead to improved outcomes in all forms of healthcare—including, and especially mental health interventions.
• This presentation will educate practitioners on how to recognize the common experiences and reactions to trauma. In addition, this presentation will equip practitioners with simple ways to begin utilizing a trauma-informed care paradigm with counseling techniques to empower and educate clients—so that they may begin the journey of recovery and continue on into personal resiliency.

What is Trauma? – Definitions

There are multiple definitions of trauma:

• Trauma. “Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (SAMHSA, 2014, p. 72).
• Although many individuals report a single specific traumatic event, others, especially those seeking mental health or substance abuse treatment services, have been exposed to multiple or chronic traumatic events.
• “Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force.
  • When the force is that of nature, we speak of disasters.
  • When that force is that of other human beings, we speak of atrocities.

Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning. (p. 33)”.

• Herman (1992) – while defining trauma, he focuses on the fact that trauma overwhelms the individual’s usual control, connection, and meaning.
  • And thus, the combination of this trauma leaves a lasting effect.
• Altmaier (2019) – “A more recent use of “trauma” is for psychological damage from external events that do not necessarily involve physical harm.”
• van der Kolk (2014) – definition of trauma in practice:

“Trauma is not the story of something that happened back then,” he adds. “It’s the current imprint of that pain, horror, and fear living inside people.”

Examples

Would anyone like to share a trauma that they have heard about in their clinical practice, that they believe influenced someone for years after the event itself?

Differences Between Trauma & PTSD

• Researchers often equate trauma to PTSD but it’s not just PTSD. According to ADAA, “a traumatic event is time-based, while PTSD is a longer-term condition where one continues to have flashbacks and re-experiencing the traumatic event”.
• However, experiencing serious trauma is a precondition of developing PTSD (Agaibi & WIlson, 2005).

Beyond “one trauma” or ”PTSD”

The Trauma definition is inadequate as a whole.

• We are talking about the way INFORMATION, physical events, social events, or perceptions of events cause a NERVOUS SYSTEM DISTURBANCE.
• Then, this disturbance is memorized by the brain, remapped—and that effect reorients you to the world in ways that cause further suffering– narrative can lead to depression, your ability to calm yourself can leave—that can lead to substance abuse, your ability to regulation your emotions—which could lead to a personality disorder or anxiety, your ability to be involved in healthy relationships and so much more.

13 Examples of Trauma in Children

1. Bullying
2. Community Violence
3. Complex Trauma*
4. Disasters
5. Early Childhood Trauma
6. Intimate Partner Violence
7. Medical Trauma
8. Physical Abuse
9. Refugee Trauma
10. Sexual Abuse
11. Sex Trafficking
12. Terrorism and Violence
13. Traumatic Grief

Many more examples available

• When a child feels intensely threatened by an event they are involved in or witnesses, we call that event a trauma. There is a range of traumatic events or trauma types to which children and adolescents can be exposed.
• And partially it depends on the child and their perception as to if this becomes a lingering traumatic issue later on.
  • https://www.nctsn.org/what-is-child-trauma/trauma-types

At Risk Populations in Youth

• Some groups of children and families are disproportionately represented among those experiencing trauma. This means that they may be exposed to trauma at particularly high rates or be at increased risk for repeated victimization. For some populations, co-occurring issues and unique adversities can complicate recovery from trauma. Others may face significant challenges related to access to services or require services that are specially adapted for their needs.

• • Trauma and Substance Abuse (A strong correlation for use and continued trauma from using)
  • Economic Stress
  • Military and Veteran Families
  • Homeless Youth
  • LGBTQ Youth
  • Children growing up in neighborhoods, or attending schools with inadequate or sparse resources
  • Children living in neighborhoods with systemic violence and where toxic stress is prevalent.

How trauma may affect a person

• Van der Kolk (2014) – ongoing damage to the whole of “living.”

“Trauma results in a fundamental reorganization of the way the mind and body manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think…The act of telling the story doesn’t necessarily alter the automatic physical and hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or violated at any time. For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.” (Van der Kolk, 2014, p. 21) – cited in Altmaier (2019).

Responses to Trauma

• Common initial reactions to trauma: exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect.
• More severe responses: continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety
• Delayed responses: persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are associated with the trauma, even remotely. (Trauma Informed Care, 2014).

Other common experiences post-trauma

• Emotional Symptoms
• Emotional Dysregulation
• Numbing
• Physical Symptoms
• Somatization
• Hyperarousal
• Sleep Disturbances
• Triggers or Cues
• Flashbacks
• Trauma-induced hallucinations or delusions
• Avoidance – Individuals begin to avoid people, places, or situations to alleviate unpleasant emotions, memories, or circumstances.

Trauma: Effects on the Body

• Changes in limbic system functioning.
• Hypothalamic–pituitary–adrenal axis activity changes with variable cortisol levels.
• Neurotransmitter-related dysregulation of arousal and endogenous opioid systems (Trauma Informed Care, 2014).

Physical Reactions to Trauma

• “fight or flight” reaction to trauma (Cannon, (1915) – the author of the phrase).
• When the sympathetic nervous system is activated (fight, flight, freeze, fawn, and collapse responses) stress hormones such as cortisol and adrenaline are released from the adrenal glands. These glands enable the body to instinctually prepare to face danger. This is natural and useful to survival.
• The problem is that AFTER the trauma is over, the body may continue preparing for danger with the slightest cue (a memory, a smell, a sound…etc.)-–and that leads to symptoms.

Trauma and Stress (the differences)

• According to Gomes (2014), ‘Trauma is an experience of extreme stress or shock that is/or was, at some point, part of life’.
• Stress is a reaction to less dramatic and actual life events such as a job loss, academic exams, deadlines, finances, a loss of a friend, or divorcing a spouse.
• While stress is not always harmful, trauma nearly always is.
• Stress is actually good. You can’t learn anything without stress but it depends on the pattern of stress: it’s moderate, predictable, and controllable.
• Stress helps us develop resilience.
• But unpredictable and extreme stressors like being in a violent atmosphere, have abnormal patterns of activation that lead to severe problems.
• E.g. Toxic Chronic Stress often leads to mental illnesses and risky behaviors such as substance use (Sinha, 2008).
• Toxic stress damages the structure and function of a child’s developing brain.

Ways to avoid stress transforming into trauma

• Releasing energy physically (e.g., crying, screaming, shaking).
• Processing it psychologically
• “A stressful event may not become a traumatic event stored in the nervous system if a person is able to fully process what has occurred psychologically and also release the energy physically”.
• Stress needs to be processed. Otherwise, the effects will remain in the autonomic nervous system and cause physical and psychological symptoms of mental disorders (Yaribeygi et al., 2017).
• Later an individual is no longer able to physically release or psychologically process the stressful event.

Trauma & Mental illnesses

• Traumatic stress increases the risk for mental illness, as well as the severity of symptoms of already existing disorders.
• In fact, it increases the symptom severity of mental illness. Research suggests that trauma often precedes the development of mental disorders (Trauma-Informed Care). (“root causes of a mental illness”)
• Childhood trauma correlates with poor health outcomes in later life (Wu et al., 2009).

When we talk about “trauma”

Trauma is not just PTSD.

• However, a PTSD diagnosis is the result of experiencing serious trauma.
• Why?
  • Because we all have a nervous system.
  • Because we are mammals (We have similar nervous systems).
  • Just because we have a larger and more developed brain and the ability to reason, tell stories, and critically think, doesn’t mean we aren’t also constantly influenced by our nervous system and its drive to keep us alive!

• Our nervous system wants to keep us alive! It wants to survive. It will always react to perceived threats before our logic systems (prefrontal cortex) even realizes that the threat is there.

Adverse Child Experiences Study

Purpose

• To describe the connection between childhood experiences and medical and public health problems in the long term.
• To assess retrospectively and prospectively the long-term impact of abuse and household dysfunction during childhood on

1. 1. disease risk factors and incidence;
   2. quality of life;
   3. health care utilization, and
   4. mortality.

• ACES expanded the medical and scientific community’s viewpoint on what trauma is and what the results can be. We are not just discussing “PTSD” anymore when we are discussing “Trauma.”
• In 1995, Kaiser Permanente and the Centers for Disease Control and Prevention began a breakthrough study on the overall health effects of people who had experienced adverse childhood experiences.
• For two years, researchers gathered comprehensive medical information from over 17,000 patients at Kaiser’s Health Clinic in San Diego, CA.
• In addition to personal and family medical histories, participants in the study were given extensive questionnaires’ regarding childhood experiences of
  • neglect
  • abuse, and
  • family dysfunction, such as physical and emotional neglect, physical and sexual abuse, exposure to household members who had substance abuse problems or had been in prison, and violence in the household.

Results

• ACE study researchers found that the presence of any of these harmful experiences in childhood was predictive of lifelong problems with health and well-being (including negative physical symptoms and outcomes, more likely to suffer from an addiction, and severe mental health problems).
• The more problems reported (higher ACE score) correlated directly with the likelihood of an individual to encounter severe problems throughout the lifespan including negative physical health issues, possible addiction, and mental health problems.

Cultural Impact

• A potentially culturally disruptive finding was that adverse childhood experiences were exceedingly common—much more than many researchers had anticipated. Approximately two-thirds of participants had undergone at least one adverse childhood experience, and more than 1 in 5 respondents had endured three or more.
• The initial data of the ACE study began decades of study on the prevalence and damaging effects of trauma. In turn, the field of psychotherapy responded by working on the development of practices such as trauma-informed counseling (stressing the importance of recognizing and treating trauma and preventing additional trauma).
• Today, many new modalities have been incorporated into the field of counseling that include a combination of trauma-informed counseling with trauma-specific interventions such as EMDR and Somatic Experiencing Therapy, which are tailored to address the effects of the precise traumatic events and situations that a person has endured.
• This study was controversial in the 1990s (it was disruptive of the cultural narrative of the nuclear family and “normality”)

Basic Summary of ACES

• The concept was developed in the 1998 Adverse Childhood Experiences Study (ACE Study)
• The interpretation of ACE score – The Higher your ACE score, the worse your health outcome.
• As your ACE score increases, so does the risk of disease, social and emotional problems.

Mini – ACE Questionnaire

10 Types of Adverse Child Experiences Studied in the initial study

• Physical abuse
• Sexual abuse
• Emotional abuse
• Physical neglect
• Emotional neglect
• Mental illness in the family
• Divorce
• Substance abuse in the household
• Violence against your mother (or Father)
• Mental illness diagnosed
• Having a relative who has been sent to jail or prison

Implications for ACE Score

• The study’s researchers came up with an ACE score to explain a person’s risk for chronic disease. Think of it as a cholesterol score for childhood toxic stress. You get one point for each type of trauma. The higher your ACE score, the higher your risk of health and social problems. (Of course, other types of trauma exist that could contribute to an ACE score, so it is conceivable that people could have ACE scores higher than 10; however, the ACE Study measured only 10 types.)
• And this study was focused on Childhood (under 18). So imagine the build up of other adverse experiences throughout the lifetime

ACE SCORE

A whopping two thirds of the 17,000 people in the ACE Study had an ACE score of at least one — 87 percent of those had more than one. Thirty-six states and the District of Columbia have done their own ACE surveys; their results are similar to the CDC’s ACE Study.

Statistics regarding ACES

• According to the CDC, 1 in 6 adults experienced four or more types of ACEs.
• At least 5 of the top 10 leading causes of death are associated with ACEs.
• More than 60% of adults report having had at least one adverse childhood experience (ACE), and almost 25 percent report three or more (Merick et al., 2018).
• Nearly 50% of all American children have experienced at least 1 ACE, with children of color at the highest risk.

Other related risks of a high ACE score

Related risks (CDC):

• Health problems (e.g. lung cancer (Brown et al., 2010)).
• Mental health problems (e.g. depression, suicide, anxiety)
• Substance abuse problems

Implications for ACE Score

• The CDC’s Adverse Childhood Experiences Study (ACE Study) uncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as social and emotional problems. This includes heart disease, lung cancer, diabetes and many autoimmune diseases, as well as depression, violence, being a victim of violence, and suicide.
• The first research results were published in 1998, followed by more than 70 other publications through 2015. They showed that:
  • childhood trauma was very common, even in employed white middle-class, college-educated people with great health insurance (that was initial Kaiser study),
  • there was a direct link between childhood trauma and adult onset of chronic disease, as well as depression, suicide, being violent and a victim of violence;
  • more types of trauma increased the risk of health, social and emotional problems.
  • people usually experience more than one type of trauma – rarely is it only sex abuse or only verbal abuse.
• As your ACE score increases, so does the risk of disease, social and emotional problems. With an ACE score of 4 or more, things start getting serious. The likelihood of chronic pulmonary lung disease increases 390 percent; hepatitis, 240 percent; depression 460 percent; attempted suicide, 1,220 percent.
• (By the way, lest you think that the ACE Study was yet another involving inner-city poor people of color, take note: The initial study’s participants were 17,000 mostly white, middle and upper-middle class college-educated San Diegans with good jobs and great health care – they all belonged to the Kaiser Permanente health maintenance organization.)
• NOW: Imagine the impact on the BIPOC (Black, Indigenous, People of Color) and other marginalized communities, who are more likely (statistically speaking) to grow up in a community without access to quality healthcare, education, or even health food markets.

Results of ACES

• ACEs are strongly correlated with the development of risk factors for long-term physical and mental health problems and overall well-being.
• The study revealed a direct link between childhood trauma and negative outcomes:
  • Psychological problems: depression, suicide, violence, and being a victim of violence.
  • Physical problems: heart disease, lung cancer, diabetes, and many autoimmune diseases.
  • Social problems: employment challenges in adulthood, imprisonment.
• Demonstrated the demographics & prevalence of emotional, physical, and sexual abuse.

Risk Factors are associated with ACES

ACEs are a risk factor for dangerous behaviors

• People exposed to high doses of adversity are more likely to engage in high-risk behavior. It can be explained by a “fight or flight” response – stress hormones are released and you’re ready to perform risky activities or run from the stressor.
  • Thus cultural judgements…

• But even if you don’t engage in any high-risk behavior, you’re still more likely to develop heart diseases or heart cancer.

How exposure to early adversity affects the development of brains and bodies of children

• It affects the pleasure and reward center (nucleus accumbens) – Oswald et al., 2014
• It inhibits the prefrontal cortex (which is a critical area for learning, vital for impulse control and executive function) – Oshri et al., 2019
• There are differences in MRI results in the amygdala (the brain’s fear response center) – Luby et al., 2017

ACES and Early Intervention for the child/family system

The ACEs study demonstrates the importance of gathering information about potential negative childhood experiences early in their lives and designing early intervention programs (Leitch, 2017).

What do we mean when we talk about “trauma” and how this impacts development

Trauma can be understood as any extraordinarily stressful experience in life that has a lasting negative impact on someone.

• What happens to a child if “trauma” is ongoing in the very environment a child lives in? It’s not an episode of trauma, it’s chronic, toxic, and pervasive.

Environment of the home, family & neighborhood

• A diverse body of research suggests that the environment plays a significant role in child development.
• The environment that affects development can mean every psychosocial characteristic, including home, family, overcrowding, noise level, or neighborhood quality; relationships with parents, siblings, teachers, or peers (e.g. Ferguson et al, 2015; Branum et al., 2003).
• This is one reason why family and community engagement is key to a sustainable recovery from trauma.

Environment of the home, family & neighborhood (effects on children)

• As a result, studies suggest maintaining a holistic approach based on Bronfenbrenner’s (1979) bioecological model to reduce risk factors on the cognitive and socioemotional development of children.

 

• ACEs are a result of a combination of both nature and nurture.

 

• Early years of childhood affects:
  • educational achievement (Li & Qiu, 2018)
  • physical well-being (Nelson et al., 2020)
  • employment opportunities in the future

The Environment also physiologically affects child development

The field of epigenetics shows that we are born with a set of genes that can be turned on and off, depending on what’s happening in our environment. In simple words, the environment influences our genes (or gene expression) (Alegría-Torres et al, 2011).

Relational Health is Key! – (Family & Community)

• “Capacity to develop and sustain safe, stable and nurturing relationships, which in turn prevent the extreme. or prolonged activation of the body’s stress response systems.” (Garner, 2021)
• Relational health refers to interpersonal interactions that are growth-fostering or mutually empathic and empowering (Liang & West, 2011).
• In terms of how to decrease ACEs – people need connection to community, connection to family, a healthy social network.

Environmental Stressors (Family & community-related sources of stress)

• Poverty and the accompanying household stressors
• Unemployment
• Housing instability
• Food insecurity
• Lack of connection to relatives or other members in the community
  • These and other risk factors lead to higher levels of social vulnerability and lower levels of community resilience.

How resilience is developed?

Resiliency is the capability to endure and thrive despite adversity

• An evolving concept (Fleming & Ledogar, 2008)
• How is resilience developed?
  • As a result of the neuroplasticity of our brain.
  • The mechanism – “Neurons that wire together, fire together” (Siegel & Perry).
  • How this is related to community resources and family life (MacPhee et al, 2015). Resilience is highly dependent on multiple factors of an emotionally and physically supportive home environment for children.
  • Strengths-Focused Perspective to develop resilience (Zimmerman, 2013).

Resilient Responses to Trauma:

• Increased bonding with family and community.
• Redefined or increased sense of purpose.
• Increased commitment to a personal mission.
• Revised priorities. Increased charitable giving and volunteerism.
  • But without positive examples of resiliency in parents/caregivers, support from the community/family and/or interventions from therapists and other professionals, these responses are less likely to occur in children.
  • Children are constantly absorbing their parent’s actions, not necessarily their “lectures.” They are absorbing the atmosphere.

The Trauma-Informed Care Paradigm and Resilience in Mental Health Care

• Understanding the Biological and behavioral foundations of human adaptation to environmental stressors, trauma, and difficult family dynamics.
• Fight, Flight, Freeze, Fawn, and Collapse
• Viewing trauma through an ecological and cultural lens
• The importance of context in perceiving and processing traumas.
• Create an environment that is predictable, nurturing, regulating.
• A transformative approach that aims to address the root causes of toxic stress and childhood adversity and to build community resilience.

Toxic Chronic Stress:
The roots of substance use & mental illness

• At the same time that the ACE Study was being done, parallel research on kids’ brains found that toxic stress damages the structure and function of a child’s developing brain. This was determined by a group of neuroscientists and pediatricians, including neuroscientist Martin Teicher and pediatrician Jack Shonkoff, both at Harvard University, neuroscientist Bruce McEwen at Rockefeller University, and child psychiatrist Bruce Perry at the Child Trauma Academy. * https://developingchild.harvard.edu/
• Using drugs or overeating or engaging in risky behavior leads to consequences as a direct result of this behavior. For example, smoking can lead to COPD (chronic obstructive pulmonary disease) or lung cancer. Overeating can lead to obesity and diabetes. In addition, there is increasing research that shows that severe and chronic stress leads to bodily systems producing an inflammatory response that leads to disease.
• In addition, toxic stress can be passed down from generation to generation.
• The field of epigenetics shows that we are born with a set of genes that can be turned on and off, depending on what’s happening in our environment. If a child grows up with an overload of toxic stress, their stress-response genes are likely to be activated so that they are easily triggered by stressful situations that don’t affect those who don’t grow up with toxic stress. They can pass that response onto their children.

Toxic Chronic Stress in the environment

When children are overloaded with stress hormones, they’re in flight, fright or freeze mode. They can’t learn well in school. They often have difficulty trusting adults or developing healthy relationships with peers (i.e., they become loners). To relieve their anxiety, depression, guilt, shame, and/or inability to focus, they turn to easily available biochemical solutions — nicotine, alcohol, marijuana, methamphetamine — or activities in which they can escape their problems — high-risk sports, proliferation of sex partners, and work/over-achievement. (e.g. Nicotine reduces anger, increases focus and relieves depression. Alcohol relieves stress.)

Building Community Resilience (BCR) model

The purposes:

1. to foster collaboration across child health systems, community-based agencies, and cross-sector partners to address the root causes of toxic stress and childhood adversity.
2. reducing stressors within the family or community that contribute to childhood adversity.
3. To redesign and align health and social service delivery systems to improve the fabric of communities.

• • (Ellis & Dietz, 2017).

Four Components of Building Community Resilience

1. Creating a shared understanding of childhood and community adversity;
2. Assessing system readiness;
3. Developing cross-sector partnerships; and
4. Engaging families and residents in a collaborative response to prevent and address the Pair of ACEs.

• • (no more shame, blame, and/or cultural scapegoating)

The main point of Building Community Resilience

• Children can become resilient if they live in communities where adults are resilient.
• This strategy is aimed at preventing or reducing stressors within the family or community that contribute to childhood adversity.

Barriers to BCR

What local policies or issues are affecting adults in your community?

• Economists say that the middle class is disappearing and the billionaires are getting richer, while the poor are getting poorer—how might this affect people in your community?
• Does your community have nonprofits and organizations that work toward empowering adults and children to succeed, or do they create a dependence model of “helping” or “toxic non-profits” which help assuage the guilt of philanthropists without addressing the root causes of sociological issues?
• Education costs are skyrocketing. Payday loan companies take advantage of those living paycheck to paycheck… etc.

Environmental Trauma: Reinforcing a Negative Narrative of those suffering

• Education Systems (public and private), often unfortunately promote “problem child” narratives for those who may be suffering from chronic toxic stress, and rely on baseless cultural tropes for classroom management.
• Many schools lack the resources and funding to implement programming or have the staff available to care for the emotional needs of their students.
• The Criminal Justice System (Which believes that ”punishment” of drug users works—when there is essentially no scientific evidence of this–so we punish people instead of offering rehabilitation inside jail)
• The Prison Industrial Complex (For Profit Prisons), which incarcerates substance users for years without any rehabilitation or treatment.
• Some Religious Institutions (Which seek to enforce moral codes on parishioners through fear/ guilt/ shame and a focus on certain scriptures which uphold their power position, while ignoring others scriptures that call for shared power).
• Judgmental Cultural Narratives in the general public, news media, stereotypes in media, etc. (The show COPS – listen to the this American Life Episode on that).
• Therapists and Social Workers who are not trauma-informed and deliver their own cultural judgements upon clients—especially difficult or “resistant” ones.
• Healthcare professionals who are not trauma-informed and freely give their opinions or judgements upon patient’s behaviors and tell them to “stop it.” Stop smoking! Stop drinking. Just stop it. Stop thinking about the abuse, think of something better– look at your life now!

Reinforcing a Negative Narrative of those suffering… (Statements from clients and people I know QUOTING social workers and therapists said to them)

• “Just don’t think about it anymore.”
• “If you just forgive them, you’ll stop being angry about what he did to you.”
• “God gave us a brain: that means you need to use it or lose it. You need to think about the consequences so that you stop doing that bad stuff.”
• “Just say no! (to drugs)”
• “It seems like you aren’t working hard enough in therapy.”
• “Sometimes I wonder if you really want to get better.”
• “Well, I’ve done all I can do for you–you are probably going to have to keep repeating the coping skills you learned or stay on medications for the rest of your life.”
• “You need to man up and take responsibility.”

Ways to help the family prevent the lasting effects of trauma

• Engage and empower adults and parents
  • Vital for buffering children from the toxic stressors that exist in communities.

• Building strong relationships between parents (or adults) and children
  • Positive supportive relationships and experiences can buffer ACEs
  • Connection to healthy people is an antidote to stress.
  • Research shows that just one positive adult can dramatically improve the outlook for a child suffering from Adverse Childhood Experiences (ACEs).

Why family engagement is vital

• We have learned about the long-term effects of adverse childhood experiences
• Yet, relational health is VITAL to how the effects of ACES play out over the life-span.
  • If you’re connected in a healthy way to family, or community – you can have a lot of adversity and even traumas in your life, and recover and even thrive (even without therapy!)

Ways to engage the family who has been through trauma

• Connectedness counterbalances adversity
  • From a public health perspective, it’s more important to focus on who you’re connected to than only the problems.
  • How do we promote healthy families and vital communities with resources and access?
  • Connection is an essential element in therapy.
• Revisiting trauma in a therapeutic way:
  • “We need to revisit traumatic memories in order to integrate them” – Bessel van der Kolk (2014).

• • Examples:
    • Family Therapy
    • EMDR Therapy (Eye Movement Desensitization and Reprocessing Therapy)
    • Trauma-Focused CBT
    • Support Groups in the Community
    • Trauma-informed Counseling
    • Internal Family Systems and Ego State Therapies

Prevention (ways to engage a family)

• Building positive buffers (prevention), and also Post-Trauma
  • The ACE score isn’t an inevitability.
  • Focus on relational connectedness.

For Families:

• • • Learning Positive Communication Skills
    • Emotional Vulnerability and Authenticity
• Suggestions for trauma-informed practice with families

Dealing with environmental trauma as the therapist

• As a counselor, we need to get comfortable with distress in order to listen to emotionally intense stories. Ideally, you would get educated on the trauma-informed paradigm of counseling, polyvagal theory, the work of Dr. Bruce Perry MD. Ph.D., and understand the intersection of environmental stress and trauma on the family, and, of course, the children.
• Get trained/ educated in a trauma-specific modality
• If you really want to help, get connected with organizations in your community that you can refer to to help the family outside of the therapy office.
• STOP PATHOLOGIZING CHILDREN INDEPENDENT OF THE FAMILY SYSTEM!
• Creating a safe environment – If you feel safe, it’s much more likely that clients open and share their feelings and thoughts.
  • Core element of self-care – supportive and safe environment (WHO).

• According to Bruce Perry MD, Ph.D, therapists should be
  • Present
  • Attentive
  • Attuned
  • Responsive

• They should identify and ask “what happened to you, how did you get here?” and not “what’s wrong with you?”
  • Question 1 is curious, empathetic, and educational.
  • Question 2 is judgmental, accusatory, and ignorant of human behaviors and their causes.

• Therapy should be based on a holistic intervention model.
  • Care coordination (Work with the schools, doctors, etc.)
  • Home visits (coordinating w/ agencies that provide this)
  • Mental health care (outpatient therapy, IOP, etc.)
  • Nutrition (education)
  • Medication when necessary.
  • Educating parents about the impact of ACEs.
    • Know your role. Depending on your job and position: What do you have the ability to do?
    • If you can’t do a certain intervention, can you provide thoughtful resources?

• In addition to regular therapeutic interventions
  • (such as family therapy, individual therapy –hopefully with trauma-specific interventions)

• Therapists should focus on
  • Increasing community engagement
  • Relational health
  • Enhancing resilience
    • In families and individuals

Educating therapists and families on the nervous system

• Polyvagal Model of understanding the nervous system
  • The theory was introduced by Stephen Porges (1996).
  • The main aim of the theory – to understand our reactions to trauma.
• Connection with the family with ACEs history
  • When we’re in a dangerous environment, the nervous system can’t detect safety. It has a low threshold for reacting and automatically may put us in a fight or flight physiological state. This is important in understanding trauma.
• Three states of the autonomic nervous system when exercising adversities (according to Porges):

1. 1. Fight or flight state (mobilization system) – dealing with adversity (hyperarousal)
      • Fight – anger, frustration, rage, irritation.
      • Flight – worry, anxiety, fear, panic

1. 2. Freeze state (Immobilization system)
      • inability to move
      • trauma survivors were describing the numbness of their bodies.

1. 3. Additional recognized states:
      • Fawn state (acquiesce to the more powerful figures so as not to be hurt)
      • Collapse ( A shut down reaction or hypoarousal state, where people are unable to “keep going.”

Using a social engagement system for families (using polyvagal theory)

• Social engagement system
  • detects features of safety (in the previous two states, you can’t detect safety cues in the environment).
  • decreased defensive responses and increased ability to connect with people.
• Clinicians use this model to help families heal from trauma. How?
  • Social interaction is a neural exercise to inhibit a primitive defense system.
  • They promote social engagement behaviors in safe environments.

How do we have a sustainable recovery for the family going through trauma or an individual from the family with trauma

• What is sustainable recovery?
  • Long-term psychological and physical well-being after experiencing adversities.
• You can’t grow up without adversity but some of the events and environmental factors have very serious effects and change the way the brain develops. Sustainable recovery helps us maintain healthy patterns of brain activity.

Why is it important to promote a resilience-oriented approach?

• A resilience-oriented approach moves from trauma information to neuroscience-based action with practical skills to build greater capacity for self-regulation and self-care in both service providers and clients (Leitch, 2017).
• To go deeper and pull out the roots of trauma instead of just coping with symptoms.
  • Many individual and family therapies work on these elements

Tips for sustainable recovery in any role

• Promote sustainable recovery for a family with a holistic approach – Integrated care:

• • Primary care (including nutrition and preventative medicine)
  • Community (Involvement in healthy community activities / organizations)
  • Family (Focusing on the health of the family and connectedness)
  • Mental Health Interventions (Support groups, counseling, family therapy, trauma-specific therapies, learning mindfulness)
  • Fitness (Promoting exercise, yoga, walking/hiking, and more)

Therapists facilitate sustainable recovery:

Sustainable recovery for the family includes:

• Understanding each members’ reactions to trauma
• Understanding the effect on family dynamics
• Helpful strategies for recovery from trauma (therapies, community engagement, etc).

Two key elements of sustainable recovery:

1. Connectedness
2. Post-traumatic wisdom

Connectedness

• Neurobiology of human beings: We are intended to live in groups or communities.
• Therefore, a personal journey is so much easier if it’s done around family members or people who are caring and people to whom you belong.
• The physiology of reward, regulation, and the way we heal from trauma is dependent on the quality of our relational opportunities.

Post-traumatic wisdom

• The term was partially coined by Dr. Bruce Perry and Oprah Winfrey.
• “That’s referring to the experience where you’ve been able to get through adversity, and you’re now at a safe place in your life and can look back and reflect.”
• In simple words, “taking the pain and turning it into power” (Oprah Winfrey).
• How it relates to sustainable recovery.
  • You can’t change what has happened to you in the past but you can recognize how they shaped your behavior and what impact they had on your life.

Post-Traumatic Growth

The concept of post-traumatic growth

• A common term in positive psychology
• Almost similar to resilience
• The idea of PTG belongs to Calhoun and Tedeschi (1999). They defined it as positive psychological change.
• 5 factors of PTG (Rozentsvit, 2016):
  • Relating to others with greater compassion
  • Finding new possibilities
  • Personal strength
  • Spiritual change
  • A deeper appreciation of life.

Neurobiology: Implications

• The scientific and health community has learned that many people who had mental health symptoms, also suffered physical symptoms, because the mind and body are connected – the nervous system begins in the brain, and moves throughout the entire body.
• The overwhelming evidence from neurobiology and the emerging field of epigenetics is making it clear that more education is needed for therapists, social workers, and healthcare workers—so that we can utilize this information in our interventions– but unfortunately most of these amazing revelations from science and the implications for treatment have not made it into graduate school programs yet!
• Many diagnoses are the results of trauma and the environment on someone’s genetics. Education, not labels, are called for to help those suffering—instead of shaming them or blaming them.
• And over the long-term, (without actual safety or therapeutic correction) many people who suffer adverse experiences or trauma– will begin to ”internalize” their adverse experiences and form negative personal narratives that believe (FOR EXAMPLE) that they are to blame for all of their problems…

Encourage Involvement

Outside of therapy, work on small goals of  helping your clients and their families to engage in various types of community organizations or social groups that could help fill in the gaps. Slowly but surely, if there are positive natural supports, this MAY lead to more long-term resiliency and recovery.

Are you ready to be trauma-informed?

• In general, you can only lead people on the  journey as far as you have gone. Transformed people transform people. When you can be healed yourself and not just talk about healing, you are, as Henri Nouwen said, a “wounded healer.”

– Richard Rohr

Additional Resources for Therapists who want to work for sustainable recovery…

• The Adolescent Community Reinforcement Approach
  • Behavioral treatment for youth and young adults with substance use disorders.
  • A-CRA
  • Godley et al., 2017

• Trauma-informed care paradigm
  • What is trauma-informed care?
  • How it leads to personal resiliency
  • The Five Principles of Trauma-Informed Care
  • How it was a shift in a paradigm (Sweeney, 2018)
  • What are trauma-specific interventions
  • Difference from other interventions (treating roots instead of the surface)
  • 16 principles
  • Key ingredients to implement trauma-informed care (linked)

• Values of trauma-informed care:
  • Promote safety
  • Earn trust
  • Embrace diversity
  • Provide holistic care
  • Respect human rights
  • Pursue the person’s strengths, choice, and autonomy
  • Share power
  • Communicate with passion
  • Understand the prevalence and impact of trauma
• Bruce Perry’s attachment theory and “circle of security” concepts
  • The Neurosequential Model From the Child Trauma Academy
  • Check out “What Happened to You? Conversations on Trauma, Resilience, and Healing” by Bruce Perry MD, PH.D and Oprah Winfrey
• EMDR therapy
  • What is EMDR
  • Using EMDR to cope with trauma (APA).
  • Effectiveness of EMDR therapy to heal individuals
    • Based on Shapiro, 2014, EMDR can:
• Relieve emotional distress after adversity
• Is quicker and more effective than CBT
• Reduces somatic symptoms (e.g. muscle tension)
• Difference from traditional therapies (e.g., focuses on the roots, focuses directly on the memory, and is intended to change the way that the memory is stored in the brain).
• The role in reprocessing trauma (van Veen et al., 2019).
• Future of EMDR Therapy (Castelnuovo et al., 2019).
• FIFE: Feelings, Ideas, Function, Expectation
• Canadian practice used in medical settings
• Pamela Thompson implemented training in Arizona
• Ideal for working on a more integrated self

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