Safety Without Restraints: Safety Without Restraints:

Trauma Informed CareTrauma Informed Care

The Neurobiological & Psychological The Neurobiological & Psychological Effects of TraumaEffects of Trauma

Dr. Janice LeBel

Rhode Island College ~ Sherlock Center on Disabilities

March 9, 2015

Adapted Presentation Developed by Glenn Saxe, MD for NASMHPD OTA 2002

“Without understanding the basic principles of how the brain develops and changes, we cannot expect to design and implement effective interventions.”

Bruce Perry, M.D.

NCTSN.ORG

Boston Medical Center Intensive Residential Treatment Program

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Significant Periods

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Kid Injury

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Acute Assessment 3 Month Assessment 0

Longitudinal Course of PTSD Symptoms Longitudinal Course of PTSD Symptoms in Children with Burnsin Children with Burns

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Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with

a Healthy, Non-Maltreated Matched Control

(De Bellis et al, 1999)

From Neurons to Neighborhoods:

The Science of Early Child Development

Report from the Institute of Medicine/National Report from the Institute of Medicine/National AcademiesAcademies

National Research CouncilNational Research Council

Trauma in U.S.A.Trauma in U.S.A.

• 3 million children were suspected of being victims of abuse and/or neglect (Mazelis, 1999)

• 3.9 million adolescents have been victims of serious physical assault, and almost 9 million have witnessed an act of serious violence (Kilpatrick et al, 2001)

• In 1998, 92% of incarcerated girls reported sexual, physical or severe emotional abuse in childhood

(Acoca & Dedel, 1998)

PTSD in U.S.A.PTSD in U.S.A.

• Over 50% of U.S. women & 60% of men report experiencing at least 1 traumatic event at some point in their lives. But, only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events.

(Koenen, 2005; Kessler et al, 1995)

• More than 80% of those diagnosed with PTSD will suffer from other psychiatric disorders. (Solomon & Davidson, 1997)

• For more than 1/3 with PTSD, it will be a persistent condition and experienced for several years.

(Solomon & Davidson, 1997)

Impact of Adult PTSD Impact of Adult PTSD

• Childhood trauma, compared to adult-onset trauma:• results in a greater probability of developing psychiatric disorders

(particularly anxiety disorders and PTSD) throughout the lifetime

(Zlotnick et al., 2008), and• is believed to have a long-term impact in the frontal, temporal and

parietal regions of the brain and how information is processed (Cook et al., 2009)

• Studies have identified 4 main risk factors for PTSD in adults: 1) a pre-existing psychiatric disorder; 2) a family history of disorders; 3) childhood trauma and 4) being female (Breslau, 2002)

• Late-onset PTSD is under recognized and undertreated in adults and creates greater probability of additional psychological difficulty and physical health symptoms later in life (Snyder, 2008)

What is PTSD, What is PTSD, really?really?

““PTSD should PTSD should notnot be considered be considereda ‘disorder.’ It is a a ‘disorder.’ It is a

psychological and emotional injury – psychological and emotional injury – a natural reaction to an unnatural a natural reaction to an unnatural

situation. situation. Why turn it into ‘pathology’ Why turn it into ‘pathology’

and make it a disorder?”and make it a disorder?”

Jonathan Shay, M.D., 2011 Boston V.A.

Effective Treatment Must Account Effective Treatment Must Account For:For:

1) A dysregulated nervous system

2) A social-environment that cannot contain this dysregulation

Core Concepts of DevelopmentCore Concepts of Development

1) Human development unfolds 1) Human development unfolds along individual pathways whose along individual pathways whose trajectories are characterized by trajectories are characterized by continuities and discontinuities, continuities and discontinuities, as well as by a series of as well as by a series of significant transitions.significant transitions.

(Shonkoff & Phillips, 2000(Shonkoff & Phillips, 2000))

Time Period

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309.81 PTSD Definition309.81 PTSD Definition

• The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons’ experience of:

– Actual or threatened death– Actual or threatened serious injury– Threat to physical integrity

Post Traumatic Stress DisorderPost Traumatic Stress Disorder

• Characterized by:– Re-experiencing the event

• Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories

– Avoidance and emotional numbing• Flattening of affect, detachment from others, loss of

interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience

Core Concepts of DevelopmentCore Concepts of Development

2) The growth of self regulation 2) The growth of self regulation is a cornerstone of early is a cornerstone of early development that cuts across all development that cuts across all behavioral domains.behavioral domains.

(Shonkoff & Phillips, 2000)(Shonkoff & Phillips, 2000)

State ChangeState Change22 year-old man with history of childhood physical abuse displayed aggressive behavior on psychiatric unit and was physically restrained.

State ChangeState Change12 year-old sexually abused girl in school when provoked by older male peer.

Parameters that change between Parameters that change between statestate

•AffectAffect•ThoughtThought•BehaviorBehavior•Sense-of-selfSense-of-self•ConsciousnessConsciousness

Emotional States and Child DevelopmentEmotional States and Child Development

• Discrete behavioral states are a central organizing experience of infancy

• Infants experiential world is divided into separate and definable emotional/behavioral states

• Critical task of early child development is to build smooth transitions/bridges between states

• Regulation of emotion is initially contingent on caregivers facilitating these transitions

(Wolff, 1987)(Wolff, 1987)

Goal of TreatmentGoal of Treatment

• Maintain Calm/ Continuous/ Maintain Calm/ Continuous/ Engaged StateEngaged State

• Prevent Discontinuous StatesPrevent Discontinuous States

• Build Cognitive Structures Build Cognitive Structures that allow Choicesthat allow Choices

Between Stimulus and ResponseBetween Stimulus and Response

ResponseResponseStimulusStimulus

Between Stimulus and ResponseBetween Stimulus and Response

ResponseResponseStimulusStimulus

Traumatic Reminder

Traumatic State

InterventionIntervention

Social-environmental intervention

Neuro-regulatory

Intervention

Between Stimulus and ResponseBetween Stimulus and Response

ResponseResponse

StimulusStimulus

Traumatic Reminder

Traumatic State

InterventionIntervention

Social-environmental Intervention

Neuro-regulatory

Intervention

COGNITION!!!COGNITION!!!

Core Concepts of DevelopmentCore Concepts of Development

3) Human development is shaped by a dynamic and continuous interplay between biology and experience.

(Shonkoff & Phillips, 2000)

Emotional BrainEmotional Brain

(Restak, 1988)(Restak, 1988)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

(LeDoux, 1996)(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus

(LeDoux, 1996)(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

Very Fast

(LeDoux, 1996(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

Cortex

Very Fast

SlowerHippocampus

(LeDoux, 1996)(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

Cortex

Very Fast

SlowerHippocampus

ResponseResponse

(LeDoux, 1996)(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

Cortex

Very Fast

SlowerHippocampus

ResponseResponse

(LeDoux, (LeDoux, 1996)1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

Cortex

Very Fast

SlowerHippocampus

ResponseResponse

(LeDoux, 1996)(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

S StimulusStimulus

Sensory Thalamus AmygdalaVery Fast

SlowerHippocampus

ResponseResponse

Cortex

(LeDoux, 1996(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

S StimulusStimulus

Sensory Thalamus AmygdalaVery Fast

Slower

ResponseResponse

Cortex

Hippocampus

(LeDoux, 1996)(LeDoux, 1996)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus AmygdalaVery Fast

Slower

ResponseResponse

Cortex

Hippocampus

Neuroregulatory InterventionPsychotherapy

Psychopharmacology

Social Environmental Intervention

(LeDoux, 1996)(LeDoux, 1996)

Rauch Brain scans

PlayPlay

Play and FearPlay and Fear

(Panksepp, 1998)(Panksepp, 1998)

Social-Ecological ModelSocial-Ecological ModelIndividual

Peer Group

SchoolNeighborhood

Culture

Family

Individual

Core Concepts of DevelopmentCore Concepts of Development

4) Human relationships, and the 4) Human relationships, and the effects of relationships on effects of relationships on relationships, are the building relationships, are the building blocks of healthy development.blocks of healthy development.

(Shonkoff & Phillips, 2000)(Shonkoff & Phillips, 2000)

AttachmentAttachment

• Earliest relationships critical for capacity to regulate state

• Early traumatic relationships set up person to respond with state dysregulation to interpersonal cues in subsequent relationships

Attachment & Relational Deficits

•Appear guarded & anxious

•Difficult to re-direct, reject support

•Highly emotionally reactive

•Hold on to grievances

•Do not take responsibility for behavior

•Make the same mistakes over and over

•Repetition compulsion / traumatic re-enactment (Hodas, 2004)(Hodas, 2004)

Trauma eats Attachment for Lunch...

Core Concepts of DevelopmentCore Concepts of Development

5) People are active participants 5) People are active participants in their own development, in their own development, reflecting the intrinsic human reflecting the intrinsic human drive to explore and master one’s drive to explore and master one’s environment. environment.

(Shonkoff & Phillips, 2000)(Shonkoff & Phillips, 2000)

Traumatic MasteryTraumatic Mastery

• Many children have primarily experienced abusive and neglectful relationships

• Extreme behaviors within relationships can be seen as defensive or self-protective and adaptive

• Traumatized people respond to their trauma history in the present. They are not able to discern that the context has changed

• This behavior must be seen as an attempt to master extremely difficult environments. In this way, traumatized children are “doing the best that they can”

Core Concepts of DevelopmentCore Concepts of Development

6) The course of development 6) The course of development can be altered…by effective can be altered…by effective interventions that change the interventions that change the balance between risk and balance between risk and protection, thereby shifting the protection, thereby shifting the odds in favor of more adaptive odds in favor of more adaptive outcomes. outcomes. (Shonkoff & Phillips, 2000)(Shonkoff & Phillips, 2000)

Recovery from TraumaRecovery from Trauma

• Stimulate the brain! Stimulate the brain!

Use of anti-depressant medications Use of anti-depressant medications (Surget et al., 2011)(Surget et al., 2011)

Cognitive stimulationCognitive stimulation• Education Education [Gilligan’s anti-prison model][Gilligan’s anti-prison model]; CBT, ; CBT, TF-CBT, DBT)TF-CBT, DBT)

Procedural learningProcedural learning (Grigsby & Stevens, 2002) (Grigsby & Stevens, 2002)

•Deconstruct behavioral sequenceDeconstruct behavioral sequence•Teach new patterns of responseTeach new patterns of response

Recovery from TraumaRecovery from Trauma• Brain plasticity Brain plasticity

• Conventional wisdom: human brain reaches 90% Conventional wisdom: human brain reaches 90% of adult weight by early childhood and little of adult weight by early childhood and little change in size after age 5 change in size after age 5 (Bryck & Fisher, 2012)(Bryck & Fisher, 2012)

• Conceptually adapted from TBI researchConceptually adapted from TBI research• Physical stimulation to promote neurogenesisPhysical stimulation to promote neurogenesis

• Exercise and gross motor movementExercise and gross motor movement• Increased V0Increased V022, increased blood flow x 2 to , increased blood flow x 2 to

hippocampus, new blood vessels, strengthens hippocampus, new blood vessels, strengthens existing connections, recruits new neural existing connections, recruits new neural connections connections (Bryck & Fisher, 2012; Pereira et al., 2007; Snyder (Bryck & Fisher, 2012; Pereira et al., 2007; Snyder

& Cameron, 2011)& Cameron, 2011)

Recovery from TraumaRecovery from Trauma• Early studies: exposing rats to stress followed by Early studies: exposing rats to stress followed by enriched environments (complexity & novelty):enriched environments (complexity & novelty):

• ↑ ↑ brain #, sizebrain #, size• ↑ ↑ dendrite branching & lengthdendrite branching & length• changes in synaptic size & #changes in synaptic size & #• behavioral & memory improvements behavioral & memory improvements

• Exercise studies with humansExercise studies with humans•↑ ↑ cognitive abilitiescognitive abilities•↑ ↑ academic performanceacademic performance•↑ ↑ executive control / functioningexecutive control / functioning• possibly continued plasticity into old age possibly continued plasticity into old age

(Bryck & Fisher, 2012) (Bryck & Fisher, 2012)

Recovery from TraumaRecovery from Trauma• Current neuroplasticity research focus:Current neuroplasticity research focus:

•Executive functioning (AKA: cognitive Executive functioning (AKA: cognitive control)control)

• Lab-based training Lab-based training w/working memory w/working memory focus – does not generalize easilyfocus – does not generalize easily

• Neurobiologically informed ecological Neurobiologically informed ecological interventions interventions – in the environment but costly– in the environment but costly

• Compensatory processes brain-trainingCompensatory processes brain-training – – ‘overactivation;’ recruit both hemispheres, not just ‘overactivation;’ recruit both hemispheres, not just where damage occurred, i.e., ‘self-talk’ strategies where damage occurred, i.e., ‘self-talk’ strategies

(Bryck & Fisher, (Bryck & Fisher, 2012) 2012)

Recovery from TraumaRecovery from Trauma

Sensori-Motor Recognition & Sensori-Motor Recognition & ApproachesApproaches• Recognize the impact of trauma on the body & Recognize the impact of trauma on the body & behavior (survival strategies); behavior (survival strategies); • Assess Assess Sensory Diet Sensory Diet (Jean Ayers) & identify (Jean Ayers) & identify Sensory-Seeking / Sensory Avoiding behaviorSensory-Seeking / Sensory Avoiding behavior• Teach skills to promote body awareness & Teach skills to promote body awareness & calmingcalming• Promote natural methods: yoga, singing, Promote natural methods: yoga, singing, recreation, etc.recreation, etc.

Recovery from TraumaRecovery from Trauma

New Language & Understanding: Steps Towards Practice & Culture Change

Trauma Aware - individual impact, risk factors, brain/behavior

Trauma Focused - treatment using evidence-based practices, service-specific

Trauma Sensitive - awareness & provision of services oriented at the organization/system level

Trauma Informed - organization/system commitment to address trauma across multiple-systems

CONCLUSIONS• Response to traumatic stress is learned behavior, mediated by

the brain & the social environment

• Traumatic stress brings the past to the present

• The survival response impacts the mind, body, behavior & speech “… the amygdala leads a hostile takeover of consciousness by

emotion.” (LeDoux, 2002 )

• To change the response, create new: language, learning & skills: – Analyze & adapt

– Buffer & bolster

– Teach, support, & build that “cognitive wedge”

““Cowardice asks the question – Cowardice asks the question – is it safe?is it safe?

Expediency asks the question – Expediency asks the question – is it politic?is it politic?

Vanity asks the question – Vanity asks the question – is it popular?is it popular?

But conscience asks the question – But conscience asks the question – is it right?is it right?

And there comes a time when one must takeAnd there comes a time when one must take

the position that is neither safe, nor politic,the position that is neither safe, nor politic,

nor popular. But one must do it becausenor popular. But one must do it because

it is right…”it is right…”

Martin Luther King, Jr. Martin Luther King, Jr.