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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether. Likewise, treatment providers may not ask questions that elicit a client's history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the constraints of their treatment program, the program's clinical orientation, or their agency's directives.

By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma-informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consultation, and supervision of staff.

This Treatment Improvement Protocol (TIP) begins by introducing the scope, purpose, and organization of the topic and describing its intended audience. Along with defining trauma and trauma-informed care (TIC), the first chapter discusses the rationale for addressing trauma in behavioral health services and reviews trauma-informed intervention and treatment principles. These principles serve as the TIP's conceptual framework.

Before You Begin

This TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organizations to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to help behavioral health practitioners and program administrators become trauma aware and informed, improve screening and assessment processes, and implement science-informed intervention strategies across settings and modalities in behavioral health services. Whether provided by an agency or an individual provider, trauma-informed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment interventions to address traumatic stress reactions). Nonetheless, TIC anticipates the role that trauma can play across the continuum of care-establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively.

Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in relational/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention ( Institute of Medicine et al., 2009): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related symptoms. This TIP identifies interventions, including trauma-informed and trauma-specific strategies, and perceives treatment as a means of prevention-building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

This TIP's target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma-informed strategies, or trauma-specific interventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B. This TIP covers TIC, trauma characteristics, the impact of traumatic experiences, assessment, and interventions for persons who have had traumatic experiences. Considering the vast knowledge base and specificity of individual, repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma, murder). Instead, this TIP provides an overview supported by examples. For more information on several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues ( Center for Substance Abuse Treatment [CSAT], 2000b), TIP 25, Substance Abuse Treatment and Domestic Violence ( CSAT, 1997b), TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d), and the planned TIP, Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse and Mental Health Services Administration [SAMHSA], planned f).

This TIP, Trauma-Informed Care in Behavioral Health Services, is guided by SAMHSA's Strategic Initiatives described in Leading Change: A Plan for SAMHSA's Roles and Actions 2011- 2014 ( SAMHSA, 2011b). Specific to Strategic Initiative #2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this initiative by providing behavioral health practitioners, supervisors, and administrators with an introduction to culturally responsive TIC.

Specifically, the TIP presents fundamental concepts that behavioral health service providers can use to:

Become trauma aware and knowledgeable about the impact and consequences of traumatic experiences for individuals, families, and communities.

Evaluate and initiate use of appropriate trauma-related screening and assessment tools.

Implement interventions from a collaborative, strengths-based approach, appreciating the resilience of trauma survivors.

Learn the core principles and practices that reflect TIC.

Anticipate the need for specific trauma-informed treatment planning strategies that support the individual's recovery.

Decrease the inadvertent retraumatization that can occur from implementing standard organizational policies, procedures, and interventions with individuals, including clients and staff, who have experienced trauma or are exposed to secondary trauma.

Evaluate and build a trauma-informed organization and workforce.

The consensus panelists, as well as other contributors to this TIP, have all had experience as substance abuse and mental health counselors, prevention and peer specialists, supervisors, clinical directors, researchers, or administrators working with individuals, families, and communities who have experienced trauma. The material presented in this TIP uses the wealth of their experience in addition to the available published resources and research relevant to this topic. Throughout the consensus process, the panel members were mindful of the strengths and resilience inherent in individuals, families, and communities affected by trauma and the challenges providers face in addressing trauma and implementing TIC.

What Is Trauma?

According to SAMHSA's Trauma and Justice Strategic Initiative, "trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being" ( SAMHSA, 2012, p. 2). Trauma can affect people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual's or community's resources to cope, and it often ignites the "fight, flight, or freeze" reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

See Appendix C to read about the history of trauma and trauma interventions.

Often, traumatic events are unexpected. Individuals may experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. Events may be human-made, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or violence, or they can be the products of nature (e.g., flooding, hurricanes, tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement).

It is not just the event itself that determines whether something is traumatic, but also the individual's experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual's immediate response and long-term reactions to trauma. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resilience-the ability to rise above the circumstances or to meet the challenges with fortitude.

For some people, reactions to a traumatic event are temporary, whereas others have prolonged reactions that move from acute symptoms to more severe, prolonged, or enduring mental health consequences (e.g., posttraumatic stress and other anxiety disorders, substance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other mental disorders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma (e.g., somatization, in which psychological stress is expressed through physical concerns). For that reason, even if an individual does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more information on traumatic events, trauma characteristics, traumatic stress reactions, and factors that heighten or decrease the impact of trauma, see Part 1, Chapter 2, "Trauma Awareness," and Part 1, Chapter 3, "Understanding the Impact of Trauma."

Trauma Matters in Behavioral Health Services

The past decade has seen an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance abuse are linked. With the attacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disastrous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the forefront of national consciousness.

Trauma was once considered an abnormal experience. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general population of the United States. In the study, 61 percent of men and 51 percent of women reported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experiencing a life-threatening accident ranking as the most common events ( Kessler et al., 1999). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma ( El-Gabalawy, 2012). For a thorough review of the impact of trauma on quality of life and health and among individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Rationale for TIC

Integrating TIC into behavioral health services provides many benefits not only for clients, but also for their families and communities, for behavioral health service organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma can pervasively affect an individual's well-being, including physical and mental health. For behavioral health service providers, trauma-informed practice offers many opportunities. It reinforces the importance of acquiring trauma-specific knowledge and skills to meet the specific needs of clients; of recognizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health services; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. TIC stresses the importance of addressing the client individually rather than applying general treatment approaches.

TIC provides clients more opportunities to engage in services that reflect a compassionate perspective of their presenting problems. TIC can potentially provide a greater sense of safety for clients who have histories of trauma and a platform for preventing more serious consequences of traumatic stress ( Fallot & Harris, 2001). Although many individuals may not identify the need to connect with their histories, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in managing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms.

Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study ( Centers for Disease Control and Prevention, 2013) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study ( SAMHSA, 2007) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services.

Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for retraumatization. The implementation may enhance communication between the client and treatment provider, thus decreasing risks associated with misunderstanding the client's reactions and presenting problems or underestimating the need for appropriate referrals for evaluation or trauma-specific treatment. Organizational investment in developing or improving trauma-informed services may also translate to cost effectiveness, in that services are more appropriately matched to clients from the outset. TIC is an essential ingredient in organizational risk management; it ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and, ultimately, the organization. A key principle is the engagement of community, clients, and staff. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services.

An organization also benefits from work development practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a trauma-informed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Trauma-informed organizations are invested in their staff and adopt similar trauma-informed principles, including establishing and providing ongoing support to promote TIC in practice and in addressing secondary trauma and implementing processes that reinforce the safety of the staff. Even though investing in a trauma-informed workforce does not necessarily guarantee trauma-informed practices, it is more likely that services will evolve more proficiently to meet client, staff, and community needs.

Advice to Counselors: The Importance of TIC

The history of trauma raises various clinical issues. Many counselors do not have extensive training in treating trauma or offering trauma-informed services and may be uncertain of how to respond to clients' trauma-related reactions or symptoms. Some counselors have experienced traumas themselves that may be triggered by clients' reports of trauma. Others are interested in helping clients with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or by discounting or disregarding a client's report of trauma. Counselors must be aware of trauma-related symptoms and disorders and how they affect clients in behavioral health treatment.

Counselors with primary treatment responsibilities should also have an understanding of how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients' treatment plans, how to help clients build a safety net to prevent further trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for further evaluations or trauma-specific treatment services. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. For example, helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client's chances of substance abuse recovery and lower the possibility of relapse ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed.

Trauma and Substance Use Disorders

Many people who have substance use disorders have experienced trauma as children or adults ( Koenen, Stellman, Sommer, & Stellman, 2008; Ompad et al., 2005). Substance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the influence ( Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse ( Reynolds et al., 2005). In addition, people who abuse substances and have experienced trauma have worse treatment outcomes than those without histories of trauma ( Driessen et al., 2008; Najavits et al., 2007). Thus, the process of recovery is more difficult, and the counselor's role is more challenging, when clients have histories of trauma. A person presenting with both trauma and substance abuse issues can have a variety of other difficult life problems that commonly accompany these disorders, such as other psychological symptoms or mental disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social support ( Mills, Teesson, Ross, & Peters, 2006; Najavits, Weiss, & Shaw, 1997). Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al., 1997), and a significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder (PTSD; Falck, Wang, Siegal, & Carlson, 2004; Grant et al., 2004; Reynolds et al., 2005).

Trauma and Mental Disorders

People who are receiving treatment for severe mental disorders are more likely to have histories of trauma, including childhood physical and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with serious mental illness who have histories of trauma present with psychological symptoms or mental disorders that are commonly associated with a history of trauma, including anxiety symptoms and disorders, mood disorders (e.g., major depression, dysthymia, bipolar disorder; Mueser et al., 2004), impulse control disorders, and substance use disorders ( Kessler, Chiu, Demler, & Walters, 2005).

Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of mental illness ( Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in perpetuating and exacerbating mental illness and suggest that trauma often precedes the development of mental disorders. As with trauma and substance use disorders, there is a bidirectional relationship; mental illness increases the risk of experiencing trauma, and trauma increases the risk of developing psychological symptoms and mental disorders. For a more comprehensive review of the interactions among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Trauma-Informed Intervention and Treatment Principles

TIC is an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health services from prevention through treatment. There are many definitions of TIC and various models for incorporating it across organizations, but a "trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice"( SAMHSA, 2012, p. 4).

TIC begins with the first contact a person has with an agency; it requires all staff members (e.g., receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board members) to recognize that the individual's experience of trauma can greatly influence his or her receptivity to and engagement with services, interactions with staff and clients, and responsiveness to program guidelines, practices, and interventions. TIC includes program policies, procedures, and practices to protect the vulnerabilities of those who have experienced trauma and those who provide trauma-related services. TIC is created through a supportive environment and by redesigning organizational practices, with consumer participation, to prevent practices that could be retraumatizing ( Harris & Fallot, 2001c; Hopper et al., 2010). The ethical principle, "first, do no harm," resonates strongly in the application of TIC.

"A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings."

( SAMHSA, 2012, p. 4)

TIC involves a commitment to building competence among staff and establishing programmatic standards and clinical guidelines that support the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent staff; involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and evaluation of trauma-informed services; developing collaborations across service systems to streamline referral processes, thereby securing trauma-specific services when appropriate; and building a continuity of TIC as consumers move from one system or service to the next. TIC involves reevaluating each service delivery component through a trauma-aware lens.

The principles described in the following subsections serve as the TIP's conceptual framework. These principles comprise a compilation of resources, including research, theoretical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost importance in working with people who have had traumatic experiences.

Advice to Counselors: Implementing Trauma-Informed Services

Recognizing that trauma affects a majority of clients served within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to guide systems of care in the development of trauma-informed services. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of trauma-informed services. For specific administrative information on TIC implementation, refer to Part 2, Chapters 1 and 2, of this TIP.

Promote Trauma Awareness and Understanding

Foremost, a behavioral health service provider must recognize the prevalence of trauma and its possible role in an individual's emotional, behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being vigilant about the prevalence and potential consequences of traumatic events among clients allows counselors to tailor their presentation styles, theoretical approaches, and intervention strategies from the outset to plan for and be responsive to clients' specific needs. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have experienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you anticipate the possibility from your initial contact and interactions, intake processes, and screening and assessment procedures.

Even the most standard behavioral health practices can retraumatize an individual exposed to prior traumatic experiences if the provider implements them without recognizing or considering that they may do harm. For example, a counselor might develop a treatment plan recommending that a female client-who has been court mandated to substance abuse treatment and was raped as an adult-attend group therapy, but without considering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices.

Becoming trauma aware does not stop with the recognition that trauma can affect clients; instead, it encompasses a broader awareness that traumatic experiences as well as the impact of an individual's trauma can extend to significant others, family members, first responders and other medical professionals, behavioral health workers, broader social networks, and even entire communities. Family members frequently experience the traumatic stress reactions of the individual family member who was traumatized (e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or under reactions to stressful events). These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children (e.g., bullying others, problems in social relationships, health-damaging behaviors), increase children's risk for developing posttraumatic stress later in life, and lead to a greater propensity for traumatic stress reactions across generations of the family. Hence, prevention and intervention services can provide education and age-appropriate programming tailored to develop coping skills and support systems.

So too, behavioral health service providers can be influenced by exposure to trauma-related affect and content when working with clients. A trauma-aware workplace supports supervision and program practices that educate all direct service staff members on secondary trauma, encourages the processing of trauma-related content through participation in peer-supported activities and clinical supervision, and provides them with professional development opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symptoms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued supervisory and administrative support, collaborative (i.e., involving consumer participation) trauma-responsive program design and implementation, and organizational policies and practices that reflect accommodation and flexibility in attending to the needs of clients affected by trauma.

Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences

A trauma-informed perspective views trauma-related symptoms and behaviors as an individual's best and most resilient attempt to manage, cope with, and rise above his or her experience of trauma. Some individuals' means of adapting and coping have produced little difficulty; the coping and adaptive strategies of others have worked in the past but are not working as well now. Some people have difficulties in one area of life but have effectively negotiated and functioned in other areas.

Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions. Traumatic stress reactions vary in severity; they are often measured by the level of impairment or distress that clients report and are determined by the multiple factors that characterize the trauma itself, individual history and characteristics, developmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how individuals respond to the environment, relationships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness, fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in regulating emotions). The breadth of these effects may be observable or subtle.

Once you become aware of the significance of traumatic experiences in clients' lives and begin to view their presentation as adaptive, your identification and classification of their presenting symptoms and behaviors can shift from a "pathology" mindset (i.e., defining clients strictly from a diagnostic label, implying that something is wrong with them) to one of resilience-a mindset that views clients' presenting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reactions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination.

This will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retraumatization by not defining traumatic stress reactions as pathological or as symptoms of pathology.

View Trauma in the Context of Individuals' Environments

Many factors contribute to a person's response to trauma, whether it is an individual, group, or community-based trauma. Individual attributes, developmental factors (including protective and risk factors), life history, type of trauma, specific characteristics of the trauma, amount and length of trauma exposure, cultural meaning of traumatic events, number of losses associated with the trauma, available resources (internal and external, such as coping skills and family support), and community reactions are a few of the determinants that influence a person's responses to trauma across time. Refer to the " View Trauma Through a Sociocultural Lens " section later in this chapter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma.

Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens-a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preceding and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the traumatic event(s), which may include housing availability, community response, adherence to or maintenance of family routines and structure, and level of family support.

To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individual characteristics and effects to a broader systemic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. Bronfenbrenner's (1979) and Bronfenbrenner and Ceci's (1994) work on ecological models sparked the development of other contextual models. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treatment interventions ( Centers for Disease Control and Prevention, 2009). Here are the three main beliefs of a social-ecological approach ( Stokols, 1996):

Environmental factors greatly influence emotional, physical, and social well-being.

A fundamental determinant of health versus illness is the degree of fit between individuals' biological, behavioral, and sociocultural needs and the resources available to them.

Prevention, intervention, and treatment approaches integrate a combination of strategies targeting individual, interpersonal, and community systems.

This TIP uses a social-ecological model to explore trauma and its effects ( Exhibit 1.1-2). The focus of this model is not only on negative attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the impact of trauma. This model also guides the inclusion of certain targeted interventions in this text, including selective and indicated prevention activities. In addition, culture, developmental processes (including the developmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can significantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources.

Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community response. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a domestic dispute. She may fear losing her children or being arrested for child neglect. Even though a number of States have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades. Thus, the traumatic event's timing is a significant component in understanding the context of trauma and trauma-related responses.

The social-ecological model depicted in Exhibit 1.1-2 provides a systemic framework for looking at individuals, families, and communities affected by trauma in general; it highlights the bidirectional influence that multiple contexts can have on the provision of behavioral health services to people who have experienced trauma (see thin arrow). Each ring represents a different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The innermost ring represents the individual and his or her biopsychosocial characteristics. The "Interpersonal" circle embodies all immediate relationships including family, friends, peers, and others. The "Community/Organizational" band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The "Societal" circle signifies the largest system-State and Federal policies and laws, such as economic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, "Period of Time in History," reflects the significance of the period of time during which the event occurred; it influences each other level represented in the circle. For example, making a comparison of society's attitudes and responses to veterans' homecomings across different wars and conflicts through time shows that homecoming environments can have either a protective or a negative effect on healing from the psychological and physical wounds of war, depending on the era in question. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of prevention, intervention, and other treatment strategies; and ways of providing hope and promoting recovery.

Case Illustration: Marisol

Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy.

She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her employer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. The other driver was charged with driving under the influence (DUI), and it was reported that he had been convicted two other times for a DUI misdemeanor.

Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event:

Based on the limited information provided in this illustration, how might Marisol's personality affect the responses of her family and friends, her coworkers, and the larger community?

In what ways could Marisol's ethnic and cultural background influence her recovery?

What societal factors could play a role in the car crash itself and the outcomes for Marisol and the other driver?

Explore the influence of the period of time in history during which the scenario occurs-compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day.

Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience particular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing-feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. For instance, clients may express feelings of powerlessness or being trapped if they are not actively involved in treatment decisions; if treatment processes or providers mirror specific behavior from the clients' past experiences with trauma, they may voice distress or respond in the same way as they did to the original trauma. Among the potentially retraumatizing elements of treatment are seclusion or "time-out" practices that isolate individuals, mislabeling client symptoms as personality or other mental disorders rather than as traumatic stress reactions, interactions that command authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign in group that reflects one of their treatment issues, even if the assignment centers on positive attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon conformity to the provider's beliefs and definitions of issues.

Clients' experiences are unique to the specific traumas they have faced and the surrounding circumstances before, during, and after that trauma, so remember that even seemingly safe and standard treatment policies and procedures, including physical plant operations (e.g., maintenance, grounds, fire and safety procedures), may feel quite the contrary for a client if one or more of those elements is reminiscent of his or her experience of trauma in some way. Examples include having limited privacy or personal space, being interviewed in a room that feels too isolating or confining, undergoing physical examination by a medical professional of the same sex as the client's previous perpetrator of abuse, attending a group session in which another client expresses anger appropriately in a role play, or being directed not to talk about distressing experiences as a means of deescalating traumatic stress reactions.

Although some treatment policies or procedures are more obviously likely to solicit distress than others, all standard practices should be evaluated for their potential to retraumatize a client; this cannot be done without knowing the specific features of the individual's history of trauma. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. You may initially perceive your client's refusal to eat or to avoid certain foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse surrounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together).

Advice to Counselors and Administrators: Sending the Right Message About Trauma

How often have you heard "We aren't equipped to handle trauma" or "We don't have time to deal with reactions that surface if traumatic experiences are discussed in treatment" from counselors and administrators in behavioral health services? For agencies, staff members, and clients, these statements present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. A hands-off approach to trauma can also reinforce the client's own desire to avoid such discussions. Even when agencies and staff are motivated in these sentiments by a good intention-to contain clients' feelings of being overwhelmed-such a perspective sends strong messages to clients that their experiences are not important, that they are not capable of handling their trauma-associated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions.

Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intra-agency collaborations for trauma-specific services. By anticipating the need for trauma-informed services and planning ahead to provide appropriate services to people who are affected by trauma, behavioral health service providers and program administrators can begin to develop informed intervention strategies that send a powerful, positive message:

Both clients and providers can competently manage traumatic experiences and reactions.

Providers are interested in hearing clients' stories and attending to their experiences.

As a treatment provider, you cannot consistently predict what may or may not be upsetting or retraumatizing to clients. Therefore, it is important to maintain vigilance and an attitude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past.

Foremost, a trauma-informed approach begins with taking practical steps to reexamine treatment strategies, program procedures, and organizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the interplay between various treatment elements and the more idiosyncratic aspects of a particular client's trauma history, you can:

Work with the client to learn the cues he or she associates with past trauma.

Maintain a supportive, empathetic, and collaborative relationship.

Encourage ongoing dialog.

Provide a clear message of availability and accessibility throughout treatment.

In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to respond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment.

Create a Safe Environment

The need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and procedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety (e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and personal property), policies and procedures (including those specific to seclusion and restraint), emergency management and disaster planning, and adherence to client rights. Providers must be responsive and adapt the environment to establish and support clients' sense of physical and emotional safety.

Beyond anticipating that various environmental stimuli within a program may generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and implementing strategies to help clients cope with triggers that evoke their experiences with trauma, other key elements in establishing a safe environment include consistency in client interactions and treatment processes, following through with what has been reviewed or agreed upon in sessions or meetings, and dependability. Mike's case illustration depicts ways in which the absence of these key elements could erode a client's sense of safety during the treatment process.

Neither providers nor service processes are always perfect. Sometimes, providers unintentionally relay information inaccurately or inconsistently to clients or other staff members; other times, clients mishear something, or extenuating circumstances prevent providers from responding as promised. Creating safety is not about getting it right all the time; it's about how consistently and forthrightly you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate communication that conveys a sense of handling the situation together generates safety. It is equally important that safety extends beyond the client. Counselors and other behavioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well-being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients.

Case Illustration: Mike

From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or support if he has emotional difficulty after the session or after agency hours. However, when he attempts to call one night, no one is available despite what you've described. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable.

Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case consultation and supervision, formal or informal processes to debrief service providers about difficult clinical issues, and referral processes for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. Jane's case illustration shows the impact of a minor but necessary postponement in staff orientation for a new hire-not an unusual circumstance in behavioral health programs that have heavy caseloads and high staff turnover.

Identify Recovery From Trauma as a Primary Goal

Often, people who initiate or are receiving mental health or substance abuse services don't identify their experiences with trauma as a significant factor in their current challenges or problems. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may already feel stuck in repetitive memories or experiences, which may add to their existing belief that any intervention will make matters worse or, at least, no better. For some clients, any introduction to their trauma-related memories or minor cues reminiscent of the trauma will cause them to experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is dangerous and that they won't be able to handle the emotions or thoughts that result from attempting to do so. Others readily view their experiences of trauma as being in the past; as a result, they engage in distraction, dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on their current lives and presenting problems. Even individuals who are quite aware of the impact that trauma has had on their lives may still struggle to translate or connect how these events continue to shape their choices, behaviors, and emotions. Many survivors draw no connection between trauma and their mental health or substance abuse problems, which makes it more difficult for them to see the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in psychoeducation, enhancing coping skills, and so forth.

Case Illustration: Jane

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired her was short of workers at the time; therefore, Jane did not have an opportunity to engage sufficiently in orientation outside of reviewing the policies and procedure manual. In an attempt to present well to her new employer and supervisor, she readily accepted client assignments without considering her recent loss. By not immersing herself in the program's perspective and policies on staff well-being, ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer panic that they would attempt suicide.

As a trauma-informed provider, it is important that you help clients bridge the gap between their mental health and substance-related issues and the traumatic experiences they may have had. All too often, trauma occurs before substance use and mental disorders develop; then, such disorders and their associated symptoms and consequences create opportunities for additional traumatic events to occur. If individuals engage in mental health and substance abuse treatment without addressing the role that trauma has played in their lives, they are less likely to experience recovery in the long run. For example, a person with a history of trauma is more likely to have anxiety and depressive symptoms, use substances to self-medicate, and/or relapse after exposure to trauma-related cues. Thus, collaboration within and between behavioral health agencies is necessary to make integrated, timely, trauma-specific interventions available from the beginning to clients/consumers who engage in substance abuse and mental health services.

Support Control, Choice, and Autonomy

Not every client who has experienced trauma and is engaged in behavioral health services wants, or sees the need for, trauma-informed or trauma-specific treatment. Clients may think that they've already dealt with their trauma adequately, or they may believe that the effects of past trauma cause minimal distress for them. Other clients may voice the same sentiments, but without conviction-instead using avoidant behavior to deter distressing symptoms or reactions. Still others may struggle to see the role of trauma in their presenting challenges, not connecting their past traumatic experiences with other, more current difficulties (e.g., using substances to self-medicate strong emotions). Simply the idea of acknowledging trauma-related experiences and/or stress reactions may be too frightening or overwhelming for some clients, and others may fear that their reactions will be dismissed. On the other hand, some individuals want so much to dispense with their traumatic experiences and reactions that they hurriedly and repeatedly disclose their experiences before establishing a sufficiently safe environment or learning effective coping strategies to offset distress and other effects of retraumatization.

As these examples show, not everyone affected by trauma will approach trauma-informed services or recognize the impact of trauma in their lives in the same manner. This can be challenging to behavioral health service providers who are knowledgeable about the impact of trauma and who perceive the importance of addressing trauma and its effects with clients. As with knowing that different clients may be at different levels of awareness or stages of change in substance abuse treatment services, you should acknowledge that people affected by trauma present an array of reactions, various levels of trauma awareness, and different degrees of urgency in their need to address trauma.

Appreciating clients' perception of their presenting problems and viewing their responses to the impact of trauma as adaptive-even when you believe their methods of dealing with trauma to be detrimental-are equally important elements of TIC. By taking the time to engage with clients and understand the ways they have perceived, adjusted to, and responded to traumatic experiences, providers are more likely to project the message that clients possess valuable personal expertise and knowledge about their own presenting problems. This shifts the viewpoint from "Providers know best" to the more collaborative "Together, we can find solutions."

How often have you heard from clients that they don't believe they can handle symptoms that emerge from reexperiencing traumatic cues or memories? Have you ever heard clients state that they can't trust themselves or their reactions, or that they never know when they are going to be triggered or how they are going to react? How confident would you feel about yourself if, at any time, a loud noise could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences have traditionally been described as exposure to events that cause intense fear, helplessness, horror, or feelings of loss of control. Participation in behavioral health services should not mirror these aspects of traumatic experience. Working collaboratively to facilitate clients' sense of control and to maximize clients' autonomy and choices throughout the treatment process, including treatment planning, is crucial in trauma-informed services.

For some individuals, gaining a sense of control and empowerment, along with understanding traumatic stress reactions, may be pivotal ingredients for recovery. By creating opportunities for empowerment, counselors and other behavioral health service providers help reinforce, clients' sense of competence, which is often eroded by trauma and prolonged traumatic stress reactions. Keep in mind that treatment strategies and procedures that prioritize client choice and control need not focus solely on major life decisions or treatment planning; you can apply such approaches to common tasks and everyday interactions between staff and consumers. Try asking your clients some of the following questions (which are only a sample of the types of questions that could be useful):

What information would be helpful for us to know about what happened to you?

Where/when would you like us to call you?

How would you like to be addressed?

Of the services I've described, which seem to match your present concerns and needs?

From your experience, what responses from others appear to work best when you feel overwhelmed by your emotions?

Likewise, organizations need to reinforce the importance of staff autonomy, choice, and sense of control. What resources can staff members access, and what choices are available to them, in processing emotionally charged content or events in treatment? How often do administrators and supervisors seek out feedback on how to handle problematic situations (e.g., staff rotations for vacations, case consultations, changes in scheduling)? Think about the parallel between administration and staff members versus staff members and clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by administrative practices are mirrored in staff-client interactions. Simply stated, if staff members do not feel empowered, it will be a challenge for them to value the need for client empowerment. (For more information on administrative and workforce development issues, refer to Part 2, Chapters 1 and 2.)

Case Illustration: Mina

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, and codependency. When asked to define "codependency" and how the term applied to her, she responded that she always felt guilty and responsible for everyone in her family and for events that occurred even when she had little or no control over them.

After the intake and screening process, she expressed interest in attending group sessions that focused primarily on family issues and substance abuse, wherein her presenting concerns could be explored. In addition to describing dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she described as life changing: the loss of her father. The story began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambulance. She rode with the paramedics to the hospital, watching them work to save her father's life; however, he was pronounced dead soon after arrival.

She always felt that she never really said goodbye to her father. In group, she was asked what she would need to do or say to feel as if she had revisited that opportunity. She responded in quite a unique way, saying, "I can't really answer this question; the lighting isn't right for me to talk about my dad." The counselor encouraged her to adjust the lighting so that it felt "right" to her. Being invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye to her father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting as others in the group patiently waited for her to return to her chair. She then began to talk about what happened during the evening of her father's death, their relationship, the events leading up to that evening, what she had wanted to say to him at the hospital, and the things that she had been wanting to share with him since his death.

Weeks later, as the group was coming to a close, each member spoke about the most important experiences, tools, and insights that he or she had taken from participating. Mina disclosed that the group helped her establish boundaries and coping strategies within her marriage, but said that the event that made the most difference for her had been having the ability to adjust the lighting in the room. She explained that this had allowed her to control something over which she had been powerless during her father's death. To her, the lighting had seemed to stand out more than other details at the scene of the accident, during the ambulance ride, and at the hospital. She felt that the personal experience of losing her father and needing to be with him in the emergency room was marred by the obtrusiveness of staff, procedures, machines, and especially, the harsh lighting. She reflected that she now saw the lighting as a representation of this tragic event and the lack of privacy she had experienced when trying to say goodbye to her father. Mina stated that this moment in group had been the greatest gift: "...to be able to say my goodbyes the way I wanted... I was given an opportunity to have some control over a tragic event where I couldn't control the outcome no matter how hard I tried."

Create Collaborative Relationships and Participation Opportunities

This trauma-informed principle encompasses three main tenets. First, ensure that the provider-client relationship is collaborative, regardless of setting or service. Agency staff members cannot make decisions pertaining to interventions or involvement in community services autocratically; instead, they should develop trauma-informed, individualized care plans and/or treatment plans collaboratively with the client and, when appropriate, with family and caregivers. The nonauthoritarian approach that characterizes TIC views clients as the experts in their own lives and current struggles, thereby emphasizing that clients and providers can learn from each other.

The second tenet is to build collaboration beyond the provider-client relationship. Building ongoing relationships across the service system, provider networks, and the local community enhances TIC continuity as clients move from one level of service to the next or when they are involved in multiple services at one time. It also allows you to learn about resources available to your clients in the service system or community and to connect with providers who have more advanced training in trauma-specific interventions and services.

The third tenet emphasizes the need to ensure client/consumer representation and participation in behavioral health program development, planning, and evaluation as well as in the professional development of behavioral health workers. To achieve trauma-informed competence in an organization or across systems, clients need to play an active role; this starts with providing program feedback. However, consumer involvement should not end there; rather, it should be encouraged throughout the implementation of trauma-informed services. So too, clients, potential clients, their families, and the community should be invited to participate in forming any behavioral health organization's plans to improve trauma-informed competence, provide TIC, and design relevant treatment services and organizational policies and procedures.

Trauma-informed principles and practices generated without the input of people affected by trauma are difficult to apply effectively. Likewise, staff trainings and presentations should include individuals who have felt the impact of trauma. Their participation reaches past the purely cognitive aspects of such education to offer a personal perspective on the strengths and resilience of people who have experienced trauma. The involvement of trauma survivors in behavioral health education lends a human face to subject matter that is all too easily made cerebral by some staff members in an attempt to avoid the emotionality of the topic.

Consumer participation also means giving clients/consumers the chance to obtain State training and certification, as well as employment in behavioral health settings as peer specialists. Programs that incorporate peer support services reinforce a powerful message-that provider-consumer partnership is important, and that consumers are valued. Peer support specialists are self-identified individuals who have progressed in their own recovery from alcohol dependence, drug addiction, and/or a mental disorder and work within behavioral health programs or at peer support centers to assist others with similar disorders and/or life experiences. Tasks and responsibilities may include leading a peer support group; modeling effective coping, help-seeking, and self-care strategies; helping clients practice new skills or monitor progress; promoting positive self-image to combat clients' potentially negative feelings about themselves and the discrimination they may perceive in the program or community; handling case management tasks; advocating for program changes; and representing a voice of hope that views recovery as possible.

Familiarize the Client With Trauma-Informed Services

Without thinking too much about it, you probably know the purpose of an intake process, the correct way to complete a screening device, the meaning of a lot of the jargon specific to behavioral health, and your program's expectations for client participation; in fact, maybe you're already involved in facilitating these processes in behavioral health services every day, and they've become almost automatic for you. This can make it easy to forget that nearly everything clients and their families encounter in seeking behavioral health assistance is new to them. Thus, introducing clients to program services, activities, and interventions in a manner that expects them to be unfamiliar with these processes is essential, regardless of their clinical and treatment history. Beyond addressing the unfamiliarity of services, educating clients about each process-from first contact all the way through recovery services-gives them a chance to participate actively and make informed decisions across the continuum of care.

Familiarizing clients with trauma-informed services extends beyond explaining program services or treatment processes; it involves explaining the value and type of trauma-related questions that may be asked during an intake process, educating clients about trauma to help normalize traumatic stress reactions, and discussing trauma-specific interventions and other available services (including explanations of treatment methodologies and of the rationale behind specific interventions). Developmentally appropriate psychoeducation about trauma-informed services allows clients to be informed participants.

Incorporate Universal Routine Screenings for Trauma

Screening universally for client histories, experiences, and symptoms of trauma at intake can benefit clients and providers. Most providers know that clients can be affected by trauma, but universal screening provides a steady reminder to be watchful for past traumatic experiences and their potential influence upon a client's interactions and engagement with services across the continuum of care. Screening should guide treatment planning; it alerts the staff to potential issues and serves as a valuable tool to increase clients' awareness of the possible impact of trauma and the importance of addressing related issues during treatment.

Nonetheless, screenings are only as useful as the guidelines and processes established to address positive screens (which occur when clients respond to screening questions in a way that signifies possible trauma-related symptoms or histories). Staff should be trained to use screening tools consistently so that all clients are screened in the same way. Staff members also need to know how to score screenings and when specific variables (e.g., race/ethnicity, native language, gender, culture) may influence screening results. For example, a woman who has been sexually assaulted by a man may be wary of responding to questions if a male staff member or interpreter administers the screening or provides translation services. Likewise, a person in a current abusive or violent relationship may not acknowledge the interpersonal violence in fear of retaliation or as a result of disconnection or denial of his or her experience, and he or she may have difficulty in processing and then living between two worlds-what is acknowledged in treatment versus what is experienced at home.

In addition, staff training on using trauma-related screening tools needs to center on how and when to gather relevant information after the screening is complete. Organizational policies and procedures should guide staff members on how to respond to a positive screening, such as by making a referral for an indepth assessment of traumatic stress, providing the client with an introductory psychoeducational session on the typical biopsychosocial effects of trauma, and/or coordinating care so that the client gains access to trauma-specific services that meet his or her needs. Screening tool selection is an important ingredient in incorporating routine, universal screening practices into behavioral health services. Many screening tools are available, yet they differ in format and in how they present questions. Select tools based not just on sound test properties, but also according to whether they encompass a broad range of experiences typically considered traumatic and are flexible enough to allow for an individual's own interpretation of traumatic events. For more information on screening and assessment of trauma and trauma-related symptoms and effects, see Chapter 4, "Screening and Assessment," in this TIP.

View Trauma Through a Sociocultural Lens

To understand how trauma affects an individual, family, or community, you must first understand life experiences and cultural background as key contextual elements for that trauma. As demonstrated in Exhibit 1.1-2, many factors shape traumatic experiences and individual and community responses to it; one of the most significant factors is culture. It influences the interpretation and meaning of traumatic events, individual beliefs regarding personal responsibility for the trauma and subsequent responses, and the meaning and acceptability of symptoms, support, and help-seeking behaviors. As this TIP proceeds to describe the differences among cultures pertaining to trauma, remember that there are numerous cross-cutting factors that can directly or indirectly influence the attitudes, beliefs, behaviors, resources, and opportunities within a given culture, subculture, or racial and/or ethnic group ( Exhibit 1.1-4). For an indepth exploration of these cross-cutting cultural factors, refer to the planned TIP, Improving Cultural Competence (SAMHSA, planned c).

Culture and Trauma

Some populations and cultures are more likely than others to experience a traumatic event or a specific type of trauma.

Rates of traumatic stress are high across all diverse populations and cultures that face military action and political violence.

Culture influences not only whether certain events are perceived as traumatic, but also how an individual interprets and assigns meaning to the trauma.

Some traumas may have greater impact on a given culture because those traumas represent something significant for that culture or disrupt cultural practices or ways of life.

Culture determines acceptable responses to trauma and shapes the expression of distress. It significantly influences how people convey traumatic stress through behavior, emotions, and thinking immediately following a trauma and well after the traumatic experience has ceased.

Traumatic stress symptoms vary according to the type of trauma within the culture.

Culture affects what qualifies as a legitimate health concern and which symptoms warrant help.

In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing practices, culture can provide a source of strength, unique coping strategies, and specific resources.

When establishing TIC, it is vital that behavioral health systems, service providers, licensing agencies, and accrediting bodies build culturally responsive practices into their curricula, standards, policies and procedures, and credentialing processes. The implementation of culturally responsive practices will further guide the treatment planning process so that trauma-informed services are more appropriate and likely to succeed.

Use a Strengths-Focused Perspective: Promote Resilience

Fostering individual strengths is a key step in prevention when working with people who have been exposed to trauma. It is also an essential intervention strategy-one that builds on the individual's existing resources and views him or her as a resourceful, resilient survivor. Individuals who have experienced trauma develop many strategies and/or behaviors to adapt to its emotional, cognitive, spiritual, and physical consequences. Some behaviors may be effective across time, whereas others may eventually produce difficulties and disrupt the healing process. Traditionally, behavioral health services have tended to focus on presenting problems, risk factors, and symptoms in an attempt to prevent negative outcomes, provide relief, increase clients' level of functioning, and facilitate healing. However, focusing too much on these areas can undermine clients' sense of competence and hope. Targeting only presenting problems and symptoms does not provide individuals with an opportunity to see their own resourcefulness in managing very stressful and difficult experiences. It is important for providers to engage in interventions using a balanced approach that targets the strengths clients have developed to survive their experiences and to thrive in recovery. A strengths-based, resilience-minded approach lets trauma survivors begin to acknowledge and appreciate their fortitude and the behaviors that help them survive.

"Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context. Validating resilience is important even when past coping behaviors are now causing problems. Understanding a symptom as an adaptation reduces a survivor's guilt and shame, increases their self-esteem and provides a guideline for developing new skills and resources to allow new and better adaptation to the current situation."

( Elliot et al., 2005, p. 467)

Advice to Counselors and Administrators: Using Strengths-Oriented Questions

Knowing a client's strengths can help you understand, redefine, and reframe the client's presenting problems and challenges. By focusing and building on an individual's strengths, counselors and other behavioral health professionals can shift the focus from "What is wrong with you?" to "What has worked for you?" It moves attention away from trauma-related problems and toward a perspective that honors and uses adaptive behaviors and strengths to move clients along in recovery.

Potential strengths-oriented questions include:

The history that you provided suggests that you've accomplished a great deal since the trauma. What are some of the accomplishments that give you the most pride?

What would you say are your strengths?

How do you manage your stress today?

What behaviors have helped you survive your traumatic experiences (during and afterward)?

What are some of the creative ways that you deal with painful feelings?

You have survived trauma. What characteristics have helped you manage these experiences and the challenges that they have created in your life?

If we were to ask someone in your life, who knew your history and experience with trauma, to name two positive characteristics that help you survive, what would they be?

What coping tools have you learned from your _____ (fill in: cultural history, spiritual practices, athletic pursuits, etc.)?

Imagine for a moment that a group of people are standing behind you showing you support in some way. Who would be standing there? It doesn't matter how briefly or when they showed up in your life, or whether or not they are currently in your life or alive.

How do you gain support today? (Possible answers include family, friends, activities, coaches, counselors, other supports, etc.)

What does recovery look like for you?

Foster Trauma-Resistant Skills

Trauma-informed services build a foundation on which individuals can begin to explore the role of trauma in their lives; such services can also help determine how best to address and tailor interventions to meet their needs. Prevention, mental health, and substance abuse treatment services should include teaching clients about how trauma can affect their lives; these services should also focus on developing self-care skills, coping strategies, supportive networks, and a sense of competence. Building trauma-resistant skills begins with normalizing the symptoms of traumatic stress and helping clients who have experienced trauma connect the dots between current problems and past trauma when appropriate.

Nevertheless, TIC and trauma-specific interventions that focus on skill-building should not do so at the expense of acknowledging individual strengths, creativity in adapting to trauma, and inherent attributes and tools clients possesses to combat the effects of trauma. Some theoretical models that use skill-building strategies base the value of this approach on a deficit perspective; they assume that some individuals lack the necessary tools to manage specific situations and, because of this deficiency, they encounter problems that others with effective skills would not experience. This type of perspective further assumes that, to recover, these individuals must learn new coping skills and behavior. TIC, on the other hand, makes the assumption that clients are the experts in their own lives and have learned to adapt and acquire skills to survive. The TIC approach honors each individual's adaptations and acquired skills, and it helps clients explore how these may not be working as well as they had in the past and how their current repertoire of responses may not be as effective as other strategies.

Advice to Administrators: Self-Assessment for Trauma-Informed Systems

NCTIC has developed a self-assessment package for trauma-informed systems to help administrators structurally incorporate trauma into programs and services. The self-assessment can be used by systems of care to guide quality improvement with the goal of establishing fully trauma-informed treatment and recovery efforts (NCTIC, Center for Mental Health Services, 2007). Behavioral health treatment program administrators can use these materials and NCTIC as resources for improvement in delivering TIC.

Demonstrate Organizational and Administrative Commitment to TIC

Becoming a trauma-informed organization requires administrative guidance and support across all levels of an agency. Behavioral health staff will not likely sustain TIC practices without the organization's ongoing commitment to support professional development and to allocate resources that promote these practices. An agency that wishes to commit to TIC will benefit from an organizational assessment of how staff members identify and manage trauma and trauma-related reactions in their clients. Are they trauma aware-do they recognize that trauma can significantly affect a client's ability to function in one or more areas of his or her life? Do the staff members understand that traumatic experiences and trauma-related reactions can greatly influence clients' engagement, participation, and response to services?

Agencies need to embrace specific strategies across each level of the organization to create trauma-informed services; this begins with staff education on the impact of trauma among clients. Other agency strategies that reflect a trauma-informed infrastructure include, but are not limited to:

Universal screening and assessment procedures for trauma.

Interagency and intra-agency collaboration to secure trauma-specific services.

Referral agreements and networks to match clients' needs.

Mission and value statements endorsing the importance of trauma recognition.

Consumer- and community-supported committees and trauma response teams.

Workforce development strategies, including hiring practices.

Professional development plans, including staff training/supervision focused on TIC.

Program policies and procedures that ensure trauma recognition and secure trauma-informed practices, trauma-specific services, and prevention of retraumatization.

TIC requires organizational commitment, and often, cultural change. For more information on implementing TIC in organizations, see Part 2, Chapter 1 of this TIP.

Develop Strategies To Address Secondary Trauma and Promote Self-Care

Secondary trauma is a normal occupational hazard for mental health and substance abuse professionals, particularly those who serve populations that are likely to include survivors of trauma ( Figley, 1995; Klinic Community Health Centre, 2008). Behavioral health staff members who experience secondary trauma present a range of traumatic stress reactions and effects from providing services focused on trauma or listening to clients recount traumatic experiences. So too, when a counselor has a history of personal trauma, working with trauma survivors may evoke memories of the counselor's own trauma history, which may increase the potential for secondary traumatization.

The range of reactions that manifest with secondary trauma can be, but are not necessarily, similar to the reactions presented by clients who have experienced primary trauma. Symptoms of secondary trauma can produce varying levels of difficulty, impairment, or distress in daily functioning; these may or may not meet diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or mood disorders ( Bober & Regehr, 2006). Symptoms may include physical or psychological reactions to traumatic memories clients have shared; avoidance behaviors during client interactions or when recalling emotional content in supervision; numbness, limited emotional expression, or diminished affect; somatic complaints; heightened arousal, including insomnia; negative thinking or depressed mood; and detachment from family, friends, and other supports ( Maschi & Brown, 2010).

Working daily with individuals who have been traumatized can be a burden for counselors and other behavioral health service providers, but all too often, they blame the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2 decades have literature and trainings begun paying attention to secondary trauma or compassion fatigue; even so, agencies often do not translate this knowledge into routine prevention practices. Counselors and other staff members may find it difficult to engage in activities that could ward off secondary trauma due to time constraints, workload, lack of agency resources, and/or an organizational culture that disapproves of help-seeking or provides inadequate staff support. The demands of providing care to trauma survivors cannot be ignored, lest the provider become increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can cause harm to clients via poorly enforced boundaries, missed appointments, or even abandonment of clients and their needs ( Pearlman & Saakvitne, 1995).

Essential components of TIC include organizational and personal strategies to address secondary trauma and its physical, cognitive, emotional, and spiritual consequences. In agencies and among individual providers, it is key for the culture to promote acceptability, accessibility, and accountability in seeking help, accessing support and supervision, and engaging in self-care behaviors in and outside of the agency or office. Agencies should involve staff members who work with trauma in developing informal and formal agency practices and procedures to prevent or address secondary trauma. Even though a number of community-based agencies face fiscal constraints, prevention strategies for secondary trauma can be intertwined with the current infrastructure (e.g., staff meetings, education, case consultations and group case discussions, group support, debriefing sessions as appropriate, supervision). For more information on strategies to address and prevent secondary trauma, see Part 2, Chapter 2 of this TIP.

The Impact of Trauma

Trauma is similar to a rock hitting the water's surface. The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for individuals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. The caregiver may hold onto the trauma's known and unknown effects or may consciously decide to engage in behaviors that provide support to further dissipate the impact of this trauma and the risk of secondary trauma.

Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting Self-Care

Peer support. Maintaining adequate social support will help prevent isolation and depression.

Supervision and consultation. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively.

Training. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries.

Personal therapy. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients.

Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face.

Setting clear limits and boundaries with clients. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver.

Provide Hope-Recovery Is Possible

What defines recovery from trauma-related symptoms and traumatic stress disorders? Is it the total absence of symptoms or consequences? Does it mean that clients stop having nightmares or being reminded, by cues, of past trauma? When clients who have experienced trauma enter into a helping relationship to address trauma specifically, they are often looking for a cure, a remission of symptoms, or relief from the pain as quickly as possible. However, they often possess a history of unpredictable symptoms and symptom intensity that reinforces an underlying belief that recovery is not possible. On one hand, clients are looking for a message that they can be cured, while on the other hand, they have serious doubts about the likely success of any intervention.

Clients often express ambivalence about dealing with trauma even if they are fully aware of trauma's effects on their lives. The idea of living with more discomfort as they address the past or as they experiment with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing prospect, and it typically elicits fear. Clients may interpret the uncomfortable feelings as dangerous or unsafe even in an environment and relationship that is safe and supportive.

How do you promote hope and relay a message that recovery is possible? First, maintain consistency in delivering services, promoting and providing safety for clients, and showing respect and compassion within the client-provider relationship. Along with clients' commitment to learning how to create safety for themselves, counselors and agencies need to be aware of, and circumvent, practices that could retraumatize clients. Projecting hope and reinforcing the belief that recovery is possible extends well beyond the practice of establishing safety; it also encompasses discussing what recovery means and how it looks to clients, as well as identifying how they will know that they've entered into recovery in earnest.

Providing hope involves projecting an attitude that recovery is possible. This attitude also involves viewing clients as competent to make changes that will allow them to deal with trauma-related challenges, providing opportunities for them to practice dealing with difficult situations, and normalizing discomfort or difficult emotions and framing these as manageable rather than dangerous. If you convey this attitude consistently to your clients, they will begin to understand that discomfort is not a signal to avoid, but a sign to engage-and that behavioral, cognitive, and emotional responses to cues associated with previous traumas are a normal part of the recovery process. It's not the absence of responses to such triggers that mark recovery, but rather, how clients experience and manage those responses. Clients can also benefit from interacting with others who are further along in their recovery from trauma. Time spent with peer support staff or sharing stories with other trauma survivors who are well on their way to recovery is invaluable-it sends a powerful message that recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future beyond the trauma.

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether.

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The How We Feel Project is a non-profit working to help everyone better understand their own emotions.

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Trauma-Informed Approaches to Working with Children, Young People and Families

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Oasis Project and Make Good Trouble present: Trauma-Informed Practice: Working with Children/Young People and Families

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'Things aren't getting any better,' I whine miserably at the therapist. 'If anything, they're getting worse. I can't sleep. I'm in constant pain. I'm up and down and all over the place. I can't stay present. I can't see a way forwards. I can't stop the flashbacks. I can't cope. I just ... can't ... do it any more ...'

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'If I could just get over it, I would,' I say, and I'm trying not to sound irritated or hurt but I'm not quite sure what emotion my face is displaying and my throat is tight and my fists are clenched and really I'd rather not be here, and neither am I convinced that I'm a good enough actor to hide all of this.

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Shame. It's a familiar word and yet the more I think about it, the stranger it becomes. What does it mean? Where does it come from? How does it go? What is the point of it? Why does it even exist?
I'd never even considered it before therapy. It was just a run-of-the-mill emotion: one that I'd heard about, but never (so I thought) really experienced.

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'But if I accept that this is real, that this stuff really happened to me, then I don't think I'll be able to cope.'

The therapist looks at me as I splutter out my confession. I have used denial all my life to cope with my abuse. Now, a couple of years into therapy, I sit perched on the edge of a precipice. Will I free-fall into life without dissociation?

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'Christmas is optional!' I announce, loudly and excitedly and with an uncharacteristic degree of gusto, at the beginning of my session. We haven't even sat down yet. Mostly sessions begin with a tense stand-off as I battle within myself to be present.

The therapist's eyes widen. I can tell she's wondering if I've switched to another part. In particular I have one whom I call 'Play' who is larger-than-life and copes with social occasions for me. She is skilled at banter, although not so skilled at reading social cues and divining if its recipients are edified by it. But this isn't 'Play'. This - surprisingly - is me.

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I shrug helplessly because the words have dried up and suddenly I feel like I've stepped partway into Narnia, into a deep place of unreality in my head. Part of me is with her in the room. Part of me is somewhere else. I'm not sure which world to choose. I'm not sure if I can choose.

We're stuck because I'm perpetually in danger mode, convinced of her hatred of me.

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Like a slow leak, drip-drip-drip, things changed. Trauma leaves you with a brain dedicated to danger. Fear isn't a choice - it's an inbuilt survival mechanism. And I used to berate myself for it. What is wrong with you?! Get a grip! Just let it go! But my survival-based back brain wasn't listening. It's not safe here, it would whisper back at me. We're going to get hurt. When I heard it, I got annoyed: We're perfectly safe. There's nothing the matter. Stop overreacting!

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'You just need to forgive.'

I hang my head as shame courses through me again. I wish I hadn't said anything. I wish I hadn't asked for help. Because this is where it always lands: that it's my fault. I'm only traumatised, Irene says, because I haven't forgiven my abusers. If I would just forgive them, her theory goes, the flashbacks and dissociation would simply melt away.

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'You just need to forgive.'

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'Things aren't getting any better,' I whine miserably at the therapist. 'If anything, they're getting worse. I can't sleep. I'm in constant pain. I'm up and down and all over the place. I can't stay present. I can't see a way forwards. I can't stop the flashbacks. I can't cope.

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February 3, 2018

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Emergence is a service user-led organisation supporting all people affected by personality disorder including service users, carers, family and friends and professionals.

Many of you may be familiar with the work of Borderline UK and/or Personality Plus. In the summer of 2009 the board of directors of both organisations decided to merge to improve the valuable services, information, training and events.

By becoming one constituted organisation we also felt it would be easier for users, carers and professionals to join.

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February 3, 2018 No Comments Emergence is a service user-led organisation supporting all people affected by personality disorder including service users, carers, family and friends and professionals. Many of you may be familiar with the work of Borderline UK and/or Personality Plus.

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An introduction to using reflective practice in organisations of any size. This guidance includes practical case studies, as well as expert insight from Psychotherapy for Healthcare.

Downloads

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Trauma Informed Care and Psychologically Informed Environments

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An introduction to using reflective practice in organisations of any size. This guidance includes practical case studies, as well as expert insight from Psychotherapy for Healthcare. Downloads

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This webinar provides important information about how to assess clinical vulnerability in people experiencing homelessness.

It includes information about 'cohorting' individuals into different groups, based on need, and shares good practice on how non-clinical services can use this approach to manage resources effectively.

Recorded: Friday, 27 November 2020.

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This webinar provides important information about how to assess clinical vulnerability in people experiencing homelessness. It includes information about 'cohorting' individuals into different groups, based on need, and shares good practice on how non-clinical services can use this approach to manage resources effectively. Recorded: Friday, 27 November 2020.

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What is Trauma Informed Care?

Trauma Informed Care (TIC) is an approach that embraces an understanding of trauma at every step of service delivery. This model requires a compassionate and understanding attitude, in order to address the intersecting effects that trauma can have on people's lives. It seeks to create a culture of nonviolence, learning, and collaboration in all aspects of treatment, while also recognizing the physical, psychological and emotional importance of clients' and providers' safety.

Trauma Informed Care does not have to be directly focused on delivering trauma-related services or treatments. Rather, it is an approach that is incorporated into the structure of a variety of practices, including housing, primary care, mental health, and addictions services. The aim is to provide services in ways that are appropriate and welcoming for those who may have been affected by trauma.

While the effects of trauma frequently have an impact on services and organizations, trauma often goes undetected. Thus, interfering with their recovery and healing, individuals may be re-traumatized by the services and organizations that they interact with.

Many people experiencing homelessness have faced traumatic events, such as being exposed to violence, experiencing losses, and dealing with severed relationships. The experience of homelessness itself is traumatic, as it involves a lack of stability, a loss of safety and the disconnection from one's community at large.

Research has found that a large proportion of mothers ( 79%) who accessed emergency shelters, transitional housing and permanent supportive housing programs, experienced traumatic events during their childhoods. Most commonly, mothers reported past experiences of interpersonal violence, physical assaults, and sexual abuse. Many also met the criteria for Post Traumatic Stress Disorder (PTSD). Furthermore, intergenerational trauma affects Indigenous communities, which have been gravely impacted by colonial practices, such as: the destruction of Indigenous institutions, disruption of traditions (including Indigenous systems of governance), linguicide, and the implementation of the reserve system, to name a few. Interwoven in many Indigenous experiences of homelessness are the impacts of individual and community traumas, often leading to high levels of mental, cognitive, behavioural, social and physical challenges.

Trauma, depression and substance abuse tend to occur simultaneously, and also have the potential to impact the ability of mothers to form healthy relationships, work consistently and parent effectively.

The effects of trauma have serious health outcomes for individuals, families and communities, and services must recognize the role they play in creating supportive and welcoming environments. As there are many different types of trauma affecting people of all ages, and across all socioeconomic backgrounds in society, a trauma informed care approach should be an essential component for all services and organizations.

Solutions

Traditionally, responses to homelessness in Canada have placed a great deal of emphasis on emergency services, such as shelters and temporary housing. However, since the challenges that many people experiencing homelessness face are complex, the necessity for different approaches to address their needs have become clear. One example of this includes the integration of trauma informed care (TIC) practices into service delivery and housing programs.

Adopting a TIC approach as a service provider, organization or system involves:

In addition to providing permanent supportive housing for trauma survivors, individuals with serious mental illnesses (SMI) need programs that directly address their mental health needs. One suggestion involves the developmental assessment of children, and mental health assessments for all members of families. Mental health services that address the needs of both mothers and their children are a recommendation for trauma informed care approaches. As research has indicated the experiences of trauma in early childhood are different from trauma experienced later on in life, trauma informed care takes into account age-appropriate service delivery. For mothers, these services may include dealing with major depression and Post-traumatic Stress Disorder (PTSD). For children, services should include therapy or supportive services to address their learning and emotional needs, a safe and supportive environment, and the presence of continuous and nurturing caregivers.

Furthermore, case management should address both individual, short-term needs along with the long-term needs of clients. Some examples of short term needs include: income, education, and employment, whereas long-term needs may involve addressing histories of trauma, health/ mental health, and emotional difficulties.

It has also been suggested that organizations make a number of changes to their overall service delivery structure, in order to incorporate a Trauma Informed Care approach. Organizations should include written statements and policy implementation that express their commitment to delivering Trauma Informed Care, such as:

Overall, housing that quickly stabilizes families while also ensuring that the individual needs of those accessing services have better outcomes for the long-term stability of families; that includes taking the affordability of the placement into consideration.

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How can we incorporate Trauma Informed Care into service delivery?

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Trauma Informed Care (TIC) is an approach that embraces an understanding of trauma at every step of service delivery. This model requires a compassionate and understanding attitude, in order to address the intersecting effects that trauma can have on people's lives.

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Clinical supervision research FLSE 18.1.21

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People who are homeless often experience trauma, mental illness, and/or substance use problems. Recovery happens in relationships that help people move past these obstacles. These ten tips can help your agency create an environment that supports recovery.

1) Create a physical environment that is welcoming and safe, where different ways of expressing emotions are tolerated. Developing a welcoming environment does not necessarily require an expensive redesign. Try incorporating living, colorful, and beautiful items such as fish tanks and plants. When clients arrive, designate someone to greet them, sit with them in the waiting area, and familiarize them with the physical space.

2) Develop policies and procedures based on the assumption that people who are homeless have been impacted by trauma. By creating an atmosphere of openness and transparency, you can help clients to feel safe. For example, be open with clients about confidentiality practices. Also, review your program's eligibility criteria to be sure it is does not unnecessarily exclude clients from services. If eligibility criteria are barriers for some clients, assist them to make alternative arrangements to get the services they need. By minimizing barriers, you can support clients in their recovery and avoid retraumatization.

3) Review policies and procedures to ensure that they do not re-traumatize people. Procedures such as "night checks" are often important to ensure physical safety, but the sudden entry of someone with a flashlight can be startling and upsetting. Let clients know who will be coming in - and how often - and ask them about the least intrusive way for someone to enter their sleeping space.

4) Establish a wide-range of voluntary services and supports where consistent, caring relationships are offered and crisis prevention activities are ongoing. Offering a wide range of services gives clients the power of choice. The creation of individual safety and crisis prevention plans is a proactive approach to physical and emotional safety. Don't forget about the kids - develop services targeted to children, and work with caregivers to learn about their greatest parenting strengths and needs.

5) Support client involvement in all aspects of services: as volunteers, board members, advisory committee members and staff. By soliciting input and participation from clients, you are sending a message of partnership and recovery. Try interviewing clients about suggestions for improving policies and procedures. Make a commitment to hiring former clients, and creating visible peer support and leadership roles within your agency.

6) Create activities that help people to think about, talk about, and get support to make recovery-focused changes. Providing an opportunity for clients to access peer-to-peer support is important. Through peer support, clients can decrease isolation, foster accountability, and increase self-esteem. Peers can act as supportive liaisons in a variety of roles, including health care visits, accessing entitlements, filling out paperwork, and going to court.

7) Talk about the principles of trauma-informed care among staff and clients. You could also place trauma-specific educational material in highly visible areas for people to read, such as posters in hallways, bathrooms, bulletin boards, kitchens, etc. The more opportunities that staff have to learn and talk about trauma-informed care, the sooner it will become part of a common language in your agency.

8) Provide training for consumers and providers on trauma-informed care. Organize trainings about the relationship between trauma, mental health, physical health and substance use, and create opportunities for staff to attend off-site conferences and trainings. Teach staff how to identify triggers and respond in a trauma-sensitive way.

9) Develop newsletters, art, poems and other ways to highlight the possibility of recovery from trauma. Have consumers and staff contribute to these activities through writing, editing, drawing or painting. Creative and artistic activities don't only help people who are in the process of recovery - they can teach others about the journey as well.

10) Create surveys, focus groups and reports to document and move your agency towards more trauma-informed practices. These activities should be part of a broader action plan to make your agency trauma-informed. Identify gaps in services and ways to fill those gaps. Hold your team accountable at monthly, quarterly or bi-annual check-ins.

Source:
1) Prescott, L., Soares, P., Konnath, K., & Bassuk, E., (2008) A Long Journey Home: A Guide for Creating Trauma-Informed Services for Mothers and Children Experiencing Homelessness. Rockville, MD: Center for Mental Health Services Administration, U.S.

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10 Tips for Recovery-Oriented, Trauma-Informed Agencies

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People who are homeless often experience trauma, mental illness, and/or substance use problems. Recovery happens in relationships that help people move past these obstacles. These ten tips can help your agency create an environment that supports recovery. 1) Create a physical environment that is welcoming and safe, where different ways of expressing emotions are tolerated.

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Opening Doors: Trauma Informed Practice for the Workforce

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This animation was developed by NHS Education for Scotland, in partnership with the Scottish Government. It is designed to be relevant to all workers within the Scottish workforce. It aims to support workers to know how to adapt the way they work to make a positive difference to people affected by trauma and adversity. If you work with children and young people, consider also viewing “Sowing Seeds” https://vimeo.com/334642616  an animation created by  NHS Education for Scotland to support people to make a positive difference to the lives of children and young people affected by trauma. Trauma is everybody’s business.
A freely available workshop, Taking a Trauma Informed Lens to your Work: Opening Doors, can be accessed here: https://vimeo.com/411406138  This workshop guides you through how to use the animation to further support the strengthening and development of trauma informed practice within your own work and/or wider service/organisation.
For further information on the NTTP and all the available resources, please visit our website: https://www.traumatransformation.scot/

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether. Likewise, treatment providers may not ask questions that elicit a client's history of trauma, may feel unprepared to address trauma-related issues proactively, or may struggle to address traumatic stress effectively within the constraints of their treatment program, the program's clinical orientation, or their agency's directives.

By recognizing that traumatic experiences and their sequelae tie closely into behavioral health problems, front-line professionals and community-based programs can begin to build a trauma-informed environment across the continuum of care. Key steps include meeting client needs in a safe, collaborative, and compassionate manner; preventing treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services; building on the strengths and resilience of clients in the context of their environments and communities; and endorsing trauma-informed principles in agencies through support, consultation, and supervision of staff.

This Treatment Improvement Protocol (TIP) begins by introducing the scope, purpose, and organization of the topic and describing its intended audience. Along with defining trauma and trauma-informed care (TIC), the first chapter discusses the rationale for addressing trauma in behavioral health services and reviews trauma-informed intervention and treatment principles. These principles serve as the TIP's conceptual framework.

Before You Begin

This TIP endorses a trauma-informed model of care; this model emphasizes the need for behavioral health practitioners and organizations to recognize the prevalence and pervasive impact of trauma on the lives of the people they serve and develop trauma-sensitive or trauma-responsive services. This TIP provides key information to help behavioral health practitioners and program administrators become trauma aware and informed, improve screening and assessment processes, and implement science-informed intervention strategies across settings and modalities in behavioral health services. Whether provided by an agency or an individual provider, trauma-informed services may or may not include trauma-specific services or trauma specialists (individuals who have advanced training and education to provide specific treatment interventions to address traumatic stress reactions). Nonetheless, TIC anticipates the role that trauma can play across the continuum of care-establishing integrated and/or collaborative processes to address the needs of traumatized individuals and communities proactively.

Individuals who have experienced trauma are at an elevated risk for substance use disorders, including abuse and dependence; mental health problems (e.g., depression and anxiety symptoms or disorders, impairment in relational/social and other major life areas, other distressing symptoms); and physical disorders and conditions, such as sleep disorders. This TIP focuses on specific types of prevention ( Institute of Medicine et al., 2009): selective prevention, which targets people who are at risk for developing social, psychological, or other conditions as a result of trauma or who are at greater risk for experiencing trauma due to behavioral health disorders or conditions; and indicated prevention, which targets people who display early signs of trauma-related symptoms. This TIP identifies interventions, including trauma-informed and trauma-specific strategies, and perceives treatment as a means of prevention-building on resilience, developing safety and skills to negotiate the impact of trauma, and addressing mental and substance use disorders to enhance recovery.

This TIP's target population is adults. Beyond the context of family, this publication does not examine or address youth and adolescent responses to trauma, youth-tailored trauma-informed strategies, or trauma-specific interventions for youth or adolescents, because the developmental and contextual issues of these populations require specialized interventions. Providers who work with young clients who have experienced trauma should refer to the resource list in Appendix B. This TIP covers TIC, trauma characteristics, the impact of traumatic experiences, assessment, and interventions for persons who have had traumatic experiences. Considering the vast knowledge base and specificity of individual, repeated, and chronic forms of trauma, this TIP does not provide a comprehensive overview of the unique characteristics of each type of trauma (e.g., sexual abuse, torture, war-related trauma, murder). Instead, this TIP provides an overview supported by examples. For more information on several specific types of trauma, please refer to TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues ( Center for Substance Abuse Treatment [CSAT], 2000b), TIP 25, Substance Abuse Treatment and Domestic Violence ( CSAT, 1997b), TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d), and the planned TIP, Reintegration-Related Behavioral Health Issues in Veterans and Military Families (Substance Abuse and Mental Health Services Administration [SAMHSA], planned f).

This TIP, Trauma-Informed Care in Behavioral Health Services, is guided by SAMHSA's Strategic Initiatives described in Leading Change: A Plan for SAMHSA's Roles and Actions 2011- 2014 ( SAMHSA, 2011b). Specific to Strategic Initiative #2, Trauma and Justice, this TIP addresses several goals, objectives, and actions outlined in this initiative by providing behavioral health practitioners, supervisors, and administrators with an introduction to culturally responsive TIC.

Specifically, the TIP presents fundamental concepts that behavioral health service providers can use to:

Become trauma aware and knowledgeable about the impact and consequences of traumatic experiences for individuals, families, and communities.

Evaluate and initiate use of appropriate trauma-related screening and assessment tools.

Implement interventions from a collaborative, strengths-based approach, appreciating the resilience of trauma survivors.

Learn the core principles and practices that reflect TIC.

Anticipate the need for specific trauma-informed treatment planning strategies that support the individual's recovery.

Decrease the inadvertent retraumatization that can occur from implementing standard organizational policies, procedures, and interventions with individuals, including clients and staff, who have experienced trauma or are exposed to secondary trauma.

Evaluate and build a trauma-informed organization and workforce.

The consensus panelists, as well as other contributors to this TIP, have all had experience as substance abuse and mental health counselors, prevention and peer specialists, supervisors, clinical directors, researchers, or administrators working with individuals, families, and communities who have experienced trauma. The material presented in this TIP uses the wealth of their experience in addition to the available published resources and research relevant to this topic. Throughout the consensus process, the panel members were mindful of the strengths and resilience inherent in individuals, families, and communities affected by trauma and the challenges providers face in addressing trauma and implementing TIC.

What Is Trauma?

According to SAMHSA's Trauma and Justice Strategic Initiative, "trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being" ( SAMHSA, 2012, p. 2). Trauma can affect people of every race, ethnicity, age, sexual orientation, gender, psychosocial background, and geographic region. A traumatic experience can be a single event, a series of events, and/or a chronic condition (e.g., childhood neglect, domestic violence). Traumas can affect individuals, families, groups, communities, specific cultures, and generations. It generally overwhelms an individual's or community's resources to cope, and it often ignites the "fight, flight, or freeze" reaction at the time of the event(s). It frequently produces a sense of fear, vulnerability, and helplessness.

See Appendix C to read about the history of trauma and trauma interventions.

Often, traumatic events are unexpected. Individuals may experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. Events may be human-made, such as a mechanical error that causes a disaster, war, terrorism, sexual abuse, or violence, or they can be the products of nature (e.g., flooding, hurricanes, tornadoes). Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement).

It is not just the event itself that determines whether something is traumatic, but also the individual's experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual's immediate response and long-term reactions to trauma. For most, regardless of the severity of the trauma, the immediate or enduring effects of trauma are met with resilience-the ability to rise above the circumstances or to meet the challenges with fortitude.

For some people, reactions to a traumatic event are temporary, whereas others have prolonged reactions that move from acute symptoms to more severe, prolonged, or enduring mental health consequences (e.g., posttraumatic stress and other anxiety disorders, substance use and mood disorders) and medical problems (e.g., arthritis, headaches, chronic pain). Others do not meet established criteria for posttraumatic stress or other mental disorders but encounter significant trauma-related symptoms or culturally expressed symptoms of trauma (e.g., somatization, in which psychological stress is expressed through physical concerns). For that reason, even if an individual does not meet diagnostic criteria for trauma-related disorders, it is important to recognize that trauma may still affect his or her life in significant ways. For more information on traumatic events, trauma characteristics, traumatic stress reactions, and factors that heighten or decrease the impact of trauma, see Part 1, Chapter 2, "Trauma Awareness," and Part 1, Chapter 3, "Understanding the Impact of Trauma."

Trauma Matters in Behavioral Health Services

The past decade has seen an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance abuse are linked. With the attacks of September 11, 2001, and other acts of terror, the wars in Iraq and Afghanistan, disastrous hurricanes on the Gulf Coast, and sexual abuse scandals, trauma has moved to the forefront of national consciousness.

Trauma was once considered an abnormal experience. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general population of the United States. In the study, 61 percent of men and 51 percent of women reported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experiencing a life-threatening accident ranking as the most common events ( Kessler et al., 1999). In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported witnessing trauma, 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma ( El-Gabalawy, 2012). For a thorough review of the impact of trauma on quality of life and health and among individuals with mental and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Rationale for TIC

Integrating TIC into behavioral health services provides many benefits not only for clients, but also for their families and communities, for behavioral health service organizations, and for staff. Trauma-informed services bring to the forefront the belief that trauma can pervasively affect an individual's well-being, including physical and mental health. For behavioral health service providers, trauma-informed practice offers many opportunities. It reinforces the importance of acquiring trauma-specific knowledge and skills to meet the specific needs of clients; of recognizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health services; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. TIC stresses the importance of addressing the client individually rather than applying general treatment approaches.

TIC provides clients more opportunities to engage in services that reflect a compassionate perspective of their presenting problems. TIC can potentially provide a greater sense of safety for clients who have histories of trauma and a platform for preventing more serious consequences of traumatic stress ( Fallot & Harris, 2001). Although many individuals may not identify the need to connect with their histories, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in managing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms.

Two Influential Studies That Set the Stage for the Development of TIC

The Adverse Childhood Experiences Study ( Centers for Disease Control and Prevention, 2013) was a large epidemiological study involving more than 17,000 individuals from United States; it analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, healthcare costs, and life expectancy.

The Women, Co-Occurring Disorders and Violence Study ( SAMHSA, 2007) was a large multisite study focused on the role of interpersonal and other traumatic stressors among women; the interrelatedness of trauma, violence, and co-occurring substance use and mental disorders; and the incorporation of trauma-informed and trauma-specific principles, models, and services.

Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for retraumatization. The implementation may enhance communication between the client and treatment provider, thus decreasing risks associated with misunderstanding the client's reactions and presenting problems or underestimating the need for appropriate referrals for evaluation or trauma-specific treatment. Organizational investment in developing or improving trauma-informed services may also translate to cost effectiveness, in that services are more appropriately matched to clients from the outset. TIC is an essential ingredient in organizational risk management; it ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and, ultimately, the organization. A key principle is the engagement of community, clients, and staff. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services.

An organization also benefits from work development practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a trauma-informed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Trauma-informed organizations are invested in their staff and adopt similar trauma-informed principles, including establishing and providing ongoing support to promote TIC in practice and in addressing secondary trauma and implementing processes that reinforce the safety of the staff. Even though investing in a trauma-informed workforce does not necessarily guarantee trauma-informed practices, it is more likely that services will evolve more proficiently to meet client, staff, and community needs.

Advice to Counselors: The Importance of TIC

The history of trauma raises various clinical issues. Many counselors do not have extensive training in treating trauma or offering trauma-informed services and may be uncertain of how to respond to clients' trauma-related reactions or symptoms. Some counselors have experienced traumas themselves that may be triggered by clients' reports of trauma. Others are interested in helping clients with trauma but may unwittingly cause harm by moving too deeply or quickly into trauma material or by discounting or disregarding a client's report of trauma. Counselors must be aware of trauma-related symptoms and disorders and how they affect clients in behavioral health treatment.

Counselors with primary treatment responsibilities should also have an understanding of how to recognize trauma-related reactions, how to incorporate treatment interventions for trauma-related symptoms into clients' treatment plans, how to help clients build a safety net to prevent further trauma, how to conduct psychoeducational interventions, and when to make treatment referrals for further evaluations or trauma-specific treatment services. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. For example, helping a client in substance abuse treatment gain control over trauma-related symptoms can greatly improve the client's chances of substance abuse recovery and lower the possibility of relapse ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed.

Trauma and Substance Use Disorders

Many people who have substance use disorders have experienced trauma as children or adults ( Koenen, Stellman, Sommer, & Stellman, 2008; Ompad et al., 2005). Substance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the influence ( Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse ( Reynolds et al., 2005). In addition, people who abuse substances and have experienced trauma have worse treatment outcomes than those without histories of trauma ( Driessen et al., 2008; Najavits et al., 2007). Thus, the process of recovery is more difficult, and the counselor's role is more challenging, when clients have histories of trauma. A person presenting with both trauma and substance abuse issues can have a variety of other difficult life problems that commonly accompany these disorders, such as other psychological symptoms or mental disorders, poverty, homelessness, increased risk of HIV and other infections, and lack of social support ( Mills, Teesson, Ross, & Peters, 2006; Najavits, Weiss, & Shaw, 1997). Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas ( Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al., 1997), and a significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or posttraumatic stress disorder (PTSD; Falck, Wang, Siegal, & Carlson, 2004; Grant et al., 2004; Reynolds et al., 2005).

Trauma and Mental Disorders

People who are receiving treatment for severe mental disorders are more likely to have histories of trauma, including childhood physical and sexual abuse, serious accidents, homelessness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Many clients with severe mental disorders meet criteria for PTSD; others with serious mental illness who have histories of trauma present with psychological symptoms or mental disorders that are commonly associated with a history of trauma, including anxiety symptoms and disorders, mood disorders (e.g., major depression, dysthymia, bipolar disorder; Mueser et al., 2004), impulse control disorders, and substance use disorders ( Kessler, Chiu, Demler, & Walters, 2005).

Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of mental illness ( Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in perpetuating and exacerbating mental illness and suggest that trauma often precedes the development of mental disorders. As with trauma and substance use disorders, there is a bidirectional relationship; mental illness increases the risk of experiencing trauma, and trauma increases the risk of developing psychological symptoms and mental disorders. For a more comprehensive review of the interactions among traumatic stress, mental illness, and substance use disorders, refer to Part 3 of this TIP, the online literature review.

Trauma-Informed Intervention and Treatment Principles

TIC is an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health services from prevention through treatment. There are many definitions of TIC and various models for incorporating it across organizations, but a "trauma-informed approach incorporates three key elements: (1) realizing the prevalence of trauma; (2) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; and (3) responding by putting this knowledge into practice"( SAMHSA, 2012, p. 4).

TIC begins with the first contact a person has with an agency; it requires all staff members (e.g., receptionists, intake personnel, direct care staff, supervisors, administrators, peer supports, board members) to recognize that the individual's experience of trauma can greatly influence his or her receptivity to and engagement with services, interactions with staff and clients, and responsiveness to program guidelines, practices, and interventions. TIC includes program policies, procedures, and practices to protect the vulnerabilities of those who have experienced trauma and those who provide trauma-related services. TIC is created through a supportive environment and by redesigning organizational practices, with consumer participation, to prevent practices that could be retraumatizing ( Harris & Fallot, 2001c; Hopper et al., 2010). The ethical principle, "first, do no harm," resonates strongly in the application of TIC.

"A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings."

( SAMHSA, 2012, p. 4)

TIC involves a commitment to building competence among staff and establishing programmatic standards and clinical guidelines that support the delivery of trauma-sensitive services. It encompasses recruiting, hiring, and retaining competent staff; involving consumers, trauma survivors, and peer support specialists in the planning, implementation, and evaluation of trauma-informed services; developing collaborations across service systems to streamline referral processes, thereby securing trauma-specific services when appropriate; and building a continuity of TIC as consumers move from one system or service to the next. TIC involves reevaluating each service delivery component through a trauma-aware lens.

The principles described in the following subsections serve as the TIP's conceptual framework. These principles comprise a compilation of resources, including research, theoretical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost importance in working with people who have had traumatic experiences.

Advice to Counselors: Implementing Trauma-Informed Services

Recognizing that trauma affects a majority of clients served within public health systems, the National Center for Trauma-Informed Care (NCTIC) has sought to establish a comprehensive framework to guide systems of care in the development of trauma-informed services. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. NCTIC also offers technical assistance in the implementation of trauma-informed services. For specific administrative information on TIC implementation, refer to Part 2, Chapters 1 and 2, of this TIP.

Promote Trauma Awareness and Understanding

Foremost, a behavioral health service provider must recognize the prevalence of trauma and its possible role in an individual's emotional, behavioral, cognitive, spiritual, and/or physical development, presentation, and well-being. Being vigilant about the prevalence and potential consequences of traumatic events among clients allows counselors to tailor their presentation styles, theoretical approaches, and intervention strategies from the outset to plan for and be responsive to clients' specific needs. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have experienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you anticipate the possibility from your initial contact and interactions, intake processes, and screening and assessment procedures.

Even the most standard behavioral health practices can retraumatize an individual exposed to prior traumatic experiences if the provider implements them without recognizing or considering that they may do harm. For example, a counselor might develop a treatment plan recommending that a female client-who has been court mandated to substance abuse treatment and was raped as an adult-attend group therapy, but without considering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices.

Becoming trauma aware does not stop with the recognition that trauma can affect clients; instead, it encompasses a broader awareness that traumatic experiences as well as the impact of an individual's trauma can extend to significant others, family members, first responders and other medical professionals, behavioral health workers, broader social networks, and even entire communities. Family members frequently experience the traumatic stress reactions of the individual family member who was traumatized (e.g., angry outbursts, nightmares, avoidant behavior, other symptoms of anxiety, overreactions or under reactions to stressful events). These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children (e.g., bullying others, problems in social relationships, health-damaging behaviors), increase children's risk for developing posttraumatic stress later in life, and lead to a greater propensity for traumatic stress reactions across generations of the family. Hence, prevention and intervention services can provide education and age-appropriate programming tailored to develop coping skills and support systems.

So too, behavioral health service providers can be influenced by exposure to trauma-related affect and content when working with clients. A trauma-aware workplace supports supervision and program practices that educate all direct service staff members on secondary trauma, encourages the processing of trauma-related content through participation in peer-supported activities and clinical supervision, and provides them with professional development opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symptoms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued supervisory and administrative support, collaborative (i.e., involving consumer participation) trauma-responsive program design and implementation, and organizational policies and practices that reflect accommodation and flexibility in attending to the needs of clients affected by trauma.

Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences

A trauma-informed perspective views trauma-related symptoms and behaviors as an individual's best and most resilient attempt to manage, cope with, and rise above his or her experience of trauma. Some individuals' means of adapting and coping have produced little difficulty; the coping and adaptive strategies of others have worked in the past but are not working as well now. Some people have difficulties in one area of life but have effectively negotiated and functioned in other areas.

Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions. Traumatic stress reactions vary in severity; they are often measured by the level of impairment or distress that clients report and are determined by the multiple factors that characterize the trauma itself, individual history and characteristics, developmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how individuals respond to the environment, relationships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world (e.g., their view of others, sense of safety), their future (e.g., hopefulness, fear of a foreshortened future), and themselves (e.g., feeling resilient, feeling incompetent in regulating emotions). The breadth of these effects may be observable or subtle.

Once you become aware of the significance of traumatic experiences in clients' lives and begin to view their presentation as adaptive, your identification and classification of their presenting symptoms and behaviors can shift from a "pathology" mindset (i.e., defining clients strictly from a diagnostic label, implying that something is wrong with them) to one of resilience-a mindset that views clients' presenting difficulties, behaviors, and emotions as responses to surviving trauma. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reactions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination.

This will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retraumatization by not defining traumatic stress reactions as pathological or as symptoms of pathology.

View Trauma in the Context of Individuals' Environments

Many factors contribute to a person's response to trauma, whether it is an individual, group, or community-based trauma. Individual attributes, developmental factors (including protective and risk factors), life history, type of trauma, specific characteristics of the trauma, amount and length of trauma exposure, cultural meaning of traumatic events, number of losses associated with the trauma, available resources (internal and external, such as coping skills and family support), and community reactions are a few of the determinants that influence a person's responses to trauma across time. Refer to the " View Trauma Through a Sociocultural Lens " section later in this chapter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma.

Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens-a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preceding and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the traumatic event(s), which may include housing availability, community response, adherence to or maintenance of family routines and structure, and level of family support.

To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individual characteristics and effects to a broader systemic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. Bronfenbrenner's (1979) and Bronfenbrenner and Ceci's (1994) work on ecological models sparked the development of other contextual models. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treatment interventions ( Centers for Disease Control and Prevention, 2009). Here are the three main beliefs of a social-ecological approach ( Stokols, 1996):

Environmental factors greatly influence emotional, physical, and social well-being.

A fundamental determinant of health versus illness is the degree of fit between individuals' biological, behavioral, and sociocultural needs and the resources available to them.

Prevention, intervention, and treatment approaches integrate a combination of strategies targeting individual, interpersonal, and community systems.

This TIP uses a social-ecological model to explore trauma and its effects ( Exhibit 1.1-2). The focus of this model is not only on negative attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the impact of trauma. This model also guides the inclusion of certain targeted interventions in this text, including selective and indicated prevention activities. In addition, culture, developmental processes (including the developmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can significantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources.

Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community response. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a domestic dispute. She may fear losing her children or being arrested for child neglect. Even though a number of States have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades. Thus, the traumatic event's timing is a significant component in understanding the context of trauma and trauma-related responses.

The social-ecological model depicted in Exhibit 1.1-2 provides a systemic framework for looking at individuals, families, and communities affected by trauma in general; it highlights the bidirectional influence that multiple contexts can have on the provision of behavioral health services to people who have experienced trauma (see thin arrow). Each ring represents a different system (refer to Exhibit 1.1-3 for examples of specific factors within each system). The innermost ring represents the individual and his or her biopsychosocial characteristics. The "Interpersonal" circle embodies all immediate relationships including family, friends, peers, and others. The "Community/Organizational" band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The "Societal" circle signifies the largest system-State and Federal policies and laws, such as economic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, "Period of Time in History," reflects the significance of the period of time during which the event occurred; it influences each other level represented in the circle. For example, making a comparison of society's attitudes and responses to veterans' homecomings across different wars and conflicts through time shows that homecoming environments can have either a protective or a negative effect on healing from the psychological and physical wounds of war, depending on the era in question. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of prevention, intervention, and other treatment strategies; and ways of providing hope and promoting recovery.

Case Illustration: Marisol

Marisol is a 28-year-old Latina woman working as a barista at a local coffee shop. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. She sustained fractures to both legs. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy.

She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her employer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. The other driver was charged with driving under the influence (DUI), and it was reported that he had been convicted two other times for a DUI misdemeanor.

Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event:

Based on the limited information provided in this illustration, how might Marisol's personality affect the responses of her family and friends, her coworkers, and the larger community?

In what ways could Marisol's ethnic and cultural background influence her recovery?

What societal factors could play a role in the car crash itself and the outcomes for Marisol and the other driver?

Explore the influence of the period of time in history during which the scenario occurs-compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day.

Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics

Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience particular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing-feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. For instance, clients may express feelings of powerlessness or being trapped if they are not actively involved in treatment decisions; if treatment processes or providers mirror specific behavior from the clients' past experiences with trauma, they may voice distress or respond in the same way as they did to the original trauma. Among the potentially retraumatizing elements of treatment are seclusion or "time-out" practices that isolate individuals, mislabeling client symptoms as personality or other mental disorders rather than as traumatic stress reactions, interactions that command authority, treatment assignments that could humiliate clients (such as asking a client to wear a sign in group that reflects one of their treatment issues, even if the assignment centers on positive attributes of the client), confronting clients as resistant, or presenting treatment as conditional upon conformity to the provider's beliefs and definitions of issues.

Clients' experiences are unique to the specific traumas they have faced and the surrounding circumstances before, during, and after that trauma, so remember that even seemingly safe and standard treatment policies and procedures, including physical plant operations (e.g., maintenance, grounds, fire and safety procedures), may feel quite the contrary for a client if one or more of those elements is reminiscent of his or her experience of trauma in some way. Examples include having limited privacy or personal space, being interviewed in a room that feels too isolating or confining, undergoing physical examination by a medical professional of the same sex as the client's previous perpetrator of abuse, attending a group session in which another client expresses anger appropriately in a role play, or being directed not to talk about distressing experiences as a means of deescalating traumatic stress reactions.

Although some treatment policies or procedures are more obviously likely to solicit distress than others, all standard practices should be evaluated for their potential to retraumatize a client; this cannot be done without knowing the specific features of the individual's history of trauma. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. You may initially perceive your client's refusal to eat or to avoid certain foods as an eating disorder or a behavioral problem. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse surrounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together).

Advice to Counselors and Administrators: Sending the Right Message About Trauma

How often have you heard "We aren't equipped to handle trauma" or "We don't have time to deal with reactions that surface if traumatic experiences are discussed in treatment" from counselors and administrators in behavioral health services? For agencies, staff members, and clients, these statements present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. A hands-off approach to trauma can also reinforce the client's own desire to avoid such discussions. Even when agencies and staff are motivated in these sentiments by a good intention-to contain clients' feelings of being overwhelmed-such a perspective sends strong messages to clients that their experiences are not important, that they are not capable of handling their trauma-associated feelings, and that dealing with traumatic experiences is simply too dangerous. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions.

Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intra-agency collaborations for trauma-specific services. By anticipating the need for trauma-informed services and planning ahead to provide appropriate services to people who are affected by trauma, behavioral health service providers and program administrators can begin to develop informed intervention strategies that send a powerful, positive message:

Both clients and providers can competently manage traumatic experiences and reactions.

Providers are interested in hearing clients' stories and attending to their experiences.

As a treatment provider, you cannot consistently predict what may or may not be upsetting or retraumatizing to clients. Therefore, it is important to maintain vigilance and an attitude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past.

Foremost, a trauma-informed approach begins with taking practical steps to reexamine treatment strategies, program procedures, and organizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). To better anticipate the interplay between various treatment elements and the more idiosyncratic aspects of a particular client's trauma history, you can:

Work with the client to learn the cues he or she associates with past trauma.

Maintain a supportive, empathetic, and collaborative relationship.

Encourage ongoing dialog.

Provide a clear message of availability and accessibility throughout treatment.

In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to respond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment.

Create a Safe Environment

The need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and procedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety (e.g., facility, environmental, and space-related concerns), security (of staff members, clients, and personal property), policies and procedures (including those specific to seclusion and restraint), emergency management and disaster planning, and adherence to client rights. Providers must be responsive and adapt the environment to establish and support clients' sense of physical and emotional safety.

Beyond anticipating that various environmental stimuli within a program may generate strong emotions and reactions in a trauma survivor (e.g., triggers such as lighting, access to exits, seating arrangements, emotionality within a group, or visual or auditory stimuli) and implementing strategies to help clients cope with triggers that evoke their experiences with trauma, other key elements in establishing a safe environment include consistency in client interactions and treatment processes, following through with what has been reviewed or agreed upon in sessions or meetings, and dependability. Mike's case illustration depicts ways in which the absence of these key elements could erode a client's sense of safety during the treatment process.

Neither providers nor service processes are always perfect. Sometimes, providers unintentionally relay information inaccurately or inconsistently to clients or other staff members; other times, clients mishear something, or extenuating circumstances prevent providers from responding as promised. Creating safety is not about getting it right all the time; it's about how consistently and forthrightly you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate communication that conveys a sense of handling the situation together generates safety. It is equally important that safety extends beyond the client. Counselors and other behavioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well-being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients.

Case Illustration: Mike

From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or support if he has emotional difficulty after the session or after agency hours. However, when he attempts to call one night, no one is available despite what you've described. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable.

Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case consultation and supervision, formal or informal processes to debrief service providers about difficult clinical issues, and referral processes for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. Jane's case illustration shows the impact of a minor but necessary postponement in staff orientation for a new hire-not an unusual circumstance in behavioral health programs that have heavy caseloads and high staff turnover.

Identify Recovery From Trauma as a Primary Goal

Often, people who initiate or are receiving mental health or substance abuse services don't identify their experiences with trauma as a significant factor in their current challenges or problems. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it. They may already feel stuck in repetitive memories or experiences, which may add to their existing belief that any intervention will make matters worse or, at least, no better. For some clients, any introduction to their trauma-related memories or minor cues reminiscent of the trauma will cause them to experience strong, quick-to-surface emotions, supporting their belief that addressing trauma is dangerous and that they won't be able to handle the emotions or thoughts that result from attempting to do so. Others readily view their experiences of trauma as being in the past; as a result, they engage in distraction, dissociation, and/or avoidance (as well as adaptation) due to a belief that trauma has little impact on their current lives and presenting problems. Even individuals who are quite aware of the impact that trauma has had on their lives may still struggle to translate or connect how these events continue to shape their choices, behaviors, and emotions. Many survivors draw no connection between trauma and their mental health or substance abuse problems, which makes it more difficult for them to see the value of trauma-informed or trauma-specific interventions, such as creating safety, engaging in psychoeducation, enhancing coping skills, and so forth.

Case Illustration: Jane

Jane, a newly hired female counselor, had a nephew who took his own life. The program that hired her was short of workers at the time; therefore, Jane did not have an opportunity to engage sufficiently in orientation outside of reviewing the policies and procedure manual. In an attempt to present well to her new employer and supervisor, she readily accepted client assignments without considering her recent loss. By not immersing herself in the program's perspective and policies on staff well-being, ethical and clinical considerations in client assignments, and how and when to seek supervision, Jane failed to engage in the practices, heavily supported by the agency, that promoted safety for herself and her clients. Subsequently, she felt emotionally overwhelmed at work and would often abruptly request psychiatric evaluation for clients who expressed any feelings of hopelessness out of sheer panic that they would attempt suicide.

As a trauma-informed provider, it is important that you help clients bridge the gap between their mental health and substance-related issues and the traumatic experiences they may have had. All too often, trauma occurs before substance use and mental disorders develop; then, such disorders and their associated symptoms and consequences create opportunities for additional traumatic events to occur. If individuals engage in mental health and substance abuse treatment without addressing the role that trauma has played in their lives, they are less likely to experience recovery in the long run. For example, a person with a history of trauma is more likely to have anxiety and depressive symptoms, use substances to self-medicate, and/or relapse after exposure to trauma-related cues. Thus, collaboration within and between behavioral health agencies is necessary to make integrated, timely, trauma-specific interventions available from the beginning to clients/consumers who engage in substance abuse and mental health services.

Support Control, Choice, and Autonomy

Not every client who has experienced trauma and is engaged in behavioral health services wants, or sees the need for, trauma-informed or trauma-specific treatment. Clients may think that they've already dealt with their trauma adequately, or they may believe that the effects of past trauma cause minimal distress for them. Other clients may voice the same sentiments, but without conviction-instead using avoidant behavior to deter distressing symptoms or reactions. Still others may struggle to see the role of trauma in their presenting challenges, not connecting their past traumatic experiences with other, more current difficulties (e.g., using substances to self-medicate strong emotions). Simply the idea of acknowledging trauma-related experiences and/or stress reactions may be too frightening or overwhelming for some clients, and others may fear that their reactions will be dismissed. On the other hand, some individuals want so much to dispense with their traumatic experiences and reactions that they hurriedly and repeatedly disclose their experiences before establishing a sufficiently safe environment or learning effective coping strategies to offset distress and other effects of retraumatization.

As these examples show, not everyone affected by trauma will approach trauma-informed services or recognize the impact of trauma in their lives in the same manner. This can be challenging to behavioral health service providers who are knowledgeable about the impact of trauma and who perceive the importance of addressing trauma and its effects with clients. As with knowing that different clients may be at different levels of awareness or stages of change in substance abuse treatment services, you should acknowledge that people affected by trauma present an array of reactions, various levels of trauma awareness, and different degrees of urgency in their need to address trauma.

Appreciating clients' perception of their presenting problems and viewing their responses to the impact of trauma as adaptive-even when you believe their methods of dealing with trauma to be detrimental-are equally important elements of TIC. By taking the time to engage with clients and understand the ways they have perceived, adjusted to, and responded to traumatic experiences, providers are more likely to project the message that clients possess valuable personal expertise and knowledge about their own presenting problems. This shifts the viewpoint from "Providers know best" to the more collaborative "Together, we can find solutions."

How often have you heard from clients that they don't believe they can handle symptoms that emerge from reexperiencing traumatic cues or memories? Have you ever heard clients state that they can't trust themselves or their reactions, or that they never know when they are going to be triggered or how they are going to react? How confident would you feel about yourself if, at any time, a loud noise could initiate an immediate attempt to hide, duck, or dive behind something? Traumatic experiences have traditionally been described as exposure to events that cause intense fear, helplessness, horror, or feelings of loss of control. Participation in behavioral health services should not mirror these aspects of traumatic experience. Working collaboratively to facilitate clients' sense of control and to maximize clients' autonomy and choices throughout the treatment process, including treatment planning, is crucial in trauma-informed services.

For some individuals, gaining a sense of control and empowerment, along with understanding traumatic stress reactions, may be pivotal ingredients for recovery. By creating opportunities for empowerment, counselors and other behavioral health service providers help reinforce, clients' sense of competence, which is often eroded by trauma and prolonged traumatic stress reactions. Keep in mind that treatment strategies and procedures that prioritize client choice and control need not focus solely on major life decisions or treatment planning; you can apply such approaches to common tasks and everyday interactions between staff and consumers. Try asking your clients some of the following questions (which are only a sample of the types of questions that could be useful):

What information would be helpful for us to know about what happened to you?

Where/when would you like us to call you?

How would you like to be addressed?

Of the services I've described, which seem to match your present concerns and needs?

From your experience, what responses from others appear to work best when you feel overwhelmed by your emotions?

Likewise, organizations need to reinforce the importance of staff autonomy, choice, and sense of control. What resources can staff members access, and what choices are available to them, in processing emotionally charged content or events in treatment? How often do administrators and supervisors seek out feedback on how to handle problematic situations (e.g., staff rotations for vacations, case consultations, changes in scheduling)? Think about the parallel between administration and staff members versus staff members and clients; often, the same philosophy, attitudes, and behaviors conveyed to staff members by administrative practices are mirrored in staff-client interactions. Simply stated, if staff members do not feel empowered, it will be a challenge for them to value the need for client empowerment. (For more information on administrative and workforce development issues, refer to Part 2, Chapters 1 and 2.)

Case Illustration: Mina

Mina initially sought counseling after her husband was admitted to an intensive outpatient drug and alcohol program. She was self-referred for low-grade depression, resentment toward her spouse, and codependency. When asked to define "codependency" and how the term applied to her, she responded that she always felt guilty and responsible for everyone in her family and for events that occurred even when she had little or no control over them.

After the intake and screening process, she expressed interest in attending group sessions that focused primarily on family issues and substance abuse, wherein her presenting concerns could be explored. In addition to describing dynamics and issues relating to substance abuse and its impact on her marriage, she referred to her low mood as frozen grief. During treatment, she reluctantly began to talk about an event that she described as life changing: the loss of her father. The story began to unfold in group; her father, who had been 62 years old, was driving her to visit a cousin. During the ride, he had a heart attack and drove off the road. As the car came to stop in a field, she remembered calling 911 and beginning cardiopulmonary resuscitation while waiting for the ambulance. She rode with the paramedics to the hospital, watching them work to save her father's life; however, he was pronounced dead soon after arrival.

She always felt that she never really said goodbye to her father. In group, she was asked what she would need to do or say to feel as if she had revisited that opportunity. She responded in quite a unique way, saying, "I can't really answer this question; the lighting isn't right for me to talk about my dad." The counselor encouraged her to adjust the lighting so that it felt "right" to her. Being invited to do so turned out to be pivotal in her ability to address her loss and to say goodbye to her father on her terms. She spent nearly 10 minutes moving the dimmer switch for the lighting as others in the group patiently waited for her to return to her chair. She then began to talk about what happened during the evening of her father's death, their relationship, the events leading up to that evening, what she had wanted to say to him at the hospital, and the things that she had been wanting to share with him since his death.

Weeks later, as the group was coming to a close, each member spoke about the most important experiences, tools, and insights that he or she had taken from participating. Mina disclosed that the group helped her establish boundaries and coping strategies within her marriage, but said that the event that made the most difference for her had been having the ability to adjust the lighting in the room. She explained that this had allowed her to control something over which she had been powerless during her father's death. To her, the lighting had seemed to stand out more than other details at the scene of the accident, during the ambulance ride, and at the hospital. She felt that the personal experience of losing her father and needing to be with him in the emergency room was marred by the obtrusiveness of staff, procedures, machines, and especially, the harsh lighting. She reflected that she now saw the lighting as a representation of this tragic event and the lack of privacy she had experienced when trying to say goodbye to her father. Mina stated that this moment in group had been the greatest gift: "...to be able to say my goodbyes the way I wanted... I was given an opportunity to have some control over a tragic event where I couldn't control the outcome no matter how hard I tried."

Create Collaborative Relationships and Participation Opportunities

This trauma-informed principle encompasses three main tenets. First, ensure that the provider-client relationship is collaborative, regardless of setting or service. Agency staff members cannot make decisions pertaining to interventions or involvement in community services autocratically; instead, they should develop trauma-informed, individualized care plans and/or treatment plans collaboratively with the client and, when appropriate, with family and caregivers. The nonauthoritarian approach that characterizes TIC views clients as the experts in their own lives and current struggles, thereby emphasizing that clients and providers can learn from each other.

The second tenet is to build collaboration beyond the provider-client relationship. Building ongoing relationships across the service system, provider networks, and the local community enhances TIC continuity as clients move from one level of service to the next or when they are involved in multiple services at one time. It also allows you to learn about resources available to your clients in the service system or community and to connect with providers who have more advanced training in trauma-specific interventions and services.

The third tenet emphasizes the need to ensure client/consumer representation and participation in behavioral health program development, planning, and evaluation as well as in the professional development of behavioral health workers. To achieve trauma-informed competence in an organization or across systems, clients need to play an active role; this starts with providing program feedback. However, consumer involvement should not end there; rather, it should be encouraged throughout the implementation of trauma-informed services. So too, clients, potential clients, their families, and the community should be invited to participate in forming any behavioral health organization's plans to improve trauma-informed competence, provide TIC, and design relevant treatment services and organizational policies and procedures.

Trauma-informed principles and practices generated without the input of people affected by trauma are difficult to apply effectively. Likewise, staff trainings and presentations should include individuals who have felt the impact of trauma. Their participation reaches past the purely cognitive aspects of such education to offer a personal perspective on the strengths and resilience of people who have experienced trauma. The involvement of trauma survivors in behavioral health education lends a human face to subject matter that is all too easily made cerebral by some staff members in an attempt to avoid the emotionality of the topic.

Consumer participation also means giving clients/consumers the chance to obtain State training and certification, as well as employment in behavioral health settings as peer specialists. Programs that incorporate peer support services reinforce a powerful message-that provider-consumer partnership is important, and that consumers are valued. Peer support specialists are self-identified individuals who have progressed in their own recovery from alcohol dependence, drug addiction, and/or a mental disorder and work within behavioral health programs or at peer support centers to assist others with similar disorders and/or life experiences. Tasks and responsibilities may include leading a peer support group; modeling effective coping, help-seeking, and self-care strategies; helping clients practice new skills or monitor progress; promoting positive self-image to combat clients' potentially negative feelings about themselves and the discrimination they may perceive in the program or community; handling case management tasks; advocating for program changes; and representing a voice of hope that views recovery as possible.

Familiarize the Client With Trauma-Informed Services

Without thinking too much about it, you probably know the purpose of an intake process, the correct way to complete a screening device, the meaning of a lot of the jargon specific to behavioral health, and your program's expectations for client participation; in fact, maybe you're already involved in facilitating these processes in behavioral health services every day, and they've become almost automatic for you. This can make it easy to forget that nearly everything clients and their families encounter in seeking behavioral health assistance is new to them. Thus, introducing clients to program services, activities, and interventions in a manner that expects them to be unfamiliar with these processes is essential, regardless of their clinical and treatment history. Beyond addressing the unfamiliarity of services, educating clients about each process-from first contact all the way through recovery services-gives them a chance to participate actively and make informed decisions across the continuum of care.

Familiarizing clients with trauma-informed services extends beyond explaining program services or treatment processes; it involves explaining the value and type of trauma-related questions that may be asked during an intake process, educating clients about trauma to help normalize traumatic stress reactions, and discussing trauma-specific interventions and other available services (including explanations of treatment methodologies and of the rationale behind specific interventions). Developmentally appropriate psychoeducation about trauma-informed services allows clients to be informed participants.

Incorporate Universal Routine Screenings for Trauma

Screening universally for client histories, experiences, and symptoms of trauma at intake can benefit clients and providers. Most providers know that clients can be affected by trauma, but universal screening provides a steady reminder to be watchful for past traumatic experiences and their potential influence upon a client's interactions and engagement with services across the continuum of care. Screening should guide treatment planning; it alerts the staff to potential issues and serves as a valuable tool to increase clients' awareness of the possible impact of trauma and the importance of addressing related issues during treatment.

Nonetheless, screenings are only as useful as the guidelines and processes established to address positive screens (which occur when clients respond to screening questions in a way that signifies possible trauma-related symptoms or histories). Staff should be trained to use screening tools consistently so that all clients are screened in the same way. Staff members also need to know how to score screenings and when specific variables (e.g., race/ethnicity, native language, gender, culture) may influence screening results. For example, a woman who has been sexually assaulted by a man may be wary of responding to questions if a male staff member or interpreter administers the screening or provides translation services. Likewise, a person in a current abusive or violent relationship may not acknowledge the interpersonal violence in fear of retaliation or as a result of disconnection or denial of his or her experience, and he or she may have difficulty in processing and then living between two worlds-what is acknowledged in treatment versus what is experienced at home.

In addition, staff training on using trauma-related screening tools needs to center on how and when to gather relevant information after the screening is complete. Organizational policies and procedures should guide staff members on how to respond to a positive screening, such as by making a referral for an indepth assessment of traumatic stress, providing the client with an introductory psychoeducational session on the typical biopsychosocial effects of trauma, and/or coordinating care so that the client gains access to trauma-specific services that meet his or her needs. Screening tool selection is an important ingredient in incorporating routine, universal screening practices into behavioral health services. Many screening tools are available, yet they differ in format and in how they present questions. Select tools based not just on sound test properties, but also according to whether they encompass a broad range of experiences typically considered traumatic and are flexible enough to allow for an individual's own interpretation of traumatic events. For more information on screening and assessment of trauma and trauma-related symptoms and effects, see Chapter 4, "Screening and Assessment," in this TIP.

View Trauma Through a Sociocultural Lens

To understand how trauma affects an individual, family, or community, you must first understand life experiences and cultural background as key contextual elements for that trauma. As demonstrated in Exhibit 1.1-2, many factors shape traumatic experiences and individual and community responses to it; one of the most significant factors is culture. It influences the interpretation and meaning of traumatic events, individual beliefs regarding personal responsibility for the trauma and subsequent responses, and the meaning and acceptability of symptoms, support, and help-seeking behaviors. As this TIP proceeds to describe the differences among cultures pertaining to trauma, remember that there are numerous cross-cutting factors that can directly or indirectly influence the attitudes, beliefs, behaviors, resources, and opportunities within a given culture, subculture, or racial and/or ethnic group ( Exhibit 1.1-4). For an indepth exploration of these cross-cutting cultural factors, refer to the planned TIP, Improving Cultural Competence (SAMHSA, planned c).

Culture and Trauma

Some populations and cultures are more likely than others to experience a traumatic event or a specific type of trauma.

Rates of traumatic stress are high across all diverse populations and cultures that face military action and political violence.

Culture influences not only whether certain events are perceived as traumatic, but also how an individual interprets and assigns meaning to the trauma.

Some traumas may have greater impact on a given culture because those traumas represent something significant for that culture or disrupt cultural practices or ways of life.

Culture determines acceptable responses to trauma and shapes the expression of distress. It significantly influences how people convey traumatic stress through behavior, emotions, and thinking immediately following a trauma and well after the traumatic experience has ceased.

Traumatic stress symptoms vary according to the type of trauma within the culture.

Culture affects what qualifies as a legitimate health concern and which symptoms warrant help.

In addition to shaping beliefs about acceptable forms of help-seeking behavior and healing practices, culture can provide a source of strength, unique coping strategies, and specific resources.

When establishing TIC, it is vital that behavioral health systems, service providers, licensing agencies, and accrediting bodies build culturally responsive practices into their curricula, standards, policies and procedures, and credentialing processes. The implementation of culturally responsive practices will further guide the treatment planning process so that trauma-informed services are more appropriate and likely to succeed.

Use a Strengths-Focused Perspective: Promote Resilience

Fostering individual strengths is a key step in prevention when working with people who have been exposed to trauma. It is also an essential intervention strategy-one that builds on the individual's existing resources and views him or her as a resourceful, resilient survivor. Individuals who have experienced trauma develop many strategies and/or behaviors to adapt to its emotional, cognitive, spiritual, and physical consequences. Some behaviors may be effective across time, whereas others may eventually produce difficulties and disrupt the healing process. Traditionally, behavioral health services have tended to focus on presenting problems, risk factors, and symptoms in an attempt to prevent negative outcomes, provide relief, increase clients' level of functioning, and facilitate healing. However, focusing too much on these areas can undermine clients' sense of competence and hope. Targeting only presenting problems and symptoms does not provide individuals with an opportunity to see their own resourcefulness in managing very stressful and difficult experiences. It is important for providers to engage in interventions using a balanced approach that targets the strengths clients have developed to survive their experiences and to thrive in recovery. A strengths-based, resilience-minded approach lets trauma survivors begin to acknowledge and appreciate their fortitude and the behaviors that help them survive.

"Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context. Validating resilience is important even when past coping behaviors are now causing problems. Understanding a symptom as an adaptation reduces a survivor's guilt and shame, increases their self-esteem and provides a guideline for developing new skills and resources to allow new and better adaptation to the current situation."

( Elliot et al., 2005, p. 467)

Advice to Counselors and Administrators: Using Strengths-Oriented Questions

Knowing a client's strengths can help you understand, redefine, and reframe the client's presenting problems and challenges. By focusing and building on an individual's strengths, counselors and other behavioral health professionals can shift the focus from "What is wrong with you?" to "What has worked for you?" It moves attention away from trauma-related problems and toward a perspective that honors and uses adaptive behaviors and strengths to move clients along in recovery.

Potential strengths-oriented questions include:

The history that you provided suggests that you've accomplished a great deal since the trauma. What are some of the accomplishments that give you the most pride?

What would you say are your strengths?

How do you manage your stress today?

What behaviors have helped you survive your traumatic experiences (during and afterward)?

What are some of the creative ways that you deal with painful feelings?

You have survived trauma. What characteristics have helped you manage these experiences and the challenges that they have created in your life?

If we were to ask someone in your life, who knew your history and experience with trauma, to name two positive characteristics that help you survive, what would they be?

What coping tools have you learned from your _____ (fill in: cultural history, spiritual practices, athletic pursuits, etc.)?

Imagine for a moment that a group of people are standing behind you showing you support in some way. Who would be standing there? It doesn't matter how briefly or when they showed up in your life, or whether or not they are currently in your life or alive.

How do you gain support today? (Possible answers include family, friends, activities, coaches, counselors, other supports, etc.)

What does recovery look like for you?

Foster Trauma-Resistant Skills

Trauma-informed services build a foundation on which individuals can begin to explore the role of trauma in their lives; such services can also help determine how best to address and tailor interventions to meet their needs. Prevention, mental health, and substance abuse treatment services should include teaching clients about how trauma can affect their lives; these services should also focus on developing self-care skills, coping strategies, supportive networks, and a sense of competence. Building trauma-resistant skills begins with normalizing the symptoms of traumatic stress and helping clients who have experienced trauma connect the dots between current problems and past trauma when appropriate.

Nevertheless, TIC and trauma-specific interventions that focus on skill-building should not do so at the expense of acknowledging individual strengths, creativity in adapting to trauma, and inherent attributes and tools clients possesses to combat the effects of trauma. Some theoretical models that use skill-building strategies base the value of this approach on a deficit perspective; they assume that some individuals lack the necessary tools to manage specific situations and, because of this deficiency, they encounter problems that others with effective skills would not experience. This type of perspective further assumes that, to recover, these individuals must learn new coping skills and behavior. TIC, on the other hand, makes the assumption that clients are the experts in their own lives and have learned to adapt and acquire skills to survive. The TIC approach honors each individual's adaptations and acquired skills, and it helps clients explore how these may not be working as well as they had in the past and how their current repertoire of responses may not be as effective as other strategies.

Advice to Administrators: Self-Assessment for Trauma-Informed Systems

NCTIC has developed a self-assessment package for trauma-informed systems to help administrators structurally incorporate trauma into programs and services. The self-assessment can be used by systems of care to guide quality improvement with the goal of establishing fully trauma-informed treatment and recovery efforts (NCTIC, Center for Mental Health Services, 2007). Behavioral health treatment program administrators can use these materials and NCTIC as resources for improvement in delivering TIC.

Demonstrate Organizational and Administrative Commitment to TIC

Becoming a trauma-informed organization requires administrative guidance and support across all levels of an agency. Behavioral health staff will not likely sustain TIC practices without the organization's ongoing commitment to support professional development and to allocate resources that promote these practices. An agency that wishes to commit to TIC will benefit from an organizational assessment of how staff members identify and manage trauma and trauma-related reactions in their clients. Are they trauma aware-do they recognize that trauma can significantly affect a client's ability to function in one or more areas of his or her life? Do the staff members understand that traumatic experiences and trauma-related reactions can greatly influence clients' engagement, participation, and response to services?

Agencies need to embrace specific strategies across each level of the organization to create trauma-informed services; this begins with staff education on the impact of trauma among clients. Other agency strategies that reflect a trauma-informed infrastructure include, but are not limited to:

Universal screening and assessment procedures for trauma.

Interagency and intra-agency collaboration to secure trauma-specific services.

Referral agreements and networks to match clients' needs.

Mission and value statements endorsing the importance of trauma recognition.

Consumer- and community-supported committees and trauma response teams.

Workforce development strategies, including hiring practices.

Professional development plans, including staff training/supervision focused on TIC.

Program policies and procedures that ensure trauma recognition and secure trauma-informed practices, trauma-specific services, and prevention of retraumatization.

TIC requires organizational commitment, and often, cultural change. For more information on implementing TIC in organizations, see Part 2, Chapter 1 of this TIP.

Develop Strategies To Address Secondary Trauma and Promote Self-Care

Secondary trauma is a normal occupational hazard for mental health and substance abuse professionals, particularly those who serve populations that are likely to include survivors of trauma ( Figley, 1995; Klinic Community Health Centre, 2008). Behavioral health staff members who experience secondary trauma present a range of traumatic stress reactions and effects from providing services focused on trauma or listening to clients recount traumatic experiences. So too, when a counselor has a history of personal trauma, working with trauma survivors may evoke memories of the counselor's own trauma history, which may increase the potential for secondary traumatization.

The range of reactions that manifest with secondary trauma can be, but are not necessarily, similar to the reactions presented by clients who have experienced primary trauma. Symptoms of secondary trauma can produce varying levels of difficulty, impairment, or distress in daily functioning; these may or may not meet diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or mood disorders ( Bober & Regehr, 2006). Symptoms may include physical or psychological reactions to traumatic memories clients have shared; avoidance behaviors during client interactions or when recalling emotional content in supervision; numbness, limited emotional expression, or diminished affect; somatic complaints; heightened arousal, including insomnia; negative thinking or depressed mood; and detachment from family, friends, and other supports ( Maschi & Brown, 2010).

Working daily with individuals who have been traumatized can be a burden for counselors and other behavioral health service providers, but all too often, they blame the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2 decades have literature and trainings begun paying attention to secondary trauma or compassion fatigue; even so, agencies often do not translate this knowledge into routine prevention practices. Counselors and other staff members may find it difficult to engage in activities that could ward off secondary trauma due to time constraints, workload, lack of agency resources, and/or an organizational culture that disapproves of help-seeking or provides inadequate staff support. The demands of providing care to trauma survivors cannot be ignored, lest the provider become increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can cause harm to clients via poorly enforced boundaries, missed appointments, or even abandonment of clients and their needs ( Pearlman & Saakvitne, 1995).

Essential components of TIC include organizational and personal strategies to address secondary trauma and its physical, cognitive, emotional, and spiritual consequences. In agencies and among individual providers, it is key for the culture to promote acceptability, accessibility, and accountability in seeking help, accessing support and supervision, and engaging in self-care behaviors in and outside of the agency or office. Agencies should involve staff members who work with trauma in developing informal and formal agency practices and procedures to prevent or address secondary trauma. Even though a number of community-based agencies face fiscal constraints, prevention strategies for secondary trauma can be intertwined with the current infrastructure (e.g., staff meetings, education, case consultations and group case discussions, group support, debriefing sessions as appropriate, supervision). For more information on strategies to address and prevent secondary trauma, see Part 2, Chapter 2 of this TIP.

The Impact of Trauma

Trauma is similar to a rock hitting the water's surface. The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its impact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for individuals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. The caregiver may hold onto the trauma's known and unknown effects or may consciously decide to engage in behaviors that provide support to further dissipate the impact of this trauma and the risk of secondary trauma.

Advice to Counselors: Decreasing the Risk of Secondary Trauma and Promoting Self-Care

Peer support. Maintaining adequate social support will help prevent isolation and depression.

Supervision and consultation. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively.

Training. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries.

Personal therapy. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients.

Maintaining balance. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face.

Setting clear limits and boundaries with clients. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver.

Provide Hope-Recovery Is Possible

What defines recovery from trauma-related symptoms and traumatic stress disorders? Is it the total absence of symptoms or consequences? Does it mean that clients stop having nightmares or being reminded, by cues, of past trauma? When clients who have experienced trauma enter into a helping relationship to address trauma specifically, they are often looking for a cure, a remission of symptoms, or relief from the pain as quickly as possible. However, they often possess a history of unpredictable symptoms and symptom intensity that reinforces an underlying belief that recovery is not possible. On one hand, clients are looking for a message that they can be cured, while on the other hand, they have serious doubts about the likely success of any intervention.

Clients often express ambivalence about dealing with trauma even if they are fully aware of trauma's effects on their lives. The idea of living with more discomfort as they address the past or as they experiment with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing prospect, and it typically elicits fear. Clients may interpret the uncomfortable feelings as dangerous or unsafe even in an environment and relationship that is safe and supportive.

How do you promote hope and relay a message that recovery is possible? First, maintain consistency in delivering services, promoting and providing safety for clients, and showing respect and compassion within the client-provider relationship. Along with clients' commitment to learning how to create safety for themselves, counselors and agencies need to be aware of, and circumvent, practices that could retraumatize clients. Projecting hope and reinforcing the belief that recovery is possible extends well beyond the practice of establishing safety; it also encompasses discussing what recovery means and how it looks to clients, as well as identifying how they will know that they've entered into recovery in earnest.

Providing hope involves projecting an attitude that recovery is possible. This attitude also involves viewing clients as competent to make changes that will allow them to deal with trauma-related challenges, providing opportunities for them to practice dealing with difficult situations, and normalizing discomfort or difficult emotions and framing these as manageable rather than dangerous. If you convey this attitude consistently to your clients, they will begin to understand that discomfort is not a signal to avoid, but a sign to engage-and that behavioral, cognitive, and emotional responses to cues associated with previous traumas are a normal part of the recovery process. It's not the absence of responses to such triggers that mark recovery, but rather, how clients experience and manage those responses. Clients can also benefit from interacting with others who are further along in their recovery from trauma. Time spent with peer support staff or sharing stories with other trauma survivors who are well on their way to recovery is invaluable-it sends a powerful message that recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future beyond the trauma.

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Many individuals who seek treatment in behavioral health settings have histories of trauma, but they often don't recognize the significant effects of trauma in their lives; either they don't draw connections between their trauma histories and their presenting problems, or they avoid the topic altogether.

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Creating a Psychologically Informed Environment - 2015

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Hi Everyone,

Emma Roberts from the UK gives us an in-depth look at trauma and many ways to provide relief with EFT. A must read for professionals and serious students.

Hugs, Gary

By Emma Roberts

Trauma comes in all shapes and sizes, as does people's response to it. EFT can be used successfully with all of them but this is one area where it may be appropriate to work with a qualified practitioner, at least initially. The primary concern when working with trauma is your safety or the safety of your client. This is paramount as re-traumatising and abreaction are to be avoided at all costs.

Trauma influences our cognitive schemas at a profound level. It undermines our beliefs in both ourselves and our existence, and also our sense of reality as we know it. The resulting beliefs can seriously disrupt the every day running of our lives without us necessarily even realising it.

EFT's effectiveness in working with trauma is extensive. Whilst it can bring immediate relief from traumatic memories, it is also a gentle tool for revealing the many layers and aspects that may be connected with trauma, working through them systematically and effectively until their emotional charge has gone.

In this article I will look at the different manifestations of trauma and the options for working with them using EFT.
Self Care for Therapists
Before beginning to work with trauma it is vital to look at ourselves as therapists and our own response to trauma in its many forms.

The first step is to work on any unresolved trauma we may still be attached to so that we are not triggered by our clients' experiences. The difference between empathising and colluding with the client needs emphasising. Whilst it is important to feel empathy for the client it is not useful for them if we are accessing our own stuff and we will be getting in the way of the process. As Gary often says, allow the work to be through you not by you. We must be a clear channel in order to fully serve our clients and get maximum results.

Test drive your trauma 'buttons' by imagining different future possible scenarios and/or past events and noticing what, if anything, still gets an emotional response.... Apply EFT to it.

Also recognise that you are human and things can sneak up on you and surprise you. You are likely to hear some horrific stories. If this happens during a client session imagine putting it out of the room, or in a box, remembering to return and work with it at the earliest opportunity. If you are tapping alongside your client you may clear your response during the session anyway.

Using EFT yourself on a regular basis is even more important in trauma work than most areas. Trauma therapists traditionally experience a high level of burnout. EFT gives us the opportunity to change that and be of even more powerful use. Walk your talk!

Trauma can be broadly broken down into four categories:

1) Prolonged past traumatic experiences

Systematic abuse over a prolonged period of time that is over in the present day eg childhood abuse, bullying, war experience etc
2) Ongoing trauma
Systematic abuse continuing today where client is constantly re-traumatised eg domestic violence and marital rape, psychological abuse, bullying at work etc.
3) One-off trauma
Rape, terrorist attack, accident, assault etc
4) Perceived trauma
Trauma not physically experienced by the client but witnessed in a secondary manner via the media, friends, colleagues, stories etc
The Presenting Client
Some clients will need to tell you their story immediately. When they do their energy system will be disrupting massively and you will need to tap continually on them. In order to do this and keep rapport with a new client it is important to preframe this when introducing yourself and your work. I recommend tapping on your clients wherever possible for the following two main reasons:

1) By connecting two energy systems physically the effects can be doubly powerful.

2) It allows the client to focus on their issue without worrying about 'getting the tapping wrong'. Whilst this can be a useful way of unearthing core beliefs, such as not being good enough, I don't consider it to be initially helpful in the context of trauma, rather another door to be returned to when they are in a more comfortable place.

Other clients will present with physical issues such as insomnia, migraines or even cancer where they make no connection to any previous traumatic events. However, when an event happens that challenges our beliefs of the world, and our personal safety, it can create a physiological response as well as an emotional one. In these cases, always start with where the client is at, using your detective skills and careful questioning to gently ease out any specific events that may be contributing to the current state.

Others will have totally detached themselves from the traumatic event/s, they will be unable to access any emotion, and often just present with a general feeling of depression or anxiety. In these cases again you will need to apply all your detective skills to coax out the underlying specific emotional contributors and events.

The following set up statements can be useful here:

Even though I have all these problems I deeply and completely accept myself
Even though life is grim I deeply and completely accept myself
Even though things can only get worse I deeply and completely accept myself
Even though I feel bad and am not sure why I deeply and completely accept myself
Here, Gary's question 'If you could live your life again which person or event would you leave out?' is an excellent way of getting to the specific core issue.

Another client group will be aware of the trauma but anxious about even thinking about it, let alone talking about it. With these clients the first thing to do is, again, to meet them where they are at and work with the presenting anxiety. Some of the following set-up statements can be useful here:
Even though I don't want to go back there again I deeply and completely accept myself
Even though I am anxious even thinking about the event I deeply and completely accept myself
Even though I am frightened to look at that time again I deeply and completely accept myself. Post Traumatic Stress Disorder (PTSD)
PTSD can be caused by one event or by prolonged exposure to traumatic experiences, such as war (see Gary's dvds The EFT Course, Part 1, Video 3, 6 Days at the VA). Sufferers of PTSD store the memories of past events in their minds as thought they are happening today, they replay them through flashbacks, hyper- vigilance, nightmares, jumpiness and other physiological symptoms. They may also have removed themselves from normal life, as the world is seen as unsafe, making them detach and withdraw both from becoming involved both physically and emotionally.
Methods for working with Trauma Tearless Trauma
This is a very gentle way of using double dissociation to keep the client safe from abreaction and is usually the best starting point when working with a specific traumatic event.

Identify a specific traumatic incident from the past. An example might be, "the time my father punched me when I was 12." By contrast, the phrase "my father abused me" would be too broad because, chances are, the abuse took place over many, many incidents.

Get them to make it into a mini movie and put it on a wall away from them

Give it a title.

Ask them to GUESS at what their emotional intensity would be (on a 0-10 scale) IF they were to vividly watch the movie. Instruct them NOT to actually watch it (although some will close their eyes and do this anyway). ThisGUESS is a surprisingly useful estimate...and...it serves to minimize emotional pain.

Have the client develop a phrase using the movie title for the EFT process such as "this father-punch emotion" and then proceed with a round of tapping.

After this round of tapping, ask the client to GUESS again around ask them to state their new number.

Perform more rounds of EFT (numbers. In my experience, a total of 3 or 4 rounds will bring just about everyone down to GUESSES of 0 to 3.

Once the client is down to acceptably low GUESSES, then perform another round of tapping and, after this round, ask them how they would feel about watching the movie. Notice that this is the first time you are asking them to do this. All previous times have been relatively painless GUESSES.

If they are OK with that get them to watch the movie, instructing them to stop at any part that still 'gets' them and tap on it.

Keep going until they are able to watch their whole movie with no emotional attachment. Often they will say something like 'It is like watching someone else' or 'I cant see it clearly any more'.

In Brief:

Locate specific trauma

Make it into a movie and put it on the wall away from you

What is it's title?

Don't look at it, draw a curtain over it

Estimate 0 - 10 intensity if you were to watch it (guess)

Create Reminder Phrase using movie title for the EFT process

Do EFT on it

Guess at the intensity again

Do more EFT rounds until 'guessed' intensity is low

Watch the movie, stopping at any part that still 'gets you'

More rounds of EFT as necessary

The Movie Technique
This is the same principle as Tearless Trauma only without the double dissociation. If the trauma is not perceived as too intense then this would be a safe starting place too.

Create a mini movie of the specific event

How intense do they feel about watching it (using SUDS scale 0 -10)

If high intensity rating revert to Tearless Trauma above

If OK run movie, stopping at any point where there is emotional intensity and tap

Keep going until whole movie is clear of any emotional intensity

Telling the Story
Telling The Story is an excellent way of testing your results and clearing up any remaining undetected aspects. Ideally, use this once you feel you have reduced the intensity to an acceptable level, or cleared it completely. However, sometimes you will need to use it immediately, as detailed above.

Have your client tell their story of the event/memory/trigger.

As soon as any emotional disturbance is detected stop and tap on the last statement the client made.

Test by having the client re-tell that part of the story. They should be able to go past the previous emotional point easily. If not, there are further aspects to be addressed.

When the client is calm on the first point, have them continue to tell the story. Stop and tap on each emotional disturbance.

Test by asking your client to tell the entire story from start to finish. Your work is completed when your client can do this and remain calm throughout.

The Tsunami Technique
In these days of mass disasters, natural or otherwise, we thought you might be interested in an EFT phenomena which came to the fore during Sue Beer and I's recent trauma workshop at The EFT Centre, London.

The workshop was for a small group of Level 2 and 3 EFT practitioners and focussed more on working with clients than self application. However, we wanted to give them an experience of Tearless Trauma so they would know how it would be for a client.

Thinking that the most contained way of doing this as a teaching example would be to go for a group experience, we asked them to each pick a specific memory/image/photograph from the Tsunami that still 'got' them now. We knew that no one had had any direct experience of the Tsunami. Most of them had a problem even finding this memory.

We did a group tap on these 'Tsunami emotions' and it quickly became apparent that each and every one of them had associated into something completely unrelated to the Tsunami. It seemed that when the slight Tsunami emotion had cleared other powerful, seemingly unconnected emotions and past events surfaced.

Whilst this in itself is not particularly unusual with EFT, it did come as a surprise in this environment. It revealed new aspects of earlier specific traumas that they thought they had cleared, and in a couple of cases specific events were recalled that had hitherto been repressed.

Obviously we then had to take a detour from the course content and help them clear these issues - swiftly achieved.

Again, none of the above may be a surprise, and although unexpected, all the responses were easy to clear and some important work was done. However, these were an unusual group in that they were all dedicated EFT practitioners who had worked consistently through their own issues and who were using EFT on an ongoing basis daily and considered they had cleared the big trees from their emotional forests.

We now use the 'Tsunami technique' with some clients who seem stuck as a way to facilitate unearthing underlying trauma, where there doesn't seem to be an obvious door to go through and it ALWAYS gets results. In a seemingly roundabout way, something good and positive has emerged from the appalling events of that Boxing Day.

Check no direct emotional involvement with Tsunami

Pick Tsunami memory/image/photograph

Put it on screen, behind a curtain (as in Tearless Trauma)

Tap on this 'Tsunami emotion'

Keep tuned into client and monitor emotional response

What does it remind you of?

Tap on whatever comes up, following the chain until emotions are fully resolved

Test results with both the emergent specific event and also original memory

Imagination Technique
I sometimes introduce this as a game, and it can be particularly useful when working with children.

Sometimes people may only have a sense of having experienced trauma. This can be to do with the age at which the trauma occurred, if it was pre-verbal and stored in pre verbal memory, and how much is stored cognitively. In cases where there is no actual memory, just a physical sense of something having happened, or a knowledge that it did, but no memory, get the client to 'make it up'. It is not important whether it is true or not, what is important is the resultant limiting behaviours and beliefs that are showing up today. Imagining and guessing in the west is what the east call sixth sense... it comes from somewhere, trust it and go with it, it is often an important door.

However, be careful to never ever suggest trauma or abuse has occurred and to frame the Imagination Technique as a game, and not the truth.

To conclude, EFT is an exciting new tool in working with Trauma. It allows the client to get immediate relief from traumatic experiences and gently opens the door to revealing and clearing the multiple layers of aspects and beliefs which may be present in a pain free, systematic manner. Trauma can be experienced at many different levels and there is no fixed formula for specific trauma groups. However, as a general rule, the higher the intensity the more the need to dissociate the client, using the Movie Technique or Tearless Trauma. For unfeeling clients, the Tsunami and Imagination Techniques are useful.

In order to achieve maximum results when working with clients it is important to keep more flexible than your clients, and whilst the above techniques provide a valuable framework within which to work, allow your creativity to flow and your intuition to guide you!

Emma Roberts

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A Detailed and Masterful Article on Using EFT for Trauma

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loadposition article-preamble} Hi Everyone, Emma Roberts from the UK gives us an in-depth look at trauma and many ways to provide relief with EFT. A must read for professionals and serious students. Hugs, Gary By Emma Roberts Trauma comes in all sha...

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Traditional psychotherapy addresses the cognitive and emotional elements of trauma, but lacks techniques that work directly with the physiological elements, despite the fact that trauma profoundly affects the body and many symptoms of traumatized individuals are somatically based.

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https://www.oneinfour.org.uk/

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University of Kentucky Center on Trauma and Children

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What is Trauma? Psychoeducation for Kids!

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Short and long-term impacts

Trauma can have both short-term and long-term impacts on children and young people.

In the short term, experiencing trauma causes individuals to have a stress response. Usually, a child or young person's brain and nervous system work together to help them make sense of incoming information from their senses like sight and sound. When they experience trauma, chemicals (like adrenaline) rush around a child or young person's body, affecting signals between brain and nervous system.

Having a stress response after trauma might make it harder for individuals to:

process information

remember things

concentrate

manage their feelings.

It may also take children and young people who've experienced trauma a long time to calm down after having a stress response.

Long-term, trauma can affect children and young people in lots of different ways that aren't always obvious.

Sometimes things like sights, sounds, smells and movements that remind children and young people of trauma can trigger stress responses again, even if the actual event happened a long time ago. Repeated trauma reactions can be embedded in the brain architecture, meaning that traumatised children and young people are more likely to experience frequent stress responses, even when there's no threat or danger.

It can be difficult for others, such as educators, to understand what's upsetting to a child or young person when they don't know what the trigger is.

Often, a child or young person doesn't understand what made them react in such a way as the response is an instinctual and involuntary response (like fight, flight or freeze) and isn't within their conscious control. Adults can help children and young people understand and manage their feelings if they work with them over time to try and understand what situations, interactions or stimulus seems to set these responses off. For example, a child or young person might often get very distressed when alarms go off or if they feel cornered.

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How trauma affects children and young people - Be You

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Trauma can have both short-term and long-term impacts on children and young people. In the short term, experiencing trauma causes individuals to have a stress response. Usually, a child or young person's brain and nervous system work together to help them make sense of incoming information from their senses like sight and sound.

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TF-CBT Telehealth Resources - Trauma-Focused Cognitive Behavioral Therapy

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Brief MUSC TF-CBT telehealth webinar (English and Spanish): https://www.dropbox.com/sh/acesnn37l9afb6p/AAAiREKk8eX32rY8axEgZ6Q0a?dl=0 with accompanying slides from the webinar (download here) Telehealth Guide from MUSC (download here) Article on Telemental Health Guidelines for providing TF-CBT (download here) Pilot study of TF-CBT via Telehealth (download here) 3-hour video webinar on Implementing TF-CBT via Telehealth (see below) Word Versions of TF-CBT...

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Adolescent Trauma Training Center (USC-ATTC)

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Download PDF versions of the treatment guides: Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) Treatment Guide, 2nd Edition Treating Substance Use Issues in Traumatized Adolescents and Young Adults: Key Principles and Components Using ITCT-A to Treat Self-injury in Traumatized Youth Increasing Mindfulness and Metacognitive Awareness in Multitraumatized Adolescents: An

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When We Are Scared by Chandra Ghosh Ippen

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Pooky Ponders - Big Questions with Brilliant People

Why do some kids misbehave? | Meic Griffiths

Today's question is "Why do some kids misbehave?" and I'm in conversation with Meic Griffiths who leads the primary and secondary response to behavioural management for the Royal Borough of Greenwich - providing assessment, outreach and nurture throughout the primary phase and the main SEMH provision for some of the most vulnerable pupils both within and across boroughs. In this episode we explore the reasons that underpin distressing and challenging behaviour in children and young people.

For more info visit http://watersideschool.co.uk or http://www.kingsoakschool.co.uk

Follow Meic on Twitter: https://twitter.com/meicllundain

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Why do some kids misbehave? | Meic Griffiths - Pooky Ponders - Big Questions with Brilliant People

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Today's question is "Why do some kids misbehave?" and I'm in conversation with Meic Griffiths who leads the primary and secondary response to behavioural management for the Royal Borough of Greenwich - providing assessment, outreach and nurture throughout the primary phase and the main SEMH provi...

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The impact of COVID-19 and its necessary restrictions to our normal way of life is being experienced across communities, impacting on children, young people, adults, the elderly and their families. It is a time when anxiety levels are high and the future seems uncertain. The revised SENSE model can be delivered remotely and provides an effective way of promoting access to and engagement with support over the coming weeks.

Special guidelines have been developed to help professionals and organisations implement this approach.
Download the guidelines.
Please feel free to get in touch with Nicola for further information.

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Making SENSE of COVID-19 - Nicola Lester, Pyschological Trauma Consultant

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The impact of COVID-19 and its necessary restrictions to our normal way of life is being experienced across communities, impacting on children, young people, adults, the elderly and their families. It is a time when anxiety levels are high and the future seems uncertain.

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Summary:
Briefing on working with children who have experienced trauma in the youth justice system.

This briefing provides information to youth justice practitioners on trauma informed practice. It was produced by the Youth Justice Board for England and Wales (YJB) in response to requests from practitioners for more information in this area. This briefing is about trauma-informed practice in youth justice, the impact on trauma on children and working with children that have experienced trauma.

The YJB has also put together a list of trauma informed interventions and assessments, which can be accessed here.

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Trauma Informed Youth Justice Briefing (2017) - Youth Justice Resource Hub

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Summary: Briefing on working with children who have experienced trauma in the youth justice system. This briefing provides information to youth justice practitioners on trauma informed practice. It was produced by the Youth Justice Board for England and Wales (YJB) in response to reque...

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Tell us whether you accept cookies

We use cookies to collect information about how you use GOV.UK. We use this information to make the website work as well as possible and improve government services.

Report of the findings of the ACMD's inquiry on children of problem drug users in the UK.

Documents

Details

This report sets out the findings of an inquiry carried out by the Advisory Council, focusing on children in the UK with a parent, parents or other guardian whose drug use has serious negative consequences for themselves and those around them.

The report sets out 48 recommendations and the following 6 key messages:

there are between 250,000 and 350,000 children of problem drug users in the UK - about 1 child for every problem drug user

parental problem drug use causes serious harm to children at every age from conception to adulthood

reducing the harm to children from parental problem drug use should become a main objective of policy and practice

effective treatment of the parent can have major benefits for the child

by working together, services can take many practical steps to protect and improve the health and well-being of affected children

the number of affected children is only likely decrease when the number of problem drug users decreases

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AMCD inquiry: 'Hidden harm' report on children of drug users

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We use cookies to collect information about how you use GOV.UK. We use this information to make the website work as well as possible and improve government services. Report of the findings of the ACMD's inquiry on children of problem drug users in the UK.

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Jo Sharpen is the Policy Manager at Against Violence and Abuse (AVA). In this blog she explains how the effects of trauma can manifest in young people affected by domestic abuse, and how practitioners and services can understand and prevent re-traumatisation of young people. For an audio version of this blog, visit our Soundcloud profile or scroll to the bottom of the page.
The term 'trauma-informed' is becoming increasingly popular, but how does trauma relate to domestic abuse and how can we provide trauma-informed care for young people?
'Individual 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'[1].
Domestic abuse certainly fits these criteria and can be exacerbated by the fact that the trauma is perpetrated by someone close to the victim and by the unpredictable nature of abuse. There are many common responses to trauma such as hyper-arousal, numbing, increased startle response, flashbacks, avoidance, sleep problems, anxiety, memory and attention problems, developmental delays and attachment issues to name a few. These are all normal responses to abnormal situations, but on the surface may manifest as behaviour that may seem irrational, illogical or even risky. A concern then is that such behaviours could potentially be misdiagnosed as a child being defiant, oppositional or as having ADHD.

Young people who have experienced abuse are making complex, daily decisions about risk and safety. Due to the trauma response, they may be living mainly in the 'survival' part of the brain, constantly hyper-vigilant and scanning for threats and danger. This may come at the expense of higher reasoning, problem solving and logical reasoning. Sometimes this alarm response can still happen, even when the person is in a safe place. The brain stores memories of trauma that may be triggered by sounds, smells etc. and can result in an automatic, unconscious response.

We need to understand these responses so we can better support young people. Services often prioritise one issue whereas young people need a trauma informed approach which understands they may be experiencing multiple disadvantages (see the previous blog from Dr Kat Ford on adverse childhood experiences). Young people also need to understand that their responses are normal, as it can be very frightening and confusing especially if they can't make the links between their behaviour and their experiences.

If we do not respond appropriately, we risk re-traumatising someone. For instance, excluding a teenage from school for 'misbehaving' can remind them of abuse or rejection. Similarly, closing a case when someone does not engage or show up to appointments does not allow for the fact that simply leaving the house can be difficult when experiencing abuse or recovering from trauma.

A trauma informed response focuses not on what is 'wrong' with someone, but rather what they have experienced.

For instance, instead of thinking a young person is disruptive or not engaging, we understand that they have been triggered; instead of thinking that a young person needs 'consequences' or anger management, we understand they need routine, support and self-worth.

SAMHSA's 'four R' model is a helpful reminder:

"A program, organisation, or system that is trauma-informed:

Realises the widespread impact of trauma and understands potential paths for recovery;

Recognises the signs and symptoms of trauma in clients, families, staff, and others involved with the system;

Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and

Seeks to actively resist re-traumatisation."

What we must always remember is that the impacts of trauma are preventable and reversible. With understanding, training and support we can ensure we are providing a more appropriate and therapeutic response that will impact on the long term wellbeing of young people affected by domestic abuse.
For more information on how to create a trauma informed response for survivors of domestic abuse, please visit the Visit our Spotlight page for more resources, guidance and survivor stories to inform your work with young people. AVA website.

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A trauma informed response for working with young people affected by domestic abuse

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Jo Sharpen is the Policy Manager at Against Violence and Abuse (AVA). In this blog she explains how the effects of trauma can manifest in young people affected by domestic abuse, and how practitioners and services can understand and prevent re-traumatisation of young people.

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TF-CBTWeb2.0 is an online training course for mental health professionals learning Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), a treatment model specifically designed for use with children and adolescents who have PTSD symptoms, depression, or behavior problems after trauma.

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Transcending Sexual Violence Through Yoga: 8 Tools for Teaching Trauma-Sensitive Yoga

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A long-standing body of research shows that adverse childhood experiences such as child abuse, trauma, sexual assault, and chronic poverty can negatively affect people well into adulthood. Adult experiences that have been associated with adverse childhood experiences include post-traumatic stress disorder, depression, dissociative symptoms, and other psychiatric disorders, plus physical illnesses such as diabetes, cancer, and cardiovascular disease.

A recent study found evidence that children who experience abuse and violence age faster, biologically, than children with no such history.

Scientists have known that the wear and tear of stress, and the way we handle it, can make the mind and body "older" or "younger." Nobel Prize-winning scientist Elizabeth Blackburn and health psychologist Elissa Epel researched the psychological factors that may damage our telomeres -the protective tips that reside at the end of chromosomes. When telomeres become too short, they stop dividing, and cells grow old. In addition to shortening, however, the scientists discovered that telomeres also lengthen, which slows down the aging process.

Some of the factors that may determine the aging of the telomeres and prevent premature aging at the cellular level are a healthy diet, genetics, how you respond to stress, ample sleep, and regular exercise. But in addition to these factors, the scientists identified five toxic thought patterns that might also lead to shorter telomeres and premature aging: pessimism, cynical hostility, rumination, thought suppression, and mind straying.

But previous research has reported mixed results on whether childhood adversity is linked to accelerated aging. In the newest study, published in the recent issue of the Psychological Bulletin, the researchers examined two categories of adversity among 116,000 participants: threat-related adversity, such as abuse and violence, and deprivation-related adversity, such as physical or emotional neglect or poverty. They found that children who suffered threat-related trauma were more likely to enter puberty early and also showed signs of faster aging on a cellular level-including shortened telomeres. But children who experienced poverty or neglect did not show either of those signs of early aging.

Next, the scientists examined data from 3,253 participants in 25 other studies to pinpoint associations between early life adversity and brain development. They found that childhood adversity was indeed associated with cortical thinning-a sign of aging, as the cortex thins as people age. Trauma and violence were related to thinning in the ventromedial prefrontal cortex (involved in social and emotional processing) and deprivation was associated with reduced cortical thickness in the frontoparietal, default mode, and visual networks, which are involved in sensory and cognitive processing.

The implications of the results, according to the study's authors: "These findings suggest specificity in the types of early environmental experiences associated with accelerated biological aging and highlight the importance of evaluating how accelerated aging contributes to health disparities and whether this process can be mitigated through early intervention."
LinkedIn and Facebook Image: sukra13/Shutterstock

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Can Childhood Trauma Make the Body and Brain Age Faster?

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A long-standing body of research shows that adverse childhood experiences such as child abuse, trauma, sexual assault, and chronic poverty can negatively affect people well into adulthood. Adult experiences that have been associated with adverse childhood experiences include post-traumatic stress disorder, depression, dissociative symptoms, and other psychiatric disorders, plus physical illnesses such as diabetes, cancer, and cardiovascular disease.

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NICABM's Blog - providing new information to psychotherapists, psychologists, and other providers on the latest research and therapies.

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Trauma is one of the leading threats to a human's physical and emotional health. While adults can be affected by traumatic life events after age 18, childhood ACEs (Adverse Childhood Experiences) can have the greatest effect on our lives. We've chosen seven podcast episodes that can help you better understand the deep-seated effects of ACEs and stay trauma-informed this year.
Please note: the following episodes may contain instances of abuse, trauma, or mature language. Listener discretion is advised.
How Childhood Trauma Affects Health Across A Lifetime by Nadine Burke Harris

Dr. Nadine Burke Harris is emphatic about protecting children's mental health, specifically in low-income areas of the United States. During her TedMed talk, Dr. Harris addresses the single largest public health threat we are facing today: childhood trauma.

The CDC found that childhood trauma dramatically increases the risk of death for adults - an almost 20-year difference in life expectancy. ACEs affect brain development, the immune system, hormones, and even the way our DNA is read. Studies also show that children living at or below the US poverty level are much more likely to experience ACEs from birth to age eighteen.

Listen to Dr. Harris' TedTalk about acknowledging, treating, and preventing childhood trauma in our nation.

iTunes | Spotify | YouTube

A Crash Course on Trauma-Informed Teaching by Truth for Teachers

How do you cultivate and maintain a trauma-sensitive classroom? Often times, we may mistake our students' negative actions as personal or intentional. In reality, they may be responding to their current or past trauma.

In this episode of Truth for Teachers Podcast, Angela Watson offers a simple guide to shaping a trauma-informed classroom. This includes simple preventative and interventive measures as well as the importance of setting boundaries.

iTunes | Spotify | Listen online

Traditional Parenting vs. Trauma-Informed Parenting by The Forgotten Podcast

Raising a child that's experienced traumatic life events may look a little different than traditional parenting. Perhaps your child has experienced extreme food insecurity, domestic abuse, a house fire, or the loss of a parent. Simple events like a family pillow fight or a book dropping to the ground may cause a child to react in flight (running away), fight (becoming hostile or worked up), or freezing (not speaking or isolating themselves).

Jami Kaeb and author/seasoned foster parent, Kristin Berry, provide practical insight for parents, foster parents, and guardians who are longing to connect with their children. Particularly those who have been traumatized by big life events.
Please note: This episode has religious undertones with a trauma-informed central message. ChildSavers is a non-religious, non-partisan organization with an appreciation for all people working to improve children's mental health and development.
iTunes | Spotify | Listen online

Bessel van der Kolk - How Trauma Lodges in the Body by On Being

You won't want to miss Peabody Award-winning broadcaster, Krista Tippett, as she interviews psychiatrist and Boston University professor, Bessel van der Kolk. During this hour-long conversation, you'll learn how some experiences imprint themselves in not just our mind, but our body as well.

iTunes | Spotify | Listen online

What Happened to You (Part 1, 2 and 3) by Terrible, Thanks For Asking

Terrible, Thanks for Asking (TTFA for short) is about as real as it gets. Throughout this three-part series*, Nora McInerny urges us to ask "what happened to you" instead of "what's wrong with you?" Listen to Brit's 3-part story of building resilience to her childhood trauma.
*Please note these episodes contain mature language and instances of verbal abuse.
Part I Episode 85: iTunes | Spotify | Listen online

Part 2 Episode 86: iTunes | Spotify | Listen online

Part 3 Episode 87: iTunes | Spotify | Listen online
ChildSavers In addition to services for children, families, and child care providers, we offer trauma training to help teachers, parents, schools, and community leaders stay trauma-sensitive. Learn more about our training opportunities or schedule a personalized training event in your area. ' mission is to guide our community's children through life's critical moments with trauma-informed mental health and development services. With nearly 100 years of service in Richmond, VA, our staff works relentlessly to ensure all children can be safe, happy, healthy, and ready to learn.

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7 Podcast Episodes to Help You Stay Trauma-Informed - ChildSavers

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Trauma is one of the leading threats to a human's physical and emotional health. While adults can be affected by traumatic life events after age 18, childhood ACEs (Adverse Childhood Experiences) can have the greatest effect on our lives. We've chosen seven podcast episodes that can help you better understand the deep-seated effects of ACEs and stay trauma-informed this year.

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Transforming Trauma is a podcast about individuals and communities thriving after Complex Trauma. In a modern world beset by trauma and a legacy of suffering, conflict and disconnection, healing trauma can serve as a vehicle for personal and social transformation. Listeners will be introduced to the NeuroAffective Relational Model (NARM), a revolutionary approach for healing Complex Trauma (C-PTSD) and restoring connection to self and others. Interviews with NARM Therapists, and other prominent trauma specialists, will highlight how NARM fills a missing gap in our current efforts to address the legacy of childhood, cultural and intergenerational trauma. These leaders in the Trauma-Informed Care movement will guide listeners through the diverse ways NARM is applied to support individuals, couples, families and communities in order to actualize Post-Traumatic Growth. Whether you are a healthcare professional, an educator, a parent, a public policy maker, a trauma survivor, or someone interested in personal healing and social justice; this podcast will provide you with a map for increased resiliency, greater health outcomes, healthier relationships, personal growth and social change through transforming trauma.

Transforming Trauma is a podcast about individuals and communities thriving after Complex Trauma. In a modern world beset by trauma and a legacy of suffering, conflict and disconnection, healing trauma can serve as a vehicle for personal and social transformation. Listeners will be introduced to the NeuroAffective Relational Model (NARM), a revolutionary approach for healing Complex Trauma (C-PTSD) and restoring connection to self and others. Interviews with NARM Therapists, and other prominent trauma specialists, will highlight how NARM fills a missing gap in our current efforts to address the legacy of childhood, cultural and intergenerational trauma. These leaders in the Trauma-Informed Care movement will guide listeners through the diverse ways NARM is applied to support individuals, couples, families and communities in order to actualize Post-Traumatic Growth. Whether you are a healthcare professional, an educator, a parent, a public policy maker, a trauma survivor, or someone interested in personal healing and social justice; this podcast will provide you with a map for increased resiliency, greater health outcomes, healthier relationships, personal growth and social change through transforming trauma.

Compassionate, responsive, educational

The team behind the podcast is dedicated to being a resource to listeners especially through challenging times such as we've been having globally in 2020. I've been learning so much as a layperson about intergnerational and complex trauma (which I never even knew was a thing before this) that I can see where it applies in my own life and the lives of people I love.

Heart-opening

Consistent with NARM Therapy, Transforming Trauma podcasts with host Sarah Buino invite me to connect information, the possibility of transformation, and my individual heart with the collective. Much gratitude & many thanks!

Professional and personal

I'm a LMHC who completed the NARM Practitioner Training in 2019. I work in a residential setting helping adult men heal from chemical dependency and trauma. I love everything about NARM and I really love listening to this Transforming Trauma podcast. My professional and personal approach to healing has shifted dramatically since day one of NARM training. I cannot speak highly enough of the NARM model for clients seeking therapy or for professionals seeking a model that can truly affect meaningful long term change for clients (& self!). Thank you to all who make this podcast possible.

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‎Transforming Trauma is a podcast about individuals and communities thriving after Complex Trauma. In a modern world beset by trauma and a legacy of suffering, conflict and disconnection, healing trauma can serve as a vehicle for personal and social transformation. Listeners will be introduced to th...

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Practical, Evidence Based Strategies for Challenging Students.

Practical, Evidence Based Strategies for Challenging Students.

Gold!

I love this podcast! As a classroom teacher with NME training, this adds to my toolbox. Thank you!

Revitalizing Talks!

This is a must listen for ALL adults working with children whether I'm a school setting or otherwise.

Teachers Need This

Teachers need this information. I read that the statistics are 40% - 50% of students will experience one experience that could cause a minor or major trauma before the age of 18.

I think any teacher, who has a child that they've struggled to teach, needs to listen to Dr. Sian Philips' interview. The episode is called Belonging and Coregulation in the Classroom. With the knowledge she imparts as she communicates the internal experience and feelings of these children all of us can feel empathy for them.

Thank you for this podcast!

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‎Trauma Informed Education on Apple Podcasts

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Practical, Evidence Based Strategies for Challenging Students.

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Fifty Best Trauma Podcasts For 2020. Latest was Dr. Robert T Muller: Trauma Treatment Through an Attachment Theory Lens - Part 2. Listen online, no signup necessary.

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Brain Model of PTSD - Psychoeducation Video

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According to Paul Gilbert, PhD, we have three types of emotion regulation systems - we've got the Threat System, the Drive System, and the Soothing System.

Now when a client is stuck in a painful cycle of self-criticism and shame, it's often because these three systems are out of balance.

You see, many clients spend the majority of their time caught in the threat and drive systems - and this can lead to distress.

So how can we help our clients get a better sense of where they might be out of balance, and begin to notice whether their soothing system might be underdeveloped?

We thought it would be helpful for you to have this infographic to use with your clients. (Feel free to make a copy of this to share).

Click the image to enlarge

Click here for the text-only version of the infographic

Three Circles of Emotional Regulation
According to Paul Gilbert's model, people often switch between three different systems to manage their emotions.

Sharing Dr. Gilbert's three circles model could be a good way to help clients become more aware of when they are in a state of threat. Not only that, it can help them learn how to shift out of the threat system and into safeness and connection.

If you'd like to print a copy to share, just click here: Color or Print-friendly

(Please be sure to include the NICABM logo as well as the credit to Paul Gilbert. We put a lot of work into creating these resources for you. Thanks!)

To hear more from Dr. Gilbert, please join us for the master series on The Clinical Application of Compassion - here's the link where you can sign up.

Now we'd like to hear from you. How will you use this in your work with clients? Please leave a comment below.

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Applying the 3 Circles Model of Emotion to Help Clients Heal Shame

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Here's an infographic tool you can use to help clients overcome shame, based on Paul Gilbert's theory on the three types of emotion regulation systems.

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Trauma can have a profound impact on a person's
memory . . .

. . . and traumatic memory can affect not only the brain, but also the body and nervous system as well.

But conceptualizing how trauma can impact the different types of memory can be challenging, so we created a free tool for practitioners to use with clients that breaks down this process.

Click the image to enlarge

If you'd like to print a copy for yourself, just click here:
Part 1: Color or Print-friendly

Part 2: Color or Print-friendly

Part 3: Color or Print-friendly

(Please be sure to include the copyright information. We put a lot of work into creating these resources for you. Thanks!)
You can hear more about how trauma affects the brain, body, and nervous system in the Treating Trauma Master Series.
You'll get insights from Dan Siegel, MD; Bessel van der Kolk, MD; Pat Ogden, PhD; Stephen Porges, PhD; and Ruth Lanius, MD, PhD.

Now we'd like to hear from you. How could this help you in your work? Please leave a comment below.

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How Trauma Can Impact Four Types of Memory [Infographic] - NICABM

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Trauma can have a profound impact on a person's memory . . . . . . and traumatic memory can affect not only the brain, but also the body and nervous system as well. But conceptualizing how trauma can impact the different types of memory can be challenging, so we created a free tool for ...

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Trauma can change the brain . . .

. . . but the person who experienced the trauma may not be the only one whose brain changes.

In the video below, Ruth Lanius, MD, PhD describes what we're discovering about the connections between a parent's trauma and their child's developing brain.

Take a look - it's about 4 minutes.

How have you seen trauma affect a person's interaction with their child? Please leave a comment below.
For information on how to help clients reclaim what's been lost to trauma, please click here.

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How Does Trauma Affect a Person's Interaction with Their Child? - NICABM

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Trauma can change the brain . . . . . . but the person who experienced the trauma may not be the only one whose brain changes. In the video below, Ruth Lanius, MD, PhD describes what we're discovering about the connections between a parent's trauma and their child's developing brain.

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AWFUL AND AWESOME: AN INTRODUCTION
Life would be okay, if it were not for the flashbacks...
How true. How many times have I heard people say that? And for so many years, my life too would have been bearable, but for the flashbacks. These are not polite house guests who turn up on cue, with flowers and chocolates. They wake you in the middle of the night; they intrude upon you at moments of intimacy, in public, at work, at the most inconvenient times and in the most unexpected places. It's hard not to feel totally out-of-control when flashbacks are dominating your life, because at the point at which they strike, you are out-of-control. And they become a vicious cycle-you end up fearing the flashbacks, fearing the loss of control, the emotional upsurge, the physical reaction, and in that stressed-out state you are more liable to experience flashbacks...

Coming to terms with flashbacks-understanding what they are, learning how to manage them, and eventually figuring out how to reduce them-has been a cornerstone of my recovery. When things are really tough and the flashbacks are unremitting, recovery often feels impossible and life itself hopeless. And yet, in a kind of paradox, flashbacks are a good sign. I believe that flashbacks are a sign of your brain trying to heal. Flashbacks contain unprocessed fragments of traumatic memory, and they burst into consciousness partly because your brain is trying to process these fragments and to see where they 'fit'. Flashbacks are horrendous-yes. But it can help if we reframe them as signs of our sanity, that our brains know that something is not right, and at least when they happen we can take some tiny crumbs of comfort from the fact that our brain wants to heal. Flashbacks, and the triggers that cause them, can be guides on our therapeutic recovery journey.

HOW DO WE DESCRIBE FLASHBACKS?
A flashback is a sudden, involuntary reexperiencing of a past traumatic event as if it is happening in the present.
To a certain extent, I've always been slightly confused about what flashbacks are. I've seen many representations in films of people having flashbacks, and none of them ring true for me. For a long time, I thought that it was me that was the problem-that I wasn't really having flashbacks, that I was a fraud, or just making it up for the attention. Of course, I hated the attention, and desperately wished that it was all 'made up', but nonetheless the doubts remained. How does anyone know what a flashback feels like-especially when you feel so 'derealised' when it's happening? How do we know that we all mean the same thing by the term 'flashback'?

A scene in the film Catching Fire depicts one. The main protagonist, Katniss, has survived the annual 'Hunger Games' in which two children from each of the twelve districts must fight each other to the death as entertainment for the ruling classes. During this, to protect an ally, she kills a boy called Marvel with an arrow. (If ever there was an allegorical representation of ritual abuse, the Hunger Games series captures it.) At the beginning of the second film, as Katniss is trying to readjust to life after her trauma, she is out in the woods, hunting. She shoots an arrow at a turkey, but instead, in a flashback, sees Marvel's body collapsing to the floor. Her immediate physical and emotional reaction is clear. And part of me wants to jump up and down and say, 'Yes, that's it! That's a flashback!' while most of me actually feels a little guilty, because I know that most of the time it's not as clear-cut as that for me.

It's hard to describe a flashback, because while it's happening, key parts of the brain required to recall and articulate our experience shut down. As bloodflow is reduced to the word-generating part of our brain, Broca's area, we find it difficult to vocalise our experience. We may recognise flashbacks when we see them in others, but the self-observing part of our brain isn't engaged when we're actually experiencing one ourselves.

And so many people are confused about whether what they're experiencing can truly be called a 'flashback'. I believe that the flashback experience exists on a spectrum, everything from a brief fleeting thought accompanied by an instant pounding heart or sinking stomach, right through to an experience lasting several minutes in which we are really, truly back in the experience of past trauma. At this end of the spectrum, it can be frightening for others to observe too-we seem to have lost touch with reality as we think that 'it's still happening now' and we mistake people in the here-and-now with people from the there-and-then.

Our behaviour make a lot more sense if we understand a little of what goes on in the brain during trauma, and how this is replicated (to a greater or lesser degree) during a flashback. Our reactions may seem bizarre to an outsider, but there really is method in our madness.

WHAT GOES ON IN THE BRAIN DURING TRAUMA?

We are primed instinctively to respond to threat, as can be seen in the nine stages of the defensive response cycle (see LATER SECTION). What therefore goes on in our bodies and brains during trauma-and its subsequent flashbacks-is entirely out of our control. Too often we feel ashamed of our reactions, both at the time of the original trauma, and when experiencing repeated flashbacks, but it's essential that we realise that these are survival processes at work, and nothing to do with attention-seeking, manipulating or being 'weak'. But that doesn't mean to say that we can't learn to handle flashbacks better, and the key to that is understanding what is actually going on in the brain.

A really simple way of understanding the brain during trauma is that our front brains turn off and our back brains turn on. When the amygdala, our brain's 'smoke alarm' detects a threat, it sends a split-second signal to the hypothalamus to sound the siren. The hypothalamus then initiates a cascade of chemical responses in the brain and the body. For example:

noradrenaline is released in the brain to help it focus and react quickly

adrenaline speeds up the heartrate to increase the availability of oxygen and nutrients to the long muscles of the arms and legs, ready to fight or flee

there is an increase in blood pressure, so that essential blood supplies reach their destination as quickly as possible

blood supply is diverted away from non-urgent activities such as digestion and reproduction

the immune system is temporarily boosted, in order to respond quickly to a potential injury

fuel supplies are maximised in the bloodstream.

By doing this, and entering the 'amber alert' phase, the body is geared up to defend itself, all of which happens outside of conscious thought, before we have even had a chance to consciously notice and think about the threat. This is a really important part of survival. We cannot risk, at the moment of threat, any kind of 'paralysis of analysis': we have to act in a split second. And so the thinking, rational, analytical, planning 'front brain', which is the seat of our conscious thoughts, is placed in neutral, while the automatic, instinctive, emotional 'back brain' is placed firmly in gear. Back brain on-front brain off.
This allows us to react quickly to the threat without too much deliberation-to react automatically and instinctively, which gives us the best chance of survival. However, this turning down of the front brain has its disadvantages for us too-blood flow is reduced to several key areas, most significantly:

The 'timekeeper', the dorsolateral prefrontal cortex. This part of the brain, along with many other functions, keeps our sense of ourselves in time and space. That's why time seems to slow down or our life 'flashes' before our eyes during a traumatic moment. It is also why we can't tell the difference between past and present (a core element of a flashback) and why it feels as if flashbacks will go on forever.

The 'dictionary', Broca's area. This is the language and speech area of the brain. That's why, at the moment of trauma, we often can't speak-'speechless terror'. It's also why when we're very stressed, it's hard to find our words. It's difficult to describe a flashback when your 'dictionary' is offline!

The 'watchtower', the medial prefrontal cortex. This is the planning, overseeing, decision-making, wise part of our brain. With this offline, we struggle to plan and make decisions, and as it talks to the body through our 'internal CCTV', the insula, we can also have difficulty feeling connected to our body (an 'out of body experience').

The 'librarian' or 'context stamp', the hippocampus. Technically part of the limbic system rather than the front brain, the hippocampus plays a leading role in memory encoding and retrieval and acts as a kind of special adviser to the watchtower. With the hippocampus offline, memories are often not stored coherently and so traumatic memories are often disjointed, lacking context, or incomplete.

The 'cook', the thalamus. Although again technically not part of the front brain, the thalamus may switch off during trauma: incoming data from our environment and senses, which is normally mixed together by the 'cook' at the point of entry before being sent to other parts of the brain, remain as raw ingredients rather than a complete autobiographical 'soup'. This is the precursor to dissociation-information entering the brain not being 'associated' in the first place.

FLASHBACKS-A REPLICATION OF THE TRAUMA RESPONSE

A flashback is the result of this 'brain mush' that happens at the moment of trauma. A flashback comprises all the fragments of memory of that event that were not integrated by the thalamus in the first place, or were not encoded or stored properly by the under-performing hippocampus. The brain shuts down to protect us: during trauma we experience a sense of 'depersonalisation' and 'derealisation' which is the outward manifestation of all these brain areas being shut down-the 'timekeeper', 'dictionary', 'cook' and 'librarian'. The good news is that during trauma our attention and focus is narrowed and we feel outside ourselves-this helps to reduce the psychological distress we are exposed to at the time. But afterwards, it is difficult for our brain to fully process what happened to us given that so much of it was offline while it was happening. The brain can struggle to move through to the recovery and integration phase when memory systems were not properly functioning at the time.

AVOIDANCE AS A SURVIVAL RESPONSE

Having been faced with a traumatic incident in which we were overwhelmed, and with an inadequate recovery and integration phase, often the brain unconsciously decides that the only course of action in future is to ensure that we avoid any such similar event. The thalamus ('cook'), which directs our attention, focuses on threat-related cues. Similarly the amygdala ('smoke alarm') is sensitised, and more likely to be activated at the merest whiff of smoke in the future. Without the complexity of the front brain, especially the 'watchtower', to mediate the process, the back brain makes broad generalisations about what might again in the future constitute 'smoke'. We became averse to a number of triggers, many of them in reality not accurate markers of 'smokiness': red as the colour of the top our attacker was wearing; the time of the day (for example night time); the contextual location (for example, a bed). Avoidance is both behavioural and mental-we avoid anything that might trigger us, and we avoid consciously thinking about anything that might remind us of the original trauma: it is pushed out of mind and becomes well and truly dissociated.

THE PATTERN-MATCHING BRAIN

In this state of heightened awareness of potential risk, with the thalamus and amygdala both contributing to a 'react first, think later' policy, the brain becomes 'trigger-happy'. The brain is predominantly a pattern-matching machine: it is looking for the same patterns everywhere. And so, upon seeing the colour red, or a bed, the amygdala sounds the alarm, having matched the pattern from previously. At this point, memory stored in or processed by the amygdala is fed into the conscious mind, albeit in its fragmentary, incomplete, and sensory format, and a 'flashback' occurs. This is the back brain's best attempt to warn us of potential danger by reminding us of what happened previously. Sometimes the memory that is activated is sufficiently complete to be 'seen' in the mind's eye (like Katniss shooting Marvel) but on many occasions the memory is too fragmented to make much sense to the conscious mind, the front brain. In that case, the body's alarm systems are activated and the defensive cycle is initiated, usually with a flight, fight or freeze response, whilst the conscious mind isn't fully aware of what is going on.
At this moment of flashback, the same responses take place in the brain and the body as they did at the moment of the original trauma. Stress hormones are released, with the resultant bodily response:

in the flight or fight response (the 'amber' alert): increased heart rate and blood pressure, redirection of bloodflow, increase of breathing, release of energy into the bloodstream and muscles primed for action;

or in the freeze/collapse response (the 'red' alert): slowing of the heartrate, loss of muscle tone, decreased breathing, lowering of blood pressure (sometimes involving 'syncope'-fainting) and immobilisation of muscles.

The flashback is a reliving and reexperiencing of the original trauma: the body and brain react exactly as they did at the time, and the memory of that event is reactivated primarily at an implicit level, in the body and back brain. This is why flashbacks play such a significant role in the lives of survivors with an unresolved traumatic history. They have the power, within a split second, to affect all the major organs of our body and to switch gears within our brain, taking us out of our thinking front brains and into our survival-based back brains. They make our hearts pound with terror, or our heartrate drop, causing a faint-and all of it outside our control.

Avoidance is a clever strategy and has helped us cope with life for many years. But it also has its limitations, because it increasingly restricts our life: there are more and more things that we need to avoid in order to eliminate the risk of being triggered into a flashback, and as many of us suffered relational trauma-abuse at the hands of people-then of course people are the most triggering thing in our world, and our world is full of them. We can end up increasingly isolated as we avoid all men or (for those of us who were abused by both genders) all men and women. Our quality of life degrades and it is little wonder that so many survivors end up depressed and suicidal. It is therefore imperative that we find another way of managing flashbacks.

THE DEFENSIVE RESPONSE CYCLE

All animals, including us as humans, have predetermined, instinctive patterns of response to defend ourselves from threat-this isn't something that is left to chance, or to our decision-making at the moment of danger, but something that is deeply ingrained in the way that our brains and bodies operate at an automatic, unconscious level. These patterns of response can be summarised into nine stages:

1. SOCIAL ENGAGEMENT

Our first level of defence is in our attachment systems-it's the inborn instincts we have to be social, to clan together, right from the infant crying to be fed, through to our long-term monogamous relationships and the societies that we create. Sticking together enhances our chances of survival, and so social engagement is the first step-a preemptive step in many ways-in protecting ourselves from threat.

2. DETECTION

To survive a hostile environment, we need to scan for threat and be able to detect it should it arise. Think of a herd of gazelles grazing, with their ears twitching and their head lifting from the grass to check out a distant sound. If they detect a predator, their arousal levels will immediately increase, becoming physically and mentally alert.

3. ORIENTING

Having detected a potential threat, the animal (or human) will 'orient' towards it, to try to locate it. The attention will be focused on it, via all the senses, for example by directing the eyes and channelling the hearing.

4. STILLING

Alongside orienting, or very shortly afterwards, there is a kind of 'stilling' of the body, an alert phase with the muscles tensed ready for action, the attention directed exclusively towards the threat, blocking out everything else. It is the rabbit caught in the headlights. Some people refer to this phase as 'freezing', but I prefer to retain that term for a later stage. It may happen only for a split second but is the precursor to the defensive response of the next three stages: flight, fight or freeze.

5. FLIGHT

The default primary option, in most scenarios, is flight: run as fast as you can away from the threat. The sooner you do this, and the faster you run, the greater your chance for escape. The gazelles fleeing from the cheetah may not be able to outrun it, but they will at least try, rather than facing certain death. We see the flight response also in the evasion of confrontation-doing whatever is required to avoid escalating conflict to a fight.

6. FIGHT

Some animals-some humans!-are not adept at running; they may have detected the threat too late; there may be no physical escape. A fight response then kicks in as the next automatic stage of the defensive cycle. For those strong enough, big enough and well-equipped enough (for example claws or weapons), this may be a successful strategy, although it does risk injury, which is why flight is usually preferred.

7. FREEZE

There are a number of reasons why flight or fight may not work: being too young, sick, weak, or ill-equipped, as in the classic example of the possum. In these cases, the next stage is to freeze, what some people refer to as collapse. This is a strategy based on submission and feigned death. If you can't flee and you can't fight, perhaps you can trick your predator into leaving you alone. Many victims of interpersonal violence, such as child sexual abuse, adult rape, domestic violence or acts of terrorism, report playing dead to evade attention or to minimise further harm. This is not a conscious choice, but is the brain and body's best way, at an instinctive level, of surviving. It is also important to note that freezing, or submitting, is in no way the same as consent: it is simply a way of responding which, faced with significant harm or death, maximises the chances of survival by not actively resisting.
This freeze response can be seen as the flight/fight response put on hold, as a crossover between active survival responses and passive ones. This then manifests in one of two ways: the first is 'tonic immobility'-the muscles are taut and tense, ready for action should the opportunity arise, but the body is otherwise paralysed. Numerous animals, including rabbits and sharks, manifest tonic immobility when trapped-search for it on YouTube to see some amazing clips! It is a very effective survival mechanism at feigning death to trick the predator.

The alternative version of the freeze response is 'collapsed immobility', where the muscles become floppy, like a ragdoll, and without tone. Sometimes it is accompanied by fainting ('vasovagal syncope'). This is the swoon of Victorian literature, passing out at the sight of blood, and other familiar experiences.

8. RECOVERY

If these active and reactive strategies of flight, fight or freeze are successful, then at some point the threat will pass, and we can move into the recovery stage. This is often characterised by what has been termed 'collapsed quiescence': it is a stage of 'licking the wounds', often accompanied by a prolonged period of rest and recuperation. It may also be characterised by trembling and shaking, which Peter Levine, in observing animals, suggests is a way of 'shaking out' the trapped energy of the freeze response, and returning to a mobilised state from the immobilisation of freeze.

9. INTEGRATION

With successful recovery, finally we can enter a period of 'integration', a way of mentally, physically and emotionally joining up and resolving the experience of threat we have just experienced, learning from it, consolidating memories of it, and developing strategies (often at an unconscious level) to survive a similar event in the future. This then takes us back, following recovery and integration, into social engagement and attachment. It is this cycle of defence and recovery that has been truncated or halted during trauma, and trauma recovery seeks to complete the cycle at whatever point it has been interrupted.

HOW CAN WE HANDLE FLASHBACKS?

Flashbacks take us from the 'here-and-now' to the 'there-and-then'. They turn off our front brain and activate our back brain. They make us feel disconnected from our bodies, while our bodies are gearing up to respond to threat. In handling them, therefore, we need to get 'grounded' in the here-and-now, in our bodies, and calm down our nervous systems again. In my experience, flashbacks pass more quickly if:

I ground myself back in my body

I bring my front brain online by thinking, and talking myself through it

I don't beat myself up, but am soothing and compassionate towards myself.

GETTING BACK INTO THE BODY

At the moment of trauma, there is a disconnect-a 'dissociation'-from the body. Many survivors, particularly of sexual abuse, talk about their experience during the trauma of detaching, perhaps floating up to the ceiling and having an 'out of body experience'. The technical reason for this seems to lie in reduced bloodflow to what Bessel van der Kolk refers to as the 'mohawk of self-awareness' and in particular two structures called the anterior cingulate cortex and the insula. The insula operates as a kind of 'internal CCTV' and relays information from the body up to the brain. There is growing evidence that this area in particular shuts down during trauma. In recovering from trauma, and handling flashbacks in particular, it can be very helpful to try to reverse this process, and to get the 'internal CCTV' back online again. Suggestions and encouragements from therapists to feel your feet on the floor is not-as many clients suspect-a distraction technique and the only thing that the therapist can think of to say! It is based in good brain science, about directing the brain's attention (and therefore directing blood flow) to the sensations of the body as relayed by the insula.

Research shows that mindfulness meditation is very effective in strengthening the insula, and that is why it is so often recommended, both as a standalone activity, as well as being incorporated into the therapy itself, for example via Pat Ogden's Sensorimotor Psychotherapy approach to treating trauma. Breathing practices are strongly associated with both mindfulness meditation and yoga, and for good reason: breathing is one of the principal ways that we can calm our body down when stressed, for example during the automatic physiological reaction of a flashback. When we breathe in, we activate our sympathetic nervous system, responsible for the 'fight and flight' response, but when we breathe out, we activate our parasympathetic nervous system, which lowers our heart rate and is often referred to as the 'feed and breed' or 'rest and digest' system. Therefore slow, steady breathing from the diaphragm, preferably while directing our attention to the bodily sensations of our lungs filling with and emptying air (to engage the insula), is a very primitive but highly effective way of beginning to calm our reactions during a flashback.

Movement is also key. Whenever we are overwhelmed and in a freeze/collapse response, our bodies become immobilised. They do this to survive, but while we remain motionless, an internal feedback loop is set in motion, informing our brains that we are in danger because we are immobilised! It's therefore really important to get moving. This can be something as simple as tossing a bean bag from one hand to another, standing up, or walking around. Changing our posture has an immediate and massive impact on the level of stress hormones in our body. Just by standing up and adopting a 'power pose' for two minutes-straight spine, chin lifted up, shoulders back, perhaps arms stretched wide and held strongly-can reduce the levels of the stress hormone cortisol in our bloodstream by 25%. Who would have thought that our physical posture could have such an impact on our physiology? This is really reassuring to know, especially when we feel so helpless in the face of flashbacks which have such a dramatic and immediate impact on our bodies. It means that we can use our bodies to counteract the effects on our bodies!

We can also help to ground ourselves in our bodies by activating our senses. We can look around and focus our attention on what we can see-where we are, how many circular objects we can see, or shades of green. Looking at a 'vista'-a long-distance view-such as through the window (or better still outside, in a park or across a lake) also has an impact on our physiology, lowering our blood pressure. We can focus our attention on what we can hear-sounds far away, sounds close-as well as on what we can smell, perhaps using smells with positive associations such as certain handwashes or creams to give us a sense of safety again. In years gone by, smelling salts would be used to rouse someone in the collapse of a faint: smell is very powerful as it bypasses the thalamus and goes direct to the amygdala. We could also try tasting something pleasant or piquant, and use our sense of touch to stroke something soft and comforting. The aim is to focus the attention on the here-and-now and on the body. It is the body that is dysregulated in a flashback, so it is highly effective to cope with the flashback by calming and grounding the body, and our main perception channel to the body is our senses.

BRING YOUR FRONT BRAIN ONLINE

The front brain is our conscious, 'thinking' brain and it is switched off-or at the very least muted-during the trauma itself and then again during flashbacks. It is the front brain that helps us to assess situations, make decisions, and plan. That's why it can be so difficult, when you are being constantly dysregulated with flashbacks, to work your way out of it: you literally cannot think. As we've also seen, Broca's area also has reduced blood flow, making it difficult to speak and form word-thoughts. The very things that are difficult to do-thinking and speaking-are the very things we need to focus on doing, in order to break the power of flashbacks.

There are many ways of doing this, but one simple way that can be prepared in advance of flashbacks is to have a series of 'thought cards'. These are designed to remind you of what is happening during a flashback, and to get your front brain back online as you talk yourself through it. For example:

'This is a flashback. It won't kill me-even though my body is reacting as if it will.'

'It's a sign of my sanity-my brain is trying to protect me.'

'This is a memory-even though it feels like it's happening now.'

It can be helpful to produce a number of these statements and carry them around with you, or display them in a prominent place where live. The aim is to get your front brain working again-nothing else. For some people, puzzles such as wordsearches or crosswords are effective. For others, doing menial, low-energy jobs such as filing, tidying or sorting can help-something that engages enough brain power to get the front brain online but isn't so demanding that it becomes stressful in and of itself.

DON'T BEAT YOURSELF UP

It can be really frustrating to be afflicted by flashbacks, especially when they happen frequently and come out of the blue. The immediate effects, in terms of the emotional and physical reactions, can be embarrassing and debilitating. For many of us, our immediate instinct is to express that frustration at ourselves- 'I'm so stupid! I hate myself! Why am I like this? Why can't I just pull myself together?' Accepting that flashbacks are the logical consequence of trauma, and that we didn't choose to be traumatised, is an important step towards recovery. But it's also important because, when we beat ourselves up, we are in fact triggering ourselves all over again!

Logically, this makes perfect sense: our brains-in particular our amygdala, the 'smoke alarm', and the thalamus, the 'cook'-have become sensitised to threat in order to try to keep us safe in the future. As I often say, we were in a lot of fires as children, so it is little wonder that our smoke alarm has become overreactive-it's working on the basis of 'better safe than sorry'. That is not a defect in our character or personality-it is simply a survival strategy as a direct consequence of the number of childhood 'fires' that we endured. And so our brains are geared towards scanning for, and responding to, threat. As the amygdala is based in our back brain, it is not complex or clever, and tends towards generalisation.

Therefore it cannot tell the difference between anger and abuse directed at us from another person-or from ourselves. When we beat ourselves up, we trigger the smoke alarm, and we react automatically to that. If we then beat ourselves up for having been triggered, we again trigger the smoke alarm, and so a vicious cycle is born.

The most helpful thing we can do, therefore, to handle flashbacks and recover from them quickly, is to show ourselves kindness and compassion, thus soothing ourselves rather than retriggering ourselves. Admittedly, it is easier said than done, but it is absolutely vital if we are to recover from trauma.

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Life would be okay, if it were not for the flashbacks... How true. How many times have I heard people say that? And for so many years, my life too would have been bearable, but for the flashbacks. These are not polite house guests who turn up on cue, with flowers and chocolates.

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All I did was walk into the kitchen and pick up a cloth. But the sudden waft of bleach flung me far, far back into some childhood memory. I switched to a traumatised part of myself. I had been 'triggered'.

Physically, I revved up into the panic and distress of the fight/flight response, everything in me taut and straining to protect me from some unseen danger. My heart lurched inside me. It's just bleach, I tried saying to myself, desperately. Just bleach. And I strained with everything I had to feel real again, to stop this mad descent into terror and shame and darkest, deepest dread.

I wonder sometimes how any of us manage to work, or parent, or socialise, or go shopping, or even sleep, when this is happening all the time. And for me there was a period of 3 or 4 years when it was constant. I made several suicide attempts during that period of my life, because it was so bewildering, so overwhelming, so exhausting. I never want to go back to that kind of misery again. Being on the other side of it now, I feel strongly that we need a solution to triggers-it's not enough just to sympathise.

THE SHAME OF TRIGGERS

I struggled too with the shame of being triggered. I didn't want to be like this. I hated people noticing. I wanted to shout and scream that I hadn't caused the abuse, so it was unfair to have to deal with the consequences. I railed against the unfairness, wanting everyone to listen. Why should I have to do the heavy lifting of dealing with triggers? I didn't cause them! But eventually I realised that no amount of anger or resentment would change the fact that I was being triggered, and that no one else was going to do anything about it-that no one else could do anything about it. Only me. So I had to learn how to deal with triggers better.

THE TRIGGER WARNING

But we live now in the world of the trigger warning. Every day on social media, I see posts trailered by asterisks, blank lines, those ominous words 'trigger warning...' Each week at PODS we receive emails from people detailing words, situations, people or images that 'triggered' them. One person is triggered when trapped in a lift with a stranger; another by the picture of a tree in their therapist's office. For some it's words like 'abuse' or 'sex'; for others simply the letter 'x'.

But what does it mean to be 'triggered'? The word means different things to different people, and therein lies our confusion as to what constitutes a trigger, and when a trigger warning may need to apply. With a fear of causing upset we err on the side of labelling everything a trigger. But by doing so, we lose a sense of scale-the word 'abuse' as a trigger is conflated with the actual experience of being assaulted. And we lack the confidence to know how to deal with these reactions. Triggers evoke your powerlessness at the moment of trauma, and they whisper to you that you are still powerless now. It makes recovery from trauma seem impossible.

Many people, believing that triggers are uncontrollable, immutable and inevitable, assume that we must avoid them, and ask others to avoid them too: hence the rise of the trigger warning. Certainly when we're assaulted day and night by them, logic suggests that our reactions cannot be controlled. After all, none of us choose to be triggered-so how we can choose not to be triggered?

THE COST OF AVOIDANCE

But there's a cost to coping with triggers through avoidance alone. Our world narrows to the point of imprisonment: if open spaces are triggering, we can't go outside; if small rooms are triggering, we can't stay inside; if things in our mouth are triggering, we can't eat; if our bed is triggering, we can't sleep. Hence why life with unresolved trauma is so debilitating, when there are so many situations to avoid. Avoidance is a smart survival strategy, but it comes at a price.

So what if there's a way to neutralise triggers, rather than just avoid them? Can you even imagine that?! What if we didn't have to avoid life, but could enjoy it? Wouldn't that be life-changing?

And it is, and I know this-again from personal experience. It is possible to live a life where triggers no longer hold sway, where most of the time I can stay in the 'green zone', in my 'window of tolerance'. And what a transformation it has been-it makes life liveable again.

WHY ARE WE TRIGGERED?

So in order to learn how to neutralise triggers, we need to go back to basics and figure out what triggers are and why they exist. Let's stop and consider: how do we manage to stay alive? What stops us from walking off cliffs, playing with fire, jumping into traffic, sitting down on a dual carriageway?

Fear is an emotion, a feeling we have, which helps us avoid danger. It can be based on reality-it's right to fear a man with a gun-or it can be a natural fear ramped up to an extreme: we can't reconcile hurtling through the air in a tin can at 30,000 feet, so we develop a fear of flying. To ensure our safety, fear exists in anticipation, before the event, so with a fear of flying we might start reacting physically even just thinking about planes.

That feeling of fear is an awful one. It's very visceral-you feel it in your guts. It starts with an uneasy, anxious sense of dread. Your tummy is queasy and your muscles are taut. As it increases, you might feel shaky; your throat might go dry; your heart begins to thud in your chest; you might feel like you can't breathe, or you start hyperventilating. It's a really aversive experience. Everything in you is screaming to run away, to make it stop. And of course it does-how would we know to avoid dangerous situations if we didn't have so strong a physical reaction? Our fear response is intended to keep us safe, to ensure we survive.

When we encounter a dangerous situation-a near miss on the motorway, a gunman, a fall near a cliff-our body reacts instantly to ensure we do something to deal with this danger. We swerve; we duck; we grab onto something. So our internal alarm sets off a chain reaction in our body of physical responses-mainly adrenaline, causing our breathing and heartrate to increase so that energy is available for us to deal with the threat. The feeling we feel is of fear, and panic.

When we suffer some harm from this threat-when our efforts to defend ourselves aren't sufficiently effective-then our body does the next best thing it can to survive. It goes into a submissive freeze response. It might curl into a ball to shield itself and to hide from view; it might play dead; it won't resist. It's a clever survival strategy that might be the only thing that actually saves our life, but it leaves us with an enduring sense of powerlessness and helplessness, that there was nothing we could do. The survival brain, seeing what has happened, marks this event as 'extremely aversive' and plans from that moment on to avoid it happening ever again. If you can't beat it, avoid it. Forever. It becomes both a physical and psychological imperative.

So to avoid it, we need some clues that it might be happening again. Was it raining when it was happening? Was it a man? Was there a smell of alcohol? Was he wearing a red jumper? The basic, survival brain adds all of these elements to a 'threat list'. So the next time it's raining, or there's a smell of alcohol, the alarm goes off again: look out, threat coming! It's as aversive as the original event. The brain doesn't check that it's right. It prefers to have the earliest possible warning, even at the risk of a false alarm. A delay could mean death, rather than life. React first, ask questions later...

That's a trigger in action. A trigger is a reminder, conscious or unconscious, of a traumatic event. It's something that sets off the alarm system in the body and brain to prepare us for a threat. The problem with triggers is that they elicit such a powerful response in the body, but they're not always accurate. The amygdala, the brain's smoke alarm, is a basic piece of kit and it generalises and jumps to conclusions-better safe than sorry. So after trauma it goes off at the slightest hint of smoke, telling us that burnt toast is as dangerous as the house on fire.

So a trigger in the strictest sense is something which activates the smoke alarm. It all happens in the blink of an eye, within 7 milliseconds. The survival-based back brain, which houses the smoke alarm, makes the decision before our conscious, thinking front brain gets to take a look. It all happens unconsciously, before we've had a chance to choose. In that sense, we are not choosing to react to a trigger. It's all beyond our conscious processing.

So if a trigger is something which activates the body's autonomic nervous system (with fight, flight or freeze-into the amber or red zones), then do we use the word accurately? Or do we use the word 'trigger' to mean other things as well? Do we use it to mean 'anything which causes an unpleasant feeling'?

A PERSONAL STORY

I used to find dogs a huge trigger. And in the midst of my breakdown, I sat in a seminar at a survivors' event, and in came another delegate with a guide dog. She sat on the front row, diagonally opposite me, unintentionally blocking my exit. I was triggered. I felt irrationally upset, like I wanted to burst into tears, but I didn't even know what at. I had a strong flight reaction-I just needed to get out of there. My heart was pounding and I could hardly breathe. But I couldn't move-at least I felt I couldn't, because the dog was in the way. In reality, if my front brain had been working, I could have figured out a route around the back of the room, or I could even have asked the owner if she could move to let me past. I could have asked someone else to ask the owner to move. In reality, there were a number of options open to me, but I couldn't see them in my terror and freeze.

If I'd had some scripts or mantras, I could have grounded myself. I could have said to myself, 'Okay, I'm being triggered by the presence of this dog. It's bringing up feelings, sensations and memories from the there-and-then. But what's going on in the here-and-now? Am I in danger from this dog? Or is it in fact just sitting there, completely uninterested in me? What is the actual risk, right here and right now? Can I just notice that this is 'a' dog, but it is not 'the' dog?'

The distinction between 'a' dog and 'the' dog was a breakthrough for me. As I walked down the street and was approached by walkers and their dogs, I began to say, over and over to myself, 'It's okay. This is 'a' dog, but it's not 'the' dog'.' I forced my brain to make the distinction between the actual, specific trigger at the time of the trauma, and the way I have generalised out from that. I got my front brain to start 'just noticing' and to play spot the difference: 'This is 'a' dog, but it's not 'the' dog. 'The dog' was a Border Collie. This dog is a Staffie. 'The dog' was alive during the 1980s and must have been dead for over twenty years. 'This dog' is safe

THREE TYPES OF TRIGGER

Instead, I think there are three things that we tend to lump together and call a 'trigger', in decreasing order of severity: true triggers, distressing reminders and uncomfortable associations.
True triggers
True triggers occur when our smoke alarm is activated by something in our environment-it's usually a felt sense, a real re-experience. Rather than just a picture of a tree, it's finding yourself under a tree, with the smell of undergrowth, the dappled sunlight, the crunch of twigs underfoot. The information comes in through the senses and sets off the smoke alarm to full alert. The front brain goes offline; the back brain comes online; and it is very difficult to manage our response as we have such reduced mental functioning. Our response occurs within 7 milliseconds, before conscious thought has had a chance to be engaged-it is, as Judith Lewis Herman described it, 'wordless terror'. It is principally a body-based response, directed almost entirely by the back brain and is mediated solely by the amygdala. The key to dealing with them is the magic phrase 'just notice', engaging the front middle brain (the medial prefrontal cortex), although to start with we might only begin to address them afterwards. But, as the saying goes, better late than never!
Distressing reminders
Distressing reminders evoke memories of a traumatic event, and cause negative, aversive feelings, but our front brain remains mostly online. They occur within conscious thought (we know why we're triggered) but there may be some unconscious elements to them as well: we can describe them, but not always explain them. It is a reaction partly in our body, and partly in our brain; partly in our front brain, and partly in our back brain. Technically, the process is mediated both by our amygdala (our smoke alarm) and our hippocampus (our context stamp). As we'll see, the key to dealing with them is via soothing, specifically activating our front right brain, the right orbitofrontal cortex, and we can learn to deal with them while they're happening.
Uncomfortable associations
Uncomfortable associations are links we have made in our mind with our trauma. They occur consciously and we can explain verbally what is going on for us, for example: 'I don't like pictures of trees, because they remind me of where the abuse took place.' It's a reaction that occurs within our brains rather than bodies; our front brain is still engaged and online; and the process is mediated by the hippocampus as it draws on explicit memory. We deal with these associations through reframing, specifically via our front left brain or the dorsolateral prefrontal cortex, and we can work on this subset of triggers even before they occur.

The table on the next page shows a summary of these three types of trigger:

MANAGING TRIGGERS

So if we break down the super-category of 'trigger' into these three sub-categories, it can help to make them less overwhelming, and we can figure out different strategies for the three types, based on three parts of our front brain. And we can also prioritise our efforts as we see which types of trigger can be worked on even before we're triggered; which we learn to manage as they happen; and which we can look at and begin to deal with after they've happened.
Managing uncomfortable associations
Let's start with associations first, as the easiest type to deal with. We may have been abused as a child in a wood, and so we associate trees with abuse. We therefore see a picture of trees in our therapist's office, and our nose curls up in disgust. There's a sense that this isn't right-this isn't good. 'Could you take that picture down?' we might ask. 'It's triggering us,' we explain. We feel uncomfortable, and it would be so much easier for us if we didn't have to feel that discomfort.

The problem with this approach is that there are a lot of trees in the world, and there are a lot of pictures of trees in the world. We can't remove them all. And this is actually the best level to start at, as it can help us to build confidence in our ability to manage the greater levels of trigger.

The problem here is to with our thoughts. We have made a negative association between the trauma and something that would otherwise be neutral, maybe even positive. So the key here is to engage the front left brain, which is based around words, facts and knowledge. We need to reframe.

So we can start to unpick the associations we have made and replace them with new ones:
Oh look! I am making an association between this picture of a tree and my abuse. I was abused near trees, and so that's why I've made this association. But it's not a helpful one, because it's not actually doing anything to keep me safe. The truth is that trees aren't dangerous; abusers are. It wasn't the location that was dangerous; it was the person. And this isn't even a tree; it's just a picture of one. So, it is an association I've made, but I'm going to break that association and I'm going to create a new one instead. I'm going to imagine beautiful fruit trees in an orchard. I'm sitting under the tree and everything is peaceful and safe. I pick the fruit from the trees-apples, pears, plums-and it all taste delicious. The branches and leaves shade me from the hot sun. It's nice sitting here by the trees. Trees are lovely. Trees are safe.
It can be helpful to create your own 'frame' for your previous trigger and write it down, and then repeat it to yourself several times daily until-as in my example-every time you think of trees, you think of the orchard. That way I can remind myself that every time I see a tree, or a picture of a tree, I can direct myself towards the positive rather than allowing my mind to chase after the negative. It might take a lot of repetition, but it is highly effective in the long run.

If we don't do this, our life narrows and everything becomes a source of misery. If we want to be free from the effects of trauma, we have to start to learn to take control of the thoughts in our head. It's not that we can necessarily stop the thoughts coming; but when they do, we can choose to 'flip' them from something negative to something positive. Learning that we can start to direct some of our thoughts-guiding them from negative to positive-is a fundamental step in recovery: instead of being powerless victims of our thoughts, we can learn to take charge of them.

Worst still, if every time we see a tree, or a picture of a tree, we replay the negative association, it will grow and strengthen in our mind. And it allows the trauma to infect all the good things in life. Certainly for me, I had to learn to impose a boundary on the trauma-to be able to say, at times, 'No, you're not ruining THAT for me as well!' It takes time, with lots of repetition and perseverance, to change the associations, but if we keep on keeping on, it can massively improve the quality of our life.
Managing distressing reminders
Distressing reminders are more powerful than associations, but not as powerful as triggers. There is an emotional reaction, rather than just a mental one, but it's not at the level of a full somatic response. It's upsetting, but it's still at the edges of my window of tolerance. My front brain is still online a little and so there is some conscious choice over what happens next. The key to distressing reminders is soothing.

Soothing is about letting both our body and our brain know that we're safe and that nothing bad is going to happen now, so that we can go back into the 'green zone' of our window of tolerance. The distress we're feeling is in our body so it's important that we address this, not just cognitively, but somatically too. Breathing is absolutely key. It might sound simplistic-of course we need to breathe!-but breathing is a secret super-weapon in our fight against trauma. Breathing sits on the interface between what is conscious and unconscious: after all, you breathe all the time, even when you're not conscious of doing so, and yet you can also consciously take control of your breathing and speed it up or slow it down.

When we breathe in, it activates our sympathetic nervous system, the amber of fight and flight-our accelerator. So even just one in-breath can make our heart beat slightly faster. Breathing out, however, activates the parasympathetic sympathetic nervous system of the 'green zone'-our brakes. So when we're activated in our bodies by a distressing reminder of trauma, we can override our body's automatic response by consciously slowing our breathing. It can be useful to breathe in to the count of five, and then breathe out deeply, to the count of five or even longer. For full effect, we can do this mindfully, with our attention on the breath, for a minute or even longer. It's the most effective response to being triggered, and our breath is available to us everywhere, no matter what we're doing.

There are other ways to soothe our body's alarm response too. Many of us trauma survivors find it difficult to actively relax our bodies, and this is because the amygdala is telling us that there's a fire, so why would we want to relax? Relaxation and fire don't mix! But when we do relax our bodies, it sends an overriding message to the smoke alarm to say, 'This is okay! I've got this! I'm not concerned!' The smoke alarm is a two-way device: it sounds the alarm, but we can also tell it to mute the alarm, and we do this by actively relaxing our bodies. How? One of the easiest ways is actually to tense the body. Pick a muscle group-say your quadriceps (front of the upper leg)-and clench them really really tight for as long as you can, say 5 or 10 seconds. Then just let them go. This automatically relaxes the muscles and is far easier than trying to figure out how to make a muscle go floppy which is rigid and tense and ready for action!

The front right brain has the best connections to our body, and is calmed when we calm our bodies. It's also the part of the brain that is most active in 'attachment moments', times when we reach out to a significant person, another human being who is attuned to us and can provide a safe haven for us when we're distressed. It's not always appropriate or possible to get help from people-people aren't always available-but sometimes they are and just a little cry for help at these moments can help pull us back into our green zone. Who can you reach out to? And even if they're not available, can you imagine a conversation with them in which they are telling you that you're okay?

In addition, we can send mental messages to our smoke alarm to calm down, with reassuring mantras. For example:
It's okay. It's just my smoke alarm sounding. But it's a false alarm-just burnt toast, not the house on fire. I'm safe now. My body and brain have noticed something that reminds them of the trauma, and they're trying to protect me. But that danger was then; this is now, and I'm safe. No need for the smoke alarm. I can breathe, and relax. Managing true triggers
If we can become proficient at reframing our uncomfortable associations, and soothing our distressing reminders, then we can move on to tackling the most difficult level of trigger, the 'true trigger'. This is the full-blown, all-out emergency that can at first be almost impossible to deal with. We go either into the amber zone, with fight or flight, manifesting even in a panic attack, or we tip even further into the red zone and we shut down with freeze. How on earth can we manage when this is happening?

To start with, we can't. We can only work on 'repairing' the brain after the event. It is very common, after being triggered like this, to feel shame and frustration. 'What happened? Oh no! I can't believe I was triggered again!' We unleash a verbal torrent of abuse on ourselves for having reacted the way we did, or we feel helpless and overwhelmed at our inability to prevent it. Either way, our attack on ourselves sends a new message to the amygdala that we are under attack. It can't distinguish between a real attack from an outside source, and an internal attack from ourselves: it just sounds the alarm! So we end up in a vicious cycle: we get triggered, and then afterwards we attack ourselves for having been triggered, which triggers us further.

REFRAMING EXAMPLES

'Oh look-I'm thinking that thought again that it's dangerous to stay in a hotel room. That's my brain trying to keep me safe because bad things happened previously in hotel rooms... So let's weigh this up. Are hotel rooms intrinsically dangerous? What about this particular hotel room? How can I check out if it's safe or not? How can I acknowledge that my back brain is trying to keep me safe, whilst allowing my front brain to make a fresh risk assessment based on the real here-and-now?'

'Oh look-I'm thinking that thought again that I can't trust men. This is because I was abused by some men. But it wasn't the fact that they were male that caused my abuse. It was their choices as individuals. There are many men, even ones that I know now, who haven't abused me. So how can I acknowledge that my back brain is trying to keep me safe, whilst also getting my front brain to perform a risk assessment based on these unique, individual men that I'm going into this meeting with?'

'Oh look-I'm thinking that thought again that the word 'abuse' is triggering. That's my brain trying to help me avoid remembering the abuse that I suffered, and it helped me survive psychologically when I was a child. But right here, right now, it's just a word made up of five letters. It refers to all sorts of things-it's not specific to my abuse. It might be that I can learn something that will help me with my recovery, and I don't want my life to be narrowed by trying to avoid it all the time. It's just a word. It can't hurt me.'

So we may not be able-at least to start with-to stop the initial trigger, but we can do something afterwards. We can be kind to ourselves, and we can just notice the fact that we were triggered, without judgment or criticism. We can say, 'Aah! I was triggered! How interesting! ' If we can take all the blame out of it, it will at the very least prevent us from being triggered again. It's like stubbing our toe and then whacking ourselves on the head for being clumsy-we end up not just with one pain, but two!

Self-compassion turns down the sensitivity of the smoke alarm. Staying calm after the event gets the smoke alarm to see a trigger as just 'one of those things', but not as representing real danger. Because afterwards, nothing bad happens. I'm walking through the woods, a dog runs up to me, I get triggered... and I may even lose time as I switch to a traumatised part of myself. But afterwards, as my front brain comes back online, I can look back at what happened and I can say, 'I was just triggered-that's all it was. Nothing bad happened. I'm safe.'

I like the word 'just'. It helps defuse situations. It gives a shrug of the shoulders to something that otherwise is clamouring to shout 'DANGER!' It's an important part of overcoming trauma. Because all of these reminders of trauma feel like they're an emergency; it feels like we're going to die. And we can validate these feelings, because yes-we really do feel this. But we mustn't believe them, because it's okay now and we're safe.

If we keep telling ourselves we're unsafe, we'll keep on being triggered. The key to recovery from triggers and flashbacks is to work towards feeling safe. And so we have to start telling ourselves that we're safe even before we feel we are. We have to base what we tell ourselves on external reality, rather than internal feelings. Are we actually safe? Even if we don't feel it, we need to be saying it, and the word 'just' can help us to tune things down a little. 'I'm just triggered... It's just a tree... It's just a dog... It's just my smoke alarm sounding... It's just trying to keep me safe.'

So to manage true triggers better, our first step is to 'just notice' that they've happened, and be compassionate and reassure ourselves that we're safe now. We learn to calm down quickly after having been triggered, so that at the very least we are minimising the harm.

The next step is to build reassuring mantras into our everyday thinking, to train the conscious mind so that our unconscious mind can start to do things habitually. These are the kinds of mantras I mentioned above for 'distressing reminders'. It's utilising the same concept as training for paramedics or people in the military-people who absolutely have to stay calm even in the midst of a crisis or a full-blown attack. They are drilled, over and over again, to keep their front brains online even while bullets are flying overhead, or a patient is in cardiac arrest. And many of them have simple mantras: 'ABC: airways, breathing, circulation.' Rather than freaking out and not knowing what to do, the emergency responder can fall back on doing the basics: the ABC. In the military, the most basic is 'ready, aim, fire!' You don't want someone to fire a gun until they've readied themselves in position and taken aim. You train the conscious mind so that it becomes a habit even under difficult conditions. And that's the same process that we can use to learn to manage triggers.

Making your own mantras, which make most sense to you, is most effective. They must be short and simple-able to be repeated easily, maybe using rhyme or alliteration to plug them into memory. Write them down, so that you can keep practising them at all times of day or night, and carry them around as 'mantra cards' so that when you are triggered and your front brain is going offline, you don't have to remember them-you just have to remember where they are. It can also be helpful to let professionals and significant others know about them, so that they can use them if you are too triggered to be able to use them for yourself.

WE CAN RECOVER!

When daily life is consumed with a battle with triggers, it can feel that nothing will ever change and that triggers are impossible to manage. But if we narrow down the problem-if we take the general and make it specific-then we can split the problem up into three types of trigger, and work out a strategy for each. We need to stop and ask: is this an association, a reminder, or a trigger?

If it's an uncomfortable association, what can I replace the negative association with? How can I reframe it?

If it's a distressing reminder, how can I soothe my body, get support and calm myself down?

If it's a true trigger, can I just notice and be compassionate towards myself? Can I practice some mantras that remind me that I'm safe?

The bad news is that this process is hard work and requires dedication and lots of repetition. Our brains are plastic and do change-but not in response to a one-off. If you want to learn a musical instrument, a foreign language or how to drive a car, you have to practice and practice and then practice some more. The same is true for changing the way our brains respond to trauma cues. We can change them, but we need to work hard at it. The rewards, however, are truly phenomenal. I cannot begin to describe how different my life is now from when I was beset with hourly, daily triggers. I'm so glad that I put the time and effort into retraining my brain, and I'm so grateful that I had the support to do it. And I hope you do too.

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Three types of Trigger ... Three techniques for taming | PODS

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All I did was walk into the kitchen and pick up a cloth. But the sudden waft of bleach flung me far, far back into some childhood memory. I switched to a traumatised part of myself. I had been 'triggered'.

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TRAUMA                                A resource for Pavilions. service users

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Joelle Rabow Maletis: The psychology of post-traumatic stress disorder

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Many of us will experience some kind of trauma during our lifetime. Sometimes, we escape with no long-term effects. But for millions of people, those experiences linger, causing symptoms like flashbacks, nightmares, and negative thoughts that interfere with everyday life. Joelle Rabow Maletis details the science behind post-traumatic stress disorder, or PTSD.

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Language: English | Spanish | French

Abstract

Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex. Traumatic stress can be associated with lasting changes in these brain areas. Traumatic stress is associated with increased cortisol and norepinephrine responses to subsequent stressors. Antidepressants have effets on the hippocampus that counteract the effects of stress. Findings from animal studies have been extended to patients with post-traumatic stress disorder (PTSD) showing smaller hippocampal and anterior cingulate volumes, increased amygdala function, and decreased medial prefrontal/anterior cingulate function. In addition, patients with PTSD show increased cortisol and norepinephrine responses to stress. Treatments that are efficacious for PTSD show a promotion of neurogenesis in animal studies, as well as promotion of memory and increased hippocampal volume in PTSD.

Keywords: positron emission tomography, depression, stress, post-traumatic stress disorder

Abstract

El estrés traumático surte efectos muy diversos sobre la función y la estructura cerebrales. Las regiones cerebrales implicadas en la respuesta al estrés son la amígdala (núcleo amigdalino), el hipocampo y la corteza prefrontal. Los sistemas neuroquímicos, como el cortisol y la noradrenalina, desempeñan una misión crítica en la respuesta al estrés. Estas regiones cerebrales influyen sobre la respuesta al estrés y sobre la memoria, lo que subraya la interrelación entre la memoria y la respuesta al estrés traumático. Los antidepresivos actúan sobre el hipocampo y contrarrestan el efecto del estrés. Los estudios sobre pacientes con trastorno por estrés postraumático (TEPT) revelan alteraciones en las regiones cerebrales implicadas en los estudios con animales como la amígdala, el hipocampo y la corteza prefrontal, así como en los sistemas neuroquímicos de respuesta al estrés, entre ellos el cortisol y la noradrenalina. Los tratamientos con eficacia frente al TEPT promueven la neurogénesis en los estudios con animales y también aumentan la memoria, y el volumen hipocámpico en el TEPT. Se requieren nuevos estudios para evaluar los mecanismos neurales de la respuesta terapéutica en el TEPT.

Résumé

Le stress traumatique exerce une grande variété d'effets sur la fonction et la structure cérébrales. Les aires cérébrales impliquées dans la réponse au stress comprennent l'amygdale, l'hippocampe et le cortex préfrontal. Les systèmes neurochimiques, incluant le cortisol et la norépinéphrine, jouent un rôle critique dans la réponse au stress. Ces aires cérébrales influent sur la mémoire et sur la réponse au stress traumatique, soulignant ainsi les interactions existant entre les deux. Les effets des antidépresseurs sur l'hippocampe compensent les effets du stress. Les études chez les patients atteints de trouble stress post-traumatique (ESPT) montrent des modifications des aires cérébrales impliquées au cours des études animales, telles l'amygdale, l'hippocampe et le cortex préfrontal, ainsi que des modifications des systèmes neurochimiques de réponse au stress comme le cortisol et la noradrénaline. Les traitements efficaces dans l'ESPT entraînent une activation de la neurogenèse chez l'animal de même qu'une amélioration de la mémoire et une augmentation du volume de l'hippocampe dans l'ESPT. Il faudra d'autres études pour évaluer les mécanismes neuronaux dans la réponse thérapeutique au cours de l'ESPT.

Effects of traumatic stress

Traumatic stressors such as early trauma can lead to posttraumatic stress disorder (PTSD), which affects about 8% of Americans at some time In their lives,1 as well as depression,2,3 substance abuse,1,4 dissociation,5 personality disorders,6,7 and health problems.8 For many trauma victims, PTSD can be a lifelong problem.9 The President's New Freedom Commission Report highlights the Importance of providing services for mental disorders related to early trauma.10-12 However, the development of effective treatments is limited by gaps in knowledge about the underlying neurobiological mechanisms that mediate symptoms of traumarelated disorders like PTSD. This paper reviews preclinical and clinical studies on the effects of traumatic stress on the brain.

Normal development of the brain across the lifespan

To understand how traumatic stress occurring at different stages of the life cycle interacts with the developing brain, it is useful to review normal brain development. The normal human brain undergoes changes in structure and function across the lifespan from early childhood to late life. Understanding these normal developmental changes is critical for determining the difference between normal development and pathology, and how normal development and pathology interact.

Although the bulk of brain development occurs in utero, the brain continues to develop after birth. In the first 5 years of life there is an overall expansion of brain volume related to development of both gray matter and white matter structures; however, from 7 to 17 years of age there is a progressive increase in white matter (felt to be related to ongoing myelination) and decrease in gray matter (felt to be related to neuronal pruning) while overall brain size stays the same.13-16 Gray matter areas that undergo the greatest increases throughout this latter developmental epoch include frontal cortex and parietal cortex.17,18 Basal ganglia decrease in size, while corpus callosum,19,20 hippocampus, and amygdala21-23 appear to increase in size during childhood, although there may be developmental sex-laterality effects for some of these structures.24 Overall brain size is 10% larger in boys than girls during childhood.24

During the middle part of life (from age 20 to 70) there is a gradual decrease in caudate,25 diencephalon,25 and gray matter,25,26 which is most pronounced in the temporal27 and frontal cortex,26 with enlargement of the ventricles26,27 and no change in white matter.25,26 Studies have not been able to document changes in hippocampal volume in normal populations during this period.27 After menopause in women at about the age of 50, however, there are changes in reproductive hormones, such as decreased levels of estrogen. Since estrogen promotes neuronal branching in brain areas such as the hippocampus,28 a loss of estrogen may lead to changes in neuronal structure. Although the effects of menopause on the brain have not been well studied, it is known that sex hormones also affect brain function and circuitry29; therefore, the changes in sex hormones with menopause will presumably affect brain function, as well as possibly structure. There is some evidence in super-elderly individuals (age >70) for modest reductions in hippocampal volume with late stages of aging.27,30 More robust findings have included increased ventricular volume and reduction in gray matter, temporal lobe, and cerebellum volumes with normal aging, that begins before the age of 70.

Therefore, trauma at different stages in life will presumably have different effects on brain development. The few studies that have looked at this issue do suggest that there are differences in the effects of trauma on neurobiology, depending on the stage of development at which the trauma occurs. Studies in this area, however, have been limited.

Neurobiology of PTSD

PTSD is characterized by specific symptoms, including intrusive thoughts, hyperarousal, flashbacks, nightmares, and sleep disturbances, changes in memory and concentration, and startle responses. Symptoms of PTSD are hypothesized to represent the behavioral manifestation of stress-induced changes in brain structure and function. Stress results in acute and chronic changes in neurochemical systems and specific brain regions, which result in longterm changes in brain "circuits," involved in the stress response.34-37 Brain regions that are felt to play an important role in PTSD include hippocampus, amygdala, and medial prefrontal cortex. Cortisol and norepinephrine are two neurochemical systems that are critical in the stress response (Figure 1 .)

The corticotropin-releasing factor (CRF)/hypothalamic-pituitary-adrenal (HPA) axis system plays an important role in the stress response. CRF is released from the hypothalamus, with stimulation of adrenocorticotropic hormone (ACTH) release from the pituitary, resulting in glucocorticoid (Cortisol in man) release from the adrenal, which in turn has a negative feedback effect on the axis at the level of the pituitary, as well as central brain sites including hypothalamus and hippocampus. Cortisol has a number of effects which facilitate survival. In addition to its role in triggering the HPA axis, CRF acts centrally to mediate fear-related behaviors,38 and triggers other neurochemical responses to stress, such as the noradrenergic system via the brain stem locus coeruleus.39 Noradrenergic neurons release transmitter throughout the brain; this is associated with an increase in alerting and vigilance behaviors, critical for coping with acute threat.40-42

Studies in animals showed that early stress has lasting effects on the HPA axis and norepinephrine. A variety of early stressors resulted in increased glucocorticoid response to subsequent stressors.43-45 Maternally deprived rats had decreased numbers of glucocorticoid receptors in the hippocampus, hypothalamus, and frontal cortex.46 Stressed animals demonstrated an inability to terminate the glucocorticoid response to stress,47,48 as well as deficits in fast-feedback of glucocorticoids on the HPA axis, which could be related to decreased glucocorticoid receptor binding in the hippocampus.49 Early postnatal adverse experiences increase hypothalamic CRF messenger ribonucleic acid (mRNA), median eminence CRF content, and stress-induced glucocorticoid50 and ACTH release.46 These effects could be mediated by an increase in synthesis of CRH mRNA following stress.51 In nonhuman primates, adverse early experiences resulted in long-term effects on behaviors, as well as elevated levels of CRF in the cerebrospinal fluid.52 Exposure to chronic stress results in potentiation of noradrenergic responsiveness to subsequent stressors and increased release of norepinephrine in the hippocampus and other brain regions.42

Preclinical and clinical studies have shown alterations in memory function following traumatic stress,53 as well as changes in a circuit of brain areas, including hippocampus, amygdala, and medial prefrontal cortex, that mediate alterations in memory.54 The hippocampus, a brain area involved in verbal declarative memory, is very sensitive to the effects of stress. Stress in animals is associated with damage to neurons in the CA3 region of the hippocampus (which may be mediated by hypercortisolemia, decreased brain-derived neurotrophic factor (BDNF), and/or elevated glutamate levels) and inhibition of neurogenesis.55-60 High levels of glucocorticoids seen with stress were also associated with deficits in new learning.61,62

Antidepressant treatments have been shown to block the effects of stress and/or promote neurogenesis.58,63-66 Animal studies have demonstrated several agents with potentially beneficial effects on stress-induced hippocampal damage. It has been found that phenytoin blocks the effects of stress on the hippocampus, probably through modulation of excitatory amino acid-induced neurotoxicity.67 Other agents, including tianeptine, dihydroepiandosterone (DHEA), and fluoxetine have similar effects.63,64,66,68-73 These medications may share a common mechanism of action through upregulation of cyclic adenosine monophosphate (cAMP) response element binding protein (CREB) that may lead to regulation of expression of specific target genes involved in structural modeling of the hippocampus. Such treatment effects on BDNF and trkB messenger ribonucleic acid (mRNA), can have long-term effects on brain structure and function. There is new evidence that neurogenesis is necessary for the behavioral effects of antidepressants,74,75 although this continues to be a source of debate.72,76

The hippocampus demonstrates an unusual capacity for neuronal plasticity and regeneration. In addition to findings noted above related to the negative effects of stress on neurogenesis, it has recently been demonstrated that changes in the environment, eg, social enrichment or learning, can modulate neurogenesis in the dentate gyrus of the hippocampus, and slow the normal age-related decline in neurogenesis.77,78 Rat pups that are handled frequently within the first few weeks of life (picking them up and then returning them to their mother) had increased type II glucocorticoid receptor binding which persisted throughout life, with increased feedback sensitivity to glucocorticoids, and reduced glucocorticoid-mediated hippocampal damage in later life.79 These effects appear to be due to a type of "stress inoculation" from the mothers' repeated licking of the handled pups.80 Considered together, these findings suggest that early in the postnatal period there is a naturally occurring brain plasticity in key neural systems that may "program" an organism's biological response to stressful stimuli. These findings may have implications for victims of childhood abuse.

Long-term dysregulation of the HPA axis is associated with PTSD, with low levels of Cortisol found in chronic PTSD in many studies81-86 and elevations in CRF.82,87 Not all studies, however, have found lower Cortisol levels in PTSD.88-91 Exposure to a traumatic reminder appears to be associated with a potentiated release of Cortisol in PTSD.92 The few studies of the effects of early stress on neurobiology conducted in clinical populations of traumatized children have generally been consistent with findings from animal studies. Research in traumatized children has been complicated by issues related to psychiatric diagnosis and assessment of trauma.93 Some studies have not specifically examined psychiatric diagnosis, while others have focused on children with trauma and depression, and others on children with trauma and PTSD. Sexually abused girls (in which effects of specific psychiatric diagnosis were not examined) had normal baseline Cortisol and blunted ACTH response to CRF,94 while women with childhood abuse-related PTSD had hypercortisolemia.95 Another study of traumatized children in which the diagnosis of PTSD was established showed increased levels of Cortisol measured in 24-hour urines.96 Emotionally neglected children from a Romanian orphanage had elevated Cortisol levels over a diurnal period compared with controls.97 Maltreated school-aged children with clinicallevel internalizing problems had elevated Cortisol compared with controls.98 Depressed preschool children showed increased Cortisol response to separation stress.99 Adult women with a history of childhood abuse showed increased suppression of Cortisol with low-dose (0.5 mg) dexamethasone.100 Women with PTSD related to early childhood sexual abuse showed decreased baseline Cortisol based on 24-hour diurnal assessments of plasma, and exaggerated Cortisol response to stressors (traumatic stressors101 more than neutral cognitive stressors).102 We also found that patients with PTSD had less of an inhibition of memory function with synthetic Cortisol (dexamethasone) than normal subjects.103 Adult women with depression and a history of early childhood abuse had an increased Cortisol response to a stressful cognitive challenge relative to controls,104 and a blunted ACTH response to CRF challenge.105 These findings show longterm changes in stress responsive systems. Early in development, stress is associated with increased Cortisol and norepinephrine responsiveness, whereas with adulthood, resting Cortisol may be normal or low, but there continues to be increased Cortisol and norepinephrine responsiveness to stressors. In addition, early stress is associated with alterations in hippocampal morphology which may not manifest until adulthood, as well as increased amygdala function and decreased medial prefrontal function.

Cognitive function and brain structure in PTSD

Studies in PTSD are consistent with changes in cognition and brain structure. Multiple studies have demonstrated verbal declarative memory deficits in PTSD.53,106-108

Patients with PTSD secondary to combat109-113 and childhood abuse114,115 were found to have deficits in verbal declarative memory function based on neuropsychological testing. Studies, using a variety of measures (including the Wechsler Memory Scale, the visual and verbal components of the Selective Reminding Test, the Auditory Verbal Learning Test, Paired Associate Recall, the California Verbal New Learning Test, and the Rivermead Behavioral Memory Test), found specific deficits in verbal declarative memory function, with a relative sparing of visual memory and IQ. These studies have been conducted in both patients with PTSD related to Vietnam combat,109-113,116,119-121,123 rape,117 the Holocaust,124-126 adults with early childhood abuse,115 and traumatized children.118 One study in adult rape survivors showed that verbal declarative memory deficits are specifically associated with PTSD, and are not a nonspecific effect of trauma exposure.117 Another study of women with early childhood sexual abuse in which some, but not all, of the patients had PTSD, showed no difference between abused and nonabused women,127 while another study was not able to show a difference between Vietnam veterans with and without PTSD.128 Other types of memory disturbances studied in PTSD include gaps in memory for everyday events (dissociative amnesia),129 deficits in autobiographical memory,130 an attentional bias for trauma-related material,131-140 and frontal lobe-related impairments.141 These studies suggest that traumas such as early abuse with associated PTSD result in deficits in verbal declarative memory. It is not clear if cognitive deficits in early abuse survivors are specific to PTSD and are not related to the non-specific effects of abuse.

These effects were specific to verbal (not visual) memory, and were significant after controlling for IQ. Some of these studies used neuropsychological tests of declarative memory, such as the Wechsler Memory Scale (WMS) and Selective Reminding Test (SRT), that have been validated as sensitive to loss of neurons in the CA3 region of the hippocampus in epileptics who underwent hippocampal resection.142,143 Vietnam veterans with PTSD were originally shown by us to have 8% smaller right hippocampal volume based on magnetic resonance imaging (MRI) relative to controls matched for a variety of factors such as alcohol abuse and education ( P<0.05); smaller volume was correlated with deficits in verbal declarative memory function as measured with the Wechsler Memory Scale.144 A second study from our group showed a 12% reduction in left hippocampal volume in 17 patients with childhood abuse-related PTSD compared with 17 case-matched controls, that was significant after controlling for confounding factors.145 Smaller hippocampal volume was shown to be specific to PTSD within the anxiety disorders, and was not seen in panic disorder.146 Gurvits et al147 showed bilateral hippocampal volume reductions in combat-related PTSD compared with combat veterans without PTSD and normal controls. Combat severity was correlated with volume reduction. Stein et al148 found a 5% reduction in left hippocampal volume. Other studies in PTSD have found smaller hippocampal volume and/or reductions in iV-acetyl aspartate (NAA), a marker of neuronal integrity.149-153 Studies in childhood154-156 and new-onset157,158 PTSD did not find hippocampal volume reduction, although reduced NAA (indicating loss of neuronal integrity) was found in medial prefrontal cortex in childhood PTSD.159 In a recent meta-analysis we pooled data from all of the published studies and found smaller hippocampal volume for both the left and the right sides, equally in adult men and women with chronic PTSD, and no change in children.160 More recent studies of holocaust survivors with PTSD did not find a reduction in hippocampal volume, although PTSD patients who developed PTSD in response to an initial trauma had smaller hippocampal volume compared with those who developed PTSD after repeated trauma, suggesting a possible vulnerability of smaller hippocampal volume.161 Two independent studies have shown that PTSD patients have deficits in hippocampal activation while performing a verbal declarative memory task,149,162 although it is unclear if this is a deficit in activation or higher hippocampal blood flow at baseline. Both hippocampal atrophy and hippocampal-based memory deficits reversed with treatment with the selective serotonin reuptake inhibitor (SSRI) paroxetine, which has been shown to promote neurogenesis (the growth of neurons) in the hippocampus in preclinical studies.163 In addition, treatment with the anticonvulsant phenytoin led to an improvement in PTSD symptoms164 and an increase in right hippocampal and right cerebral volume.165 We hypothesize that stress-induced hippocampal dysfunction may mediate many of the symptoms of PTSD which are related to memory dysregulation, including both explicit memory deficits as well as fragmentation of memory in abuse survivors. It is unclear at the current time whether these changes are specific to PTSD, whether certain common environmental events (eg, stress) in different disorders lead to similar brain changes, or whether common genetic traits lead to similar outcomes.

The meaning of findings related to deficits in memory and the hippocampus in PTSD, and questions related to the relative contribution of genetic and environmental factors, has become an important topic in the field of PTSD and stress research. There are three possible models, taking into account genetic or environmental factors, which have been proposed to explain smaller hippocampal volume in PTSD: Model A (Environment), Model B (Environment and Genetic), and Model C (Genetic).166-169 In Model C (Genetic), smaller hippocampal volume represents a premorbid risk factor for PTSD. In support of this model Pitman and colleagues170 have demonstrated that lower premilitary IQ is associated with combat-related PTSD, as well as finding a correlation between PTSD symptoms and hippocampal volume in twin brothers.151 Model A (Environment) states that stress leads to damage or inhibition of neurogenesis via hypercortisolemia, decreased BDNF, or increased glutamate. Model B (Environment/Genetic) states that a combination of environmental and genetic factors leads to deficits in hippocampal function and structure. Showing that an intervention like medication changes hippocampal volume and cognition would provide support for at least a partial contribution of the environment to the outcomes of interest.

In addition to the hippocampus, other brain structures have been implicated in a neural circuitry of stress, including the amygdala and prefrontal cortex. The amygdala is involved in memory for the emotional valence of events, and plays a critical role in the acquisition of fear responses. The medial prefrontal cortex includes the anterior cingulate gyrus (Brodmann's area [BA] 32) and subcallosal gyrus (area 25) as well as orbitofrontal cortex. Lesion studies demonstrated that the medial prefrontal cortex modulates emotional responsiveness through inhibition of amygdala function. Conditioned fear responses are extinguished following repeated exposure to the conditioned stimulus in the absence of the unconditioned (aversive, eg, electric shock) stimulus. This inhibition appears to be mediated by medial prefrontal cortical inhibition of amygdala responsiveness.

Animal studies also show that early stress is associated with a decrease in branching of neurons in the medial prefrontal cortex.171 Rauch and colleagues found smaller volume of the anterior cingulate based on MRI measurements in PTSD172; we have replicated these findings in women with abuse and PTSD.160 An important question is whether these effects are reversible with treatment.

Neural circuits in PTSD

Brain imaging studies have shown alterations in a circuit including medial prefrontal cortex (including anterior cingulate), hippocampus, and amygdala in PTSD. Many of these studies have used different methods to trigger PTSD symptoms (eg, using traumatic cues) and then look at brain function. Stimulation of the noradrenergic system with yohimbine resulted in a failure of activation in dorsolateral prefrontal, temporal, parietal, and orbitofrontal cortex, and decreased function in the hippocampus.173 Exposure to traumatic reminders in the form of traumatic slides and/or sounds or traumatic scripts was associated with an increase in PTSD symptoms, decreased blood flow, and/or failure of activation in the medial prefrontal cortex/anterior cingulate, including Brodmann's area 25, or subcallosal gyrus, area 32 and 24, as measured with positron emission tomography (PET) or functional MRI (fMRI).174-183 Other findings in studies of traumatic reminder exposure include decreased function in hippocampus,176 visual association cortex,176,180 parietal cortex, and inferior frontal gyrus, and increased function in amygdala,181,184 posterior cingulate, and parahippocampal gyrus.174,176,178 Shin and colleagues found a correlation between increased amygdala function and decreased medial prefrontal function with traumatic reminders,181 indicating a failure of inhibition of the amygdala by the medial prefrontal cortex that could account for increased PTSD symptoms with traumatic reminders. Other studies found increased amygdala and parahippocampal function and decreased medial prefrontal function during performance of an attention task,182 increased posterior cingulate and parahippocampal gyrus and decreased medial prefrontal and dorsolateral prefrontal function during an emotional Stroop paradigm,185 and increased amygdala function with exposure to masked fearful faces.186 Retrieval of emotionally valenced words187 (eg "rape-mutilate") in women with PTSD from early abuse resulted in decreases in blood flow in an extensive area which included orbitofrontal cortex, anterior cingulate, and medial prefrontal cortex (BA 25, 32, and 9), left hippocampus, and fusiform gyrus/inferior temporal gyrus, with increased activation in posterior cingulate, left inferior parietal cortex, left middle frontal gyrus, and visual association and motor cortex.188 Another study found a failure of medial prefrontal cortical/anterior cingulate activation, and decreased visual association and parietal cortex function, in women with abuse and PTSD relative to women with abuse without PTSD, during performance of the emotional Stroop task (ie, naming the color of a word such as "rape").189 We recently found increased amygdala activation with classical fear conditioning (pairing a shock and a visual stimulus), and decreased medial prefrontal cortex function with extinction, in abuse-related PTSD.190 The findings described above point to a network of related regions mediating symptoms of PTSD, including medial prefrontal cortex, anterior cingulate, hippocampus, amygdala, posterior cingulate, parietal, visual association, and dorsolateral prefrontal cortex.191

Fewer brain imaging studies have been performed in children with PTSD. Several studies have shown alterations in electroencephalogram (EEG) measures of brain activity in children with a variety of traumas who were not selected for diagnosis compared with healthy children. About half of the children in these studies had a psychiatric diagnosis. Abnormalities were located in the anterior frontal cortex and temporal lobe and were localized to the left hemisphere.192,193 Two studies have found reductions in brain volume in children with trauma and PTSD symptoms.154,155 One group did not find reductions in hippocampal volume, either at baseline or over a longitudinal period,154,156 while another group found an 8.5% reduction in hippocampal volume that was not significant after controlling for smaller brain volumes in the PTSD group.155 One study used single-voxel proton magnetic resonance spectroscopy (proton MRS) to measure relative concentration of NAA and creatinine (a marker of neuronal viability) in the anterior cingulate of 11 children with maltreatment-related PTSD and 11 controls. The authors found a reduction in the ratio of NAA to creatinine in PTSD relative to controls.159 Studies have also found smaller size of the corpus callosum in children with abuse and PTSD relative to controls.154 as well as larger volume of the superior temporal gyrus.194 In a study of abused children in whom diagnosis was not specified, there was an increase in T2 relaxation time in the cerebellar vermis, suggesting dysfunction in this brain region.195 The reason for differences in findings between adults and children are not clear; however, factors such as chronicity of illness or interaction between trauma and development may explain findings to date.

In summary, dysfunction of a circuit involving the medial prefrontal cortex, dorsolateral prefrontal cortex, and possibly hippocampus and amygdala during exposure to traumatic reminders may underlie symptoms of PTSD. These studies have primarily assessed neural correlates of traumatic remembrance, while little has been done in the way of utilizing cognitive tasks as probes of specific regions, such as memory tasks as probes of hippocampal function.

MRI assessment of brain abnormalities in PTSD and trauma spectrum disorders

Findings of smaller hippocampal volume appear to be associated with a range of trauma related psychiatric disorders, as long as there is the presence of psychological trauma. We have used MRI to show smaller hippocampal volume in PTSD, depression,197 depression with early abuse,198 borderline personality disorder (BPD) with early abuse,199 and Dissociative Identity Disorder (DID) with early abuse.200 The greatest magnitude of difference was seen in the DID patients, who had unusually severe early childhood sexual abuse histories. We did not find changes in hippocampal volume in patients with panic disorder without a history of abuse (suggesting that findings are not generalized to other anxiety disorders).201 We found smaller amygdala volume in BPD with early abuse199 and increased amygdala volume in depression.197,202 Patients with depression had smaller orbitofrontal cortex volume with no changes in anterior cingulate (BA 32) or medial prefrontal cortex (BA 25).203 More recently, we found smaller anterior cingulate volume in women with abuse and PTSD relative to controls.204

Neural circuits in women with abuse and PTSD

We have used PET to study neural circuits of traumarelated disorders in women with early abuse and a variety of trauma spectrum mental disorders. Initially we studied women with abuse and PTSD.54,205-208 We initially measured brain activation with a paragraph-encoding task in conjunction with PET 0-15 water measurement of brain blood flow. Women with abuse and PTSD showed a failure of hippocampal activation during the memory task relative to controls.149 Women with abuse and PTSD in this study also had smaller hippocampal volume measured with MRI relative to both women with abuse without PTSD and nonabused non-PTSD women. The failure of hippocampal activation was significant after controlling differences in hippocampal volume as well as accuracy of encoding. In another study we measured neural correlates of exposure to a personalized script of childhood sexual abuse. Women with abuse and PTSD showed a failure of medial prefrontal and hippocampal activation relative to abused women without PTSD.176 Women with abuse and PTSD also showed a failure of medial prefrontal and hippocampal function during recall of paired word associates with traumaticemotional content (eg, "rape-mutilate"),188 and decreased medial prefrontal function during an emotional Stroop task with trauma-content words.209 Other studies showed a failure of medial prefrontal activation in women with BPD and early abuse during an abandonment script.210 Women with BPD and abuse had increased psychophysiological responses to abandonment scripts relative to trauma scripts, while women with PTSD and abuse had the opposite pattern,211 indicating differential responding in those two disorders in spite of the common exposure to early abuse.

In another project we studied 19 physically healthy women including women with a history of severe childhood sexual abuse and the diagnosis of current PTSD (N=8) and women without childhood abuse or PTSD (N=11).212 All subjects underwent PET measurement of cerebral blood flow and psychophysiology measurement of heart rate and skin conductance during habituation, acquisition, and extinction conditions, on a single day, with scanning during a control condition on another day separated by 1 week from the active condition. Subjects were randomly assigned to undergo either the active condition or the control condition first (ie, active-control or control-active). Subjects were told at the beginning of the study that they would be exposed to electric shocks and viewing images on a screen during collection of PET and psychophysiology data. During habituation subjects were exposed to a blue square on a screen (conditioned stimulus [CS]), 4 seconds in duration, followed by 6 seconds of a blank screen. CS exposure was repeated eight times at regular intervals over 80 seconds in two separate blocks separated by 8 minutes. One PET image of brain blood flow was obtained starting from the beginning of each of the blocks. During active fear acquisition exposure to the blue square (CS) was paired with an electric shock to the forearm (unconditioned stimulus [UCS]).Subjects had 8 paired CS-UCS presentations at 10-second intervals for each of two blocks. With extinction subjects were again exposed to the blue squares (CS) with out shock ("active" extinction). On a second day subjects went through the same procedure with electric shocks delivered randomly when the blue square was not present (unpaired CS-UCS) (an equal number as on day 1) during scans 3 and 4, which served as a control for active fear acquisition.

PTSD subjects had increased symptoms of anxiety, fear, dissociation, distress, substance use disorders (SUDs), and PTSD at all time points during both study days relative to non-PTSD. Acquisition of fear was associated with increased skin conductance (SC) responses to CS exposure during the active versus the control conditions in all subjects. There was increased SC for PTSD during the first CS-UCS presentation. Extinction of fear was associated with increased skin conductance (SC) responses to CS exposure during the active versus the control conditions in all subjects. When PTSD and non-PTSD subjects were examined separately, SC levels were significantly elevated in non-PTSD subjects undergoing extinction following the active compared with the control condition during session one.

PTSD subjects showed activation of the bilateral amygdala during fear acquisition compared with the control condition. Non-PTSD subjects showed an area of activation in the region of the left amygdala. When PTSD subjects and control subjects were directly compared, PTSD subjects showed greater activation of the left amygdala during the fear conditioning condition (pairing of US and CS) relative to the random shock control than healthy women. Other areas that showed increased activation with fear acquisition in PTSD included bilateral superior temporal gyrus (BA 22), cerebellum, bilateral inferior frontal gyrus (BA 44, 45), and posterior cingulate (BA 24). Fear acquisition was associated with decreased function in medial prefrontal cortex, visual association cortex, and medial temporal cortex, inferior parietal lobule function, and other areas. Extinction of fear responses was associated with decreased function in the orbitofrontal and medial prefrontal cortex (including subcallosal gyrus, BA 25, and anterior cingulate BA 32), visual association cortex, and other areas, in the PTSD subjects, but not in the controls. Amygdala blood flow with fear acquisition was negatively correlated with medial prefrontal blood flow with fear extinction (increased blood flow in amygdala correlated with decreased blood flow in medial prefrontal cortex) in all subjects ( r=-0.48; P<0.05). Increased amygdala blood flow with fear acquisition was positively correlated with PTSD ( r=0.45), anxiety ( r=0.44) and dissociative ( r=0.80) symptom levels in PTSD (but not non-PTSD) subjects. There was a negative correlation between medial prefrontal blood flow during extinction and anxiety as measured with the Panic Attack Symptom Scale (PASS) during extinction in the PTSD group only, which was significant after correction for multiple comparisons ( r=-0.90; P=0.006).190 This study was consistent with increased amygdala function with fear acquisition, and decreased medial prefrontal (anterior cingulate) function during extinction in PTSD. This is consistent with the model of an overactive amygdala and a failure of medial prefrontal cortex to extinguish, or shut off, the amygdala, when the acute threat is no longer present.

Treatment of PTSD

Intervening soon after the trauma is critical for long-term outcomes, since with time traumatic memories become indelible and resistant to treatment.213 Early treatments are not necessarily effective. For instance, studies have shown that Critical Incident Stress Debriefing (CISD) can be associated with a worsening of outcome relative to no treatment at all.214 Pharmacological treatment of chronic PTSD has shown efficacy originally for imipramine,215 amitriptyline,216 and phenalzine,215 and later for brofaramine,217 paroxetine,218,219 and sertraline.220 Selective serotonin reuptake inhibitors (SSRIs) and tianeptine are now recommended as first-line treatment for PTSD.221-226

The utility of early treatment is also demonstrated by animal studies showing that pretreatment before stress with antidepressants reduces chronic behavioral deficits related to stress.227,228 Antidepressants, including both norepinephrine and serotonin reuptake inhibitors, as well as gabapentine and phenytoin, promote nerve growth (neurogenesis) in the hippocampus, while stress inhibits neurogenesis.63,64,66,69,71,75,229 This is important because hippocampal neurogenesis has been shown to be required for antidepressant response.74

Few studies have examined the effects of pharmacological treatment on brain structure and function in patients with trauma-related mental disorders. We studied a group of patients with depression and found no effect of fluoxetine on hippocampal volume, although there were increases in memory function230 and hippocampal activation measured with PET during a memory encoding task. Depressed patients with a history of childhood trauma were excluded, and we subsequently have found hippocampal volume reductions at baseline in women with early abuse and depression but not in women with depression without early abuse;198 this suggests that the study design of excluding patients with early trauma may account for the negative result. Other studies in depression showed that smaller hippocampal volume was a predictor of resistance to antidepressant treatment.231 Smaller orbitofrontal cortex volume is associated with depression; one study in geriatric depression found smaller orbitofrontal cortex volume, while length of antidepressant exposure was correlated with larger orbitofrontal volume.232

Several studies have looked at functional brain imaging response to antidepressants in depression. Single photonemission computed tomography (SPECT) blood flow studies in depression showed that antidepressants increased anterior cingulate, right putamen, and right thalamus function.233 SPECT Xenon-133 studies showed reduced prefrontal function at baseline in depression, with treatment responders showing reduced perfusion in prefrontal cortex compared with non-responders after treatment.234 In a fluorodeoxyglucose (FDG) PET study of brain function patients with depression treated with fluoxetine who had a positive response to treatment had limbic and striatal decreases (subgenual cingulate, hippocampus, insula, and pallidum) and brain stem and dorsal cortical increases (prefrontal, parietal, anterior, and posterior cingulate) in function. Failed response was associated with a persistent 1-week pattern and absence of either subgenual cingulate or prefrontal changes.235 Sertraline resulted in an increase in middle frontal gyrus activity in depression measured with PET FDG, as well as increased function in right parietal lobe and visual association cortex.236 Successful paroxetine therapy of depression was associated with increased glucose metabolism measured with PET in dorsolateral, ventrolateral, and medial aspects of the prefrontal cortex, parietal cortex, and dorsal anterior cingulate. Areas of decreased metabolism were noted in both anterior and posterior insular regions (left) as well as right hippocampal and parahippocampal regions.237 In another PET FDG study, at baseline, subjects with depression had higher normalized metabolism than controls in the prefrontal cortex (and caudate and thalamus), and lower metabolism in the temporal lobe. With treatment with paroxetine, subjects with depression had metabolic changes in the direction of normalization in these regions.238 A PET FDG study of patients with depression and controls showed that at baseline, the mean metabolism was increased in the left and right lateral orbital cortex/ventrolateral prefrontal cortex (PFC), left amygdala, and posterior cingulate cortex, and decreased in the subgenual anterior cingulate cortex (ACC) and dorsal medial/dorsal anterolateral PFC in depressives relative to controls. Following treatment with antidepressants, metabolism significantly decreased in the left amygdala and left subgenual ACC. The metabolic reduction in the amygdala and right subgenual ACC appeared largely limited to those subjects who both responded to treatment and remained well at 6 months' follow-up.239 Another study showed that antidepressant treatment of depression resulted in a decrease in amygdala activation with emotional faces as measured with fMRI.240 In summary, studies show changes in limbic and prefrontal cortical regions with successful antidepressant treatment of depression.

Fewer studies have looked at the effects of pharmacological treatment on the brain in anxiety disorders. One PET FDG study showed that caudate function decreased with treatment of obsessive compulsive disorder with antidepressants.241 Paroxetine resulted in a decrease in glutamate/glutamine measured with magnetic resonance spectroscopy (MRS) in children with obsessive-compulsive disorder (OCD).242 Patients with PTSD were shown to have an increase in hippocampal volume and memory function with paroxetine,163 and increased right hippocampal and right cerebral volume with phenytoin.165 No published studies have looked at the effects of pharmacological treatment on brain function in PTSD, or on sensitive markers of brain chemistry like NAA.

Figure 2 .

Brain biomarkers like NAA represent an objective marker of neural plasticity. To date psychiatry has relied on subjective reports as the gold standard. However, this is limited by self-reporting and the subjective interpretations of symptoms and response to treatment. Brain markers of antidepressant response may provide a complementary approach to assessing response to treatment, as well as providing insight into the mechanisms of treatment response. Our group is trying to look at mechanisms in the brain underlying treatment response in PTSD.

Effects of pharmacotherapy on brain function and structure in PTSD

We have begun to assess the effects of pharmacotherapy on brain structure and function in PTSD.243 We recently assessed the effects of phenytoin on brain structure and function. Studies in animals show that phenytoin, which is used in the treatment of epilepsy and is known to modulate glutamatergic function, blocks the effects of stress on the hippocampus.67 We studied nine patients with PTSD in an open-label function before and after treatment with phenytoin. Phenytoin resulted in a significant improvement in PTSD symptoms.164 Phenytoin also resulted in increases in both right hippocampal volume and right hemisphere volume.165 These findings indicate that phenytoin has an effects on PTSD symptoms as well as brain structure in PTSD patients.

We have assessed the effects of open4abel paroxetine on memory and the hippocampus in PTSD. Male and female patients with symptoms of PTSD were medication-free for at least 4 weeks before participation in the study. Twenty-eight patients were found to be eligible and started the medication phase. Of the total patient sample five patients did not finish due to noncompliance; 23 patients completed the study.

Before patients started the medication phase, neuropsychological tests were administered, including the Wechsler Adult Intelligence Scale - Revised, WAISR (arithmetic, vocabulary, picture arrangement, and block design test), two subtests of the Wechsler Memory ScaleRevised.WMS-R, including logical memory (free recall of two story narratives, which represents verbal memory) and figural memory (which represents visual memory and involved reproduction of designs after a 6-second presentation); and the verbal and visual components of the Selective Reminding Test, SRT.

Paroxetine was prescribed in the first visit after the pre-treatment assessments. All patients started open-label with a dose of 10 mg daily and were titrated up to 20 mg in 4 days.

Paroxetine treatment resulted in a mean 54% reduction in PTSD symptoms as measured with mean changes from baseline on the CAPS total score ( P<0.005) among study completers. Improvement was equally strong on all symptom cluster scores (Reexperiencing, Avoidance/Numbing, Hyperarousal). Treatment also resulted in significant improvements in verbal declarative memory as measured with the WMS-R paragraph recall for delayed recall ( P<0.005) and percent retention (80.2 to 91.1; P=0.003), but not immediate recall. Improvements were significant on all subscales of the Verbal Component of the SRT; including long-term recall and delayed recall.

Repeated measures ANOVA with side as the repeated measure showed a main effect for treatment related to a 4.6% increase in mean hippocampal volume (1857.3 mm 3 [SD 225.6] to 1906.2 mm 3, [SD 243.2]) with treatment (F=8.775 df=1.36; P=0.005). Increased hippocampal volume was seen for both left (5.6%) (1807.6 mm 3 [SD 255.5] to 1909.3 mm 3 [SD 236.9]) and right (3.7%) (1906.9 mm 3 [SD 195.8] to 1976.7 mm 3 [SD 249.6]) hippocampus. There was no change in whole brain volume with treatment. Increase in hippocampal volume was significant after adding whole brain volume before and after treatment to the model.

Discussion

Traumatic stress has a broad range of effects on brain function and structure, as well as on neuropsychological components of memory. Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex. Neurochemical systems, including Cortisol and norepinephrine, play a critical role in the stress response. These brain areas play an important role in the stress response. They also play a critical role in memory, highlighting the important interplay between memory and the traumatic stress response. Preclinical studies show that stress affects these brain areas. Furthermore, antidepressants have effects on the hippocampus that counteract the effects of stress. In fact, promotion of nerve growth (neurogenesis) in the hippocampus may be central to the efficacy of the antidepressants. Studies in patients with PTSD show alterations in brain areas implicated in animal studies, including the amygdala, hippocampus, and prefrontal cortex, as well as in neurochemical stress response systems, including Cortisol and norepinephrine. Treatments that are efficacious for PTSD show a promotion of neurogenesis in animal studies, as well as promotion of memory and increased hippocampal volume in PTSD. Future studies are needed to assess neural mechanisms in treatment response in PTSD.

Selected abbreviations and acronyms

ACTH

adrenocorticotropic hormone

BDNF

brain-derived neurotropic factor

BPD

bipolar disorder

CRF

corticotropin-releasing factor

CS

conditioned stimulus

FDG

fluorodeoxyglucose

HPA

hypothalamic-pituitary-adrenal

MRI

magnetic resonance imaging

mRNA

messenger ribonucleic acid

NAA

N-acetyl aspartate

PET

positron emission tomography

PTSD

post-traumatic stress disorder

US

unconditioned stimulus

REFERENCES

85. Yehuda R., Teicher MH., Levengood RA., et al. Circadian regulation of basal Cortisol levels in posttraumatic stress disorder. [ Ann NY Acad Sci. 1994:378-380. [ PubMed] Google Scholar]

161. Yehuda R., Golier JA., Tischler L., et al. Hippocampal volume in aging combat veterans with and without post-traumatic stress disorder: Relation to risk and resilience factors. [ J Psychiatr Res. Jan 27, 2006 [Epub ahead of print] [ PubMed] Google Scholar]

204. Kitayama N., Quinn S., Bremner JD. Smaller volume of anterior cingulate cortex in abuse-related posttraumatic stress disorder. [[ J Affect Disord. Jan 10, 2006 [Epub ahead of print] PMC free article] [ PubMed] Google Scholar]

207. Bremner JD. Effects of traumatic stress on brain structure and function: Relevance to early responses to trauma. In: Cardena E, Croyle K, eds. [ Acute Reactions to Trauma and Psychotherapy: Multidisciplinary and International Perspective. Binghamton, NY: Haworth Medical Press; 2005 [ PubMed] Google Scholar]

Articles from Dialogues in Clinical Neuroscience are provided here courtesy of Taylor & Francis

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Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex. Traumatic stress can be associated with lasting changes in these brain areas. Traumatic stress is associated with increased cortisol and norepinephrine ...

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Child abuse. Rape. Sexual assault. Brutal physical attack. Being in a war and witnessing violence, bloodshed, and death from close quarters. Near death experiences. These are extremely traumatic events, and some victims bear the scars for life.

The physical scars heal, but some emotional wounds stop the lives of these people dead in their tracks. They are afraid to get close to people or form new relationships. Change terrifies them, and they remain forever hesitant to express their needs or desire to meet their creative potential. It may not be always apparent, but post-traumatic stress disorder ( PTSD) stifles the life force out of its victims. It is no use telling them to "get over" it because PTSD fundamentally changes the brain's structure and alters its functionalities.
What goes on inside the brains of people with PTSD?
PTSD is painful and frightening. The memories of the event linger and victims often have vivid flashbacks. Frightened and traumatized, they are almost always on edge, and the slightest of cues sends them hurtling back inside their protective shells. Usually, victims try to avoid people, objects, and situations that remind them of their hurtful experiences-this behavior is debilitating and prevents them from living their lives meaningfully.

Many victims forget the details of the incident, presumably in an attempt to lessen the blow. But this coping mechanism has negative repercussions as well. Without accepting and reconciling with "reality," they turn into fragmented souls.

Extensive neuroimaging studies on the brains of PTSD patients show that several regions differ structurally and functionally from those of healthy individuals. The amygdala, the hippocampus, and the ventromedial prefrontal cortex play a role in triggering the typical symptoms of PTSD. These regions collectively impact the stress response mechanism in humans, so that the PTSD victim, even long after their experience, continues to perceive and respond to stress differently than someone who is not suffering the aftermath of trauma.
Effect of trauma on the hippocampus
The most significant neurological impact of trauma is seen in the hippocampus. PTSD patients show a considerable reduction in the volume of the hippocampus. This region of the brain is responsible for memory functions. It helps an individual to record new memories and retrieve them later in response to specific and relevant environmental stimuli. The hippocampus also helps us distinguish between past and present memories.

PTSD patients with reduced hippocampal volume lose the ability to discriminate between past and present experiences or correctly interpret environmental contexts. The particular neural mechanisms involved trigger extreme stress responses when confronted with environmental situations that only remotely resemble something from their traumatic past. For example, this is why a sexual assault victim may be terrified of parking lots because she was once raped in a similar place. Or a war veteran cannot watch violent movies because they remind them of his trench days; their hippocampus cannot minimize the interference of past memories.
Effect of trauma on the ventromedial prefrontal cortex
Severe emotional trauma causes lasting changes in the ventromedial prefrontal cortex region of the brain that is responsible for regulating emotional responses triggered by the amygdala. Specifically, this region regulates negative emotions such as fear that occur when confronted with specific stimuli. PTSD patients show a marked decrease in the volume of the ventromedial prefrontal cortex and the functional ability of this region. This explains why people suffering from PTSD tend to exhibit fear, anxiety, and extreme stress responses even when faced with stimuli not connected-or only remotely connected-to their experiences from the past.
Effect of trauma on the amygdala
Trauma appears to increase activity in the amygdala. This region of the brain helps us process emotions and is also linked to fear responses. PTSD patients exhibit hyperactivity in the amygdala in response to stimuli that are somehow connected to their traumatic experiences. They exhibit anxiety, panic, and extreme stress when they are shown photographs or presented with narratives of trauma victims whose experiences match theirs, or if they listen to sounds or words related to their traumatic encounters.

What is interesting is that the amygdala in PTSD patients may be so hyperactive that these people exhibit fear and stress responses even when they are confronted with stimuli not associated with their specific trauma, such as when they are simply shown photographs of people exhibiting fear.

The hippocampus, the ventromedial prefrontal cortex, and the amygdala are part of the neural circuitry that mediates stress. The hippocampus facilitates appropriate responses to environmental stimuli, so the amygdala does not go into stress mode unecessarily. The ventromedial prefrontal cortex regulates emotional responses by controlling the functions of the amygdala. It is thus not surprising that when the hypoactive hippocampus and the functionally-challenged ventromedial prefrontal cortex stop pulling the chains, the amygdala gets into a tizzy.

Hyperactivity of the amygdala is positively related to the severity of PTSD symptoms. The aforementioned developments explain the tell-tale signs of PTSD-startle responses to the most harmless of stimuli, frequent flashbacks, and intrusive recollections.

Researchers believe that the brain changes caused by PTSD increase the likelihood of a person developing other psychotic and mood disorders. Understanding how PTSD alters brain chemistry is critical to empathize with the condition of the victims and devise treatment methods that will enable them to live fully and fulfill their true potential.

But in the midst of such grim findings, scientists also sound a note of hope for PTSD patients and their loved ones. According to them, by delving into the pathophysiology of PTSD, they have also realized that the disorder is reversible. The human brain can be re-wired. In fact, drugs and behavioral therapies have been shown to increase the volume of the hippocampus in PTSD patients. The brain is a finely-tuned instrument. It is fragile, but it is heartening to know that the brain also has the amazing capacity to regenerate.
References

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How Does Post-Traumatic Stress Disorder Change the Brain?

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Child abuse. Rape. Sexual assault. Brutal physical attack. Being in a war and witnessing violence, bloodshed, and death from close quarters. Near death experiences. These are extremely traumatic events, and some victims bear the scars for life. The physical scars heal, but some emotional wounds stop the lives of these people dead in their tracks.

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Our brains are truly amazing, aren't they?

Have you ever watched one of those specials on someone who experienced amazing, unexpected recovery after a traumatic brain injury, stroke, or other brain damage? Some of those stories seem like the only explanation is magic!

Although it certainly seems inexplicable, scientists have been hard at work studying exactly these cases over the last several decades, and have found the explanation behind the magic: neuroplasticity.
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What is the Meaning of Neuroplasticity?

Neuroplasticity refers to the brain's ability to adapt. Or, as Dr. Campbell puts it:

"It refers to the physiological changes in the brain that happen as the result of our interactions with our environment. From the time the brain begins to develop in utero until the day we die, the connections among the cells in our brains reorganize in response to our changing needs. This dynamic process allows us to learn from and adapt to different experiences." - Celeste Campbell (n.d.).

Our brains are truly extraordinary; unlike computers, which are built to certain specifications and receive software updates periodically, our brains can actually receive hardware updates in addition to software updates. Different pathways form and fall dormant, are created and are discarded, according to our experiences.

When we learn something new, we create new connections between our neurons. We rewire our brains to adapt to new circumstances. This happens on a daily basis, but it's also something that we can encourage and stimulate.

A Brief History of Neuroplasticity

The term "neuroplasticity" was first used by Polish neuroscientist Jerzy Konorski in 1948 to describe observed changes in neuronal structure (neurons are the cells that make up our brains)-although it wasn't widely used until the 1960s-but the idea goes back even farther (Demarin, Morović, & Béne, 2014). The "father of neuroscience," Santiago Ramón y Cajal, talked about "neuronal plasticity" in the early 1900s (Fuchs & Flügge, 2014). He recognized that, in contrast to current belief at that time, brains could indeed change after a person had reached adulthood.

In the 1960s, it was discovered that neurons could "reorganize" after a traumatic event. Further research found that stress can change not only the functions but also the structure of the brain itself (Fuchs & Flügge, 2014).

In the late 1990s, researchers found that stress can actually kill brain cells-although these conclusions are still not completely certain.

For many decades, it was thought that the brain was a "nonrenewable organ," that brain cells are bestowed in a finite amount and they slowly die as we age, whether we attempt to keep them around or not. As Ramón y Cajal said, "In adult centers the nerve paths are something fixed, ended, immutable. Everything may die, nothing may be regenerated" (as cited in Fuchs & Flügge, 2014).

This research found that there are other ways for brain cells to die, other ways for them to adapt and reconnect, and perhaps even ways for them to regrow or replenish. This is what's known as "neurogenesis."

Neuroplasticity vs. Neurogenesis

Although related, neuroplasticity and neurogenesis are two different concepts.

Neuroplasticity is the ability of the brain to form new connections and pathways and change how its circuits are wired; neurogenesis is the even more amazing ability of the brain to grow new neurons (Bergland, 2017).

You can see how neurogenesis is the more exciting concept. It's one thing to work with what we already have, but the potential to actually replace neurons that have died may open up new frontiers in the treatment and prevention of dementia, recovery from traumatic brain injuries, and other areas we probably haven't even thought of.

The Theory and Principles of Neuroplasticity

Before we get too ahead of ourselves though, let's take a moment to look at the theory and principles underpinning neuroplasticity.

First, we should note that, although we gave a fairly succinct definition of neuroplasticity above, the reality is a bit less well-defined. Neuroplasticity experts Christopher A. Shaw and Jill C. McEachern describe it this way:

"While many neuroscientists use the word neuroplasticity as an umbrella term, it means different things to researchers in different subfields... In brief, a mutually agreed upon framework does not appear to exist" (2001).

Shaw and McEachern write that there are two main perspectives on neuroplasticity:

Neuroplasticity is one fundamental process that describes any change in final neural activity or behavioral response.

Neuroplasticity is an umbrella term for a vast collection of different brain change and adaptation phenomena.

The first perspective lends itself to a single theory of neuroplasticity with some basic principles, and that research on the subject would contribute to a single, all-inclusive framework of neuroplasticity. The second perspective would require numerous different frameworks and systems to understand each phenomenon.

Unfortunately, there is still no unifying theory of neuroplasticity that I can lay out in simple terms here. All I can say with certainty is that this is still a young field and new findings are popping up every day.

What we do know right now is that there are two main types of neuroplasticity:

Structural neuroplasticity, in which the strength of the connections between neurons (or synapses) changes.

Functional neuroplasticity, which describes the permanent changes in synapses due to learning and development (Demarin, Morović, & Béne, 2014).

Both types have exciting potential, but structural neuroplasticity is probably the one that is more attended to at the moment; we already know that some functions can be rerouted, relearned, and re-established in the brain, but changes to the actual structure of the brain are where many of the exciting possibilities lie.

Neuroplasticity and Psychology

These new lines of research are exciting for neuroscientists, biologists, and chemists, but they are also exciting for psychologists. In addition to changes in the way the brain works and functional adaptations, neuroplasticity offers potential avenues for psychological change as well.

As Christopher Bergland (2017) notes,

"One could speculate that this process opens up the possibility to reinvent yourself and move away from the status quo or to overcome past traumatic events that evoke anxiety and stress. Hardwired fear-based memories often lead to avoidance behaviors that can hold you back from living your life to the fullest."

We already use medications and chemicals to change the way our brain works, and psychology has certainly put forth tons of effort to learn how to change the way the brain works through modifying our thought patterns. What if we really can make permanent, significant changes to our brain structure and function through simple activities that we often do in a normal day?

This is where the importance of learning comes in.

Neuroplasticity and Learning

The relation between neuroplasticity and learning is an easy one to surmise-when we learn, we form new pathways in the brain. Each new lesson has the potential to connect new neurons and change our brain's default mode of operation.

Of course, not all learning is created equal-learning new facts doesn't necessarily take advantage of the amazing neuroplasticity of the brain, but learning a new language or a musical instrument certainly does. It is through this sort of learning that we may be able to figure out how to purposefully rewire the brain.

The extent to which we apply the brain's near-magical abilities is also dependent on how invested we are in promoting neuroplasticity and how we approach life in general.

A Growth Mindset and Neuroplasticity

We've written about the growth mindset before (click here for an overview), but we didn't really connect the topic to neuroplasticity.

The connection is an important one! The concepts actually mirror each other; a growth mindset is a mindset that one's innate skills, talents, and abilities can be developed and/or improved with determination, while neuroplasticity refers to the brain's ability to adapt and develop beyond the usual developmental period of childhood.

A person with a growth mindset believes that he or she can get smarter, better, or more skilled at something through sustained effort-which is exactly what neuroplasticity tells us. You might say that a growth mindset is simply accepting the idea of neuroplasticity on a broad level!

Does Neuroplasticity Change with Age?

As you might expect, neuroplasticity definitely changes with age, but it's not as black and white as you might think.

Neuroplasticity in Kids

Children's brains are constantly growing, developing, and changing. Each new experience prompts a change in brain structure, function, or both.

At birth, each neuron in an infant's brain has about 7,500 connections with other neurons; by the age of 2, the brain's neurons have more than double the number of connections in an average adult brain (Mundkur, 2005). These connections are slowly pruned away as the child grows up and starts forming their own unique patterns and connections.

There are four main types of neuroplasticity observed in children:

Adaptive: changes that occur when children practice a special skill and allow the brain to adapt to functional or structural changes in the brain (like injuries).

Impaired: changes occur due to genetic or acquired disorders.

Excessive: the reorganization of new, maladaptive pathways that can cause disability or disorders.

Plasticity that makes the brain vulnerable to injury: harmful neuronal pathways are formed that make injury more likely or more impactful (Mundkur, 2005).

These processes are stronger and more pronounced in young children, allowing them to recover from injury far more effectively than most adults. In children, profound cases of neuroplastic growth, recovery, and adaptation can be seen.

Neuroplasticity in Adults

This ability is not absent in adults, but it is generally observed less than in children and at lower strengths; however, the adult brain is still capable of extraordinary change.

It can restore old, lost connections and functions that have not been used in some time, enhance memory, and even enhance overall cognitive skills.

The potential is generally not as great in older adults as it is in children and young adults, but with sustained effort and a healthy lifestyle, adults are just as able to promote positive change and growth in their brains as the younger generations.

To see some of the amazing ways that neuroplasticity can affect the adult brain, read on!

Research and Studies on Neuroplasticity

So what new things have we learned about neuroplasticity lately? As it turns out, quite a bit!

Here are some of the newest and most exciting developments in the field:

Enriched environments (saturated with novelty, focused attention, and challenge) are critical for promoting neuroplasticity, and can provoke growth and positive adaptation long after the "critical learning period" of early childhood and young adulthood is over (Kempermann et al., 2002; Vemuri et al., 2014).

"Newborn" neurons at 8 weeks old and older neurons are generally at the same level of maturation (Deshpande et al., 2013).

As few as ten ~ 1-hour sessions of cognitive training over 5 or 6 weeks have the potential to reverse the same amount of age-related decline that has been observed in the same time period (Ball et al., 2002).

Physical activity and good physical fitness can prevent or slow the normal age-related neuronal death and damage to the hippocampus, and even increase the volume of the hippocampus (Niemann et al., 2014).

Intermittent fasting can promote adaptive responses in synapses (Vasconcelos et al., 2014).

Chronic insomnia is associated with atrophy (neuronal death and damage) in the hippocampus, while adequate sleep may enhance neurogenesis (Joo et al., 2014).

This is but a small selection of the recent findings on neuroplasticity (see Shaffer, 2016 to learn more), but it highlights the enormous potential impact of harnessing the power of neuroplasticity to improve health and well-being in humans.

7 Benefits Neuroplasticity Has on the Brain

Building on the studies we just mentioned, there are tons of ways that neuroplasticity benefits the brain. In addition to the improvements and advantages outlined above, these are some of the other ways your brain benefits from brain adaptation:

Recovery from brain events like strokes.

Recovery from traumatic brain injuries.

Ability to rewire functions in the brain (e.g., if an area that controls one sense is damaged, other areas may be able to pick up the slack).

Losing function in one area may enhance functions in other areas (e.g., if one sense is lost, the others may become heightened).

Enhanced memory abilities.

Wide range of enhanced cognitive abilities.

More effective learning.

So, how can we apply neuroplasticity and get these benefits?

How to Rewire Your Brain with Neuroplasticity

10 Examples of How Neuroplasticity Works

First, let's get an idea of some of the ways that neuroplasticity can be applied.

A few of the methods that have been shown to enhance or boost neuroplasticity include:

Intermittent fasting (as noted earlier): increases synaptic adaptation, promotes neuron growth, improve overall cognitive function, and decreases the risk of neurodegenerative disease.

Traveling: exposes your brain to novel stimuli and new environments, opening up new pathways and activity in the brain.

Using mnemonic devices: memory training can enhance connectivity in the prefrontal parietal network and prevent some age-related memory loss.

Learning a musical instrument: may increase connectivity between brain regions and help form new neural networks.

Non-dominant hand exercises: can form new neural pathways and strengthen the connectivity between neurons.

Reading fiction: increases and enhances connectivity in the brain.

Expanding your vocabulary: activates the visual and auditory processes as well as memory processing.

Creating artwork: enhances connectivity of the brain at rest (the "default mode network" or DMN), which can boost introspection, memory, empathy, attention, and focus.

Dancing: reduces the risk of Alzheimer's and increases neural connectivity.

Sleeping: encourages learning retention through the growth of the dendritic spines that act as connections between neurons and help transfer information across cells (Nguyen, 2016).

For references on each of these methods, see Thai Nguyen's piece here.

Healing the Brain with Neuroplasticity After Trauma

Research on neuroplasticity has gained in leaps and bounds from observing changes in the brains of those who suffered serious trauma. Scientists saw that some patients with severe damage to the brain were able to recover to an amazing degree, given the extent of the damage, and wondered how this was possible; as we now know, neuroplasticity is what allows this recovery to happen.

According to researchers Su, Veeravagu, and Grant (2016), there are three phases of neuroplasticity after trauma:

Immediately after the injury, neurons begin to die and cortical inhibitory pathways are decreased; this phase lasts one to two days, and may uncover secondary neural networks that have never been used or have been rarely used.

After a few days, the activity of these cortical pathways changes from inhibitory to excitatory and new synapses are formed; both neurons and other cells are recruited to replace the damaged or dead cells and facilitate healing.

After a few weeks, new synapses continue to appear and the "remodeling" of the brain is in full swing-this is the time when rehabilitation and therapy can help the brain to learn some helpful new pathways.

There are many pharmacological treatments currently in development and testing that aim to help recovery through encouraging neuroplasticity, in addition to therapies involving stem cells, modifying gene expression and cellular proliferation, regulating inflammatory reactions, and recruiting immune cells to stop the damage (Su, Veeravagu, & Grant, 2016).

Although injury to the brain is a difficult thing to recover from, it is paradoxically one of the best times to take advantage of the brain's neuroplastic abilities, because post-injury or trauma is when the brain is most capable of making significant changes, reorganizing, and recovering (Su, Veeravagu, & Grant, 2016).

Neuroplasticity Rehabilitation for Stroke Recovery

Neuroplasticity has been observed quite often in those recovering from strokes. Strokes often leave patients with brain damage, ranging from moderate (e.g., some facial muscular impairment) to severe (e.g., serious cognitive impairments, memory problems); however, we have also seen amazing recovery from stroke patients.

According to the experts at stroke-rehab.com, the best way to encourage neuroplasticity in stroke recovery is to use two key methods:

Task repetition

Task-specific practice

In other words, learning a new skill or activity (or re-learning an old one) through specific, regular practice can result in significant changes in the brain. You may not be able to learn anything with repetition and specific practice, but you can certainly learn a lot-and improvements in one area can often spill over into improvements in other abilities and skills.

How can Neuroplasticity Help with Depression?

The connection between neuroplasticity and depression is a good news/bad news one.

The bad news is that, when it comes to psychiatric disorders, there's a sort of negative neuroplasticity; depression can cause damage to the brain, encouraging unhealthy and maladaptive pathways and discouraging healthy and adaptive ones (Hellerstein, 2011).

The good news is that some treatments for depression seem to be able to halt the damage and perhaps even reverse. The even better news is that research on neuroplasticity has shown us that "your day-to-day behaviors can have measurable effects on brain structure and function," which can offer healing and recovery from psychiatric disorders (Hellerstein, 2011).

It may not be easy and it will likely take sustained effort, but we have the ability to "remodel" our brains at any age in ways that can help us to function more effectively.

Using Neuroplasticity to Help with Anxiety

The same principles apply to managing and treating anxiety disorders-our brains are also perfectly capable of rewiring and remodeling to improve our ability to manage anxiety.

However, as life coach and clinician Ian Cleary (2015) says:

"Any brain changes are at the expense of other changes. The development of these parts of our brain that effortlessly trigger anxiety, it is at the detriment of the ones that aid calmness & confidence... it is not enough to just stop anxiety in any given moment which is often people's focus. The anxiety wiring is still there and waiting to be triggered. We need to create competitive wiring. We need to create specific wiring of what we want to achieve which is 'competitive wiring' to the problem. Without this we loop endlessly in anxiety with no neural pathway to take us forward."

Basically, neuroplasticity can be applied to help you manage, treat, and perhaps even "cure" anxiety, but it takes some time and effort! These more permanent brain changes can be achieved through adapting and changing thought patterns, through recall and memory patterning, breathing exercises, eye patterning, modifying postural habits, increasing body awareness, and targeting sensory perception (Cleary, 2015).

8 Neuroplasticity Exercises for Anxiety and Depression

There aren't many neuroplasticity exercises designed specifically for depression, but that doesn't mean you can't do anything about it.

All of these activities and exercises-many of which you'll recognize from more traditional advice on managing depression-have been found to improve neuroplasticity and may be helpful for dealing with depression:

Memory tasks and games

Learning to juggle

Learning to play a new instrument

Learning a new language

Mild to moderate regular exercise

Challenging brain activities like crosswords or sudoku

Learning a new subject-especially a large, complex subject in a short period of time (Hellerstein, 2011).

Chronic Pain and Neuroplasticity

Neuroplasticity can also play an important role in helping people manage and treat chronic pain. After all, pain itself is experienced as a set or sequence of neuronal firings-if we can change the way our brains are wired, what's to stop us from changing the experience of pain?

A recent study on the subject found that there are at least four methods that can help your brain adapt and manage chronic pain:

Transcranial direct current stimulation (electrodes implanted in certain areas of the brain to stimulate certain responses)

Transcranial magnetic stimulation (non-invasive magnetic stimulation of the brain via a "wand" to engage specific areas)

Intermittent fasting (periods of fasting followed by periods of normal food intake)

Glucose administration (taking glucose supplements to replace what we lose due to normal aging; (Sibille, Fartsch, Reddy, Fillingim, & Keil, 2016)

In addition to these more intensive treatments, there are many things you can do to apply the principles of neuroplasticity to your experience of pain, and the good news is that most of them are things that we should all do to become more healthy anyway!

6 Neuroplasticity Exercises for Treating Chronic Pain

These six practices and exercises have proven useful for dealing with chronic pain, and they all have the ability to affect how our brain wiring receives and translates the message of pain:

Regular exercise

Healthy eating

Quitting smoking

Keeping your mind active, engaged, and challenged

Relaxation techniques to keep stress at bay

Mindfulness meditation (Irving, 2016).

Each of these activities has the potential to rewire and retrain your brain to react differently to pain.

Neuroplasticity Therapy for ADHD, OCD, and Autism

The methods of using neuroplasticity to treat ADHD, OCD, and autism largely mirror the methods we have already covered. There are games, activities, and programs designed around the principles of neuroplasticity to help people and children with a wide range of issues and impairments.

However, they all come down to the same general themes: learning new things, being open to new experiences and new activities, consciously adapting and modifying your thought patterns, and using science-backed techniques to challenge yourself.

To learn more about how neuroplasticity can benefit children with ADHD, click here for a description of the Atentiv System.

To get specific information on how neuroplasticity therapy can be applied to OCD, click here.

For information on the connection between neuroplasticity therapy and autism spectrum disorders, visit the nonprofit Autism Speaks' website here.

The Role of Mindfulness in Neuroplasticity

Proponents of mindfulness meditation have long thought that meditation can actually cause physical changes in the brain; as it turns out, they were right! Mindfulness meditation can, in fact, change the brain, through neuroplasticity.

Jessica Cassity (n.d.) writes this about mindfulness meditation and neuroplasticity:

"With meditation, your brain is effectively being rewired: As your feelings and thoughts morph toward a more pleasant outlook your brain is also transforming, making this way of thought more of a default... The more your brain changes from meditation, the more you react to everyday life with that same sense of calm, compassion, and awareness."

The more mindful we become and the more we meditate, the more our brain adapts to this state as our default state. This is why mindfulness meditation has such a big impact on regular practitioners even outside of their dedicated practice time; they have taught their brain to be mindful, calm, at peace, and centered all throughout the day, not just when they are actively meditating.

Using Meditation to Promote Neuroplasticity

To learn more about the connection between meditation and neuroplasticity and to take advantage of the neuroplasticity that mindfulness meditation brings, check out this PDF from Harvard Health.

In it, you'll learn about some recent studies on the subject and find guided meditations, yoga sequences, and other exercises that can help you gain the benefits outlined.

You can also watch a great TED Talk from Sara Lazar on how meditation can change the brain here:

How Music Changes the Brain

Listening to music is not only an enjoyable way to pass the time or influence our mood and energy level; it may also be an impactful way to make structural and functional changes to the brain.

A 2010 article reviewing several relevant studies found that those who trained as musicians displayed several differences in the structure and connectivity of their brains compared to non-musicians, including:

The anterior portion of the corpus callosum (the thick part of the brain that connects the two hemispheres) was larger in musicians, especially those who began their training at a young age.

The right motor cortex was larger in right-handed musicians than right-handed non-musicians, especially for those who began their musical training at a young age.

The volume of the cerebellum in male musicians is larger than in male non-musicians.

The volume of the grey matter in motor, auditory, and visuospatial cerebral areas is larger in musicians than non-musicians.

Musicians have more structured right posterior internal capsules than non-musicians, especially for those who began practicing their craft early on.

Musicians have higher gray and white matter density in the left primary sensory-motor cortex and right cerebellum, as well as higher white matter integrity in the right posterior internal capsule.

Pianists have increased cortical representation of piano tones.

Musicians have enhanced responses to temporal novelty in the anterior left hippocampus.

Musicians have earlier and larger auditory and audiovisual responses to speech and music stimuli (Rodrigues, Loureiro, & Caramelli, 2010).

If none of this makes sense to you, don't worry-you're not alone! I'll let the authors describe what all these findings suggest:

"...[S]everal forms of intensive training have an impact on brain and cognition, but it is possible that musical training has specific effects that other forms of training do not have, or even produces a range of different effects... [The] cognitive enhancement effects of musical training, the result of neuroplastic processes, might be due to a combination of skills required by music study, such as decoding visual information into motor activity, memorizing extended passages of music, learning music structures and rules, learning to make fine auditory spectral and temporal discriminations and learning to perform skilled bimanual finger movements." (Rodrigues, Loureiro, & Caramelli, 2010, p. 284).

Basically, findings on how music affects the brain indicate that musical training-and perhaps even habitual engagement with listening to and appreciating music-can help the brain enhance its natural neuroplasticity and improve countless abilities and cognitive skills.

Do Online Games and Apps Really Work?

You've no doubt heard of the many games and apps designed to harness the power of neuroplasticity and apply it to improving your memory, processing speed, and problem-solving skills. A few of them even purport to protect you against developing dementia!

Unfortunately, on the whole, these games and apps are not grounded in relevant science. In fact, a large group of scientists has this to say about the brain game trend:

"In summary: We object to the claim that brain games offer consumers a scientifically grounded avenue to reduce or reverse cognitive decline when there is no compelling scientific evidence to date that they do. The promise of a magic bullet detracts from the best evidence to date, which is that cognitive health in old age reflects the long-term effects of healthy, engaged lifestyles" ("A Consensus on the Brain Training Industry from the Scientific Community", 2014).

In other words, there may not be any harm in playing these games (except for a slightly lighter wallet), but engaging in healthy habits and regularly exercising, learning, and trying new things is the much more evidence-backed way to go.

The Sentis Brain Animation Series

This fascinating, engaging video series on the brain and its amazing abilities is a great way to learn more about this topic. If any of the brain terms and areas in this piece left you scratching your head, you're not alone-but this series can help you learn more about the puzzle that is the brain!

In particular, check out this video on neuroplasticity. It's only 2 minutes long, but it's a great overview.

Click here to see the YouTube channel for this series.

TED Talks and YouTube Videos on Neuroplasticity

For a quick lesson on neuroplasticity or to learn more, these TED talks and brief lectures on the subject might just hit the spot:

After Watching This, Your Brain Will Not Be the Same by Lara Boyd

Growing Evidence of Brain Plasticity by Michael Merzenich

How to Increase Neuroplasticity (6 Neuroplasticity Exercises) by Siim Land

The Most Important Lesson from 83,000 Brain Scans by Daniel Amen

Make Your Brain Smarter: It's Not What You Think by Sandra Chapman

Thinking to Doing to Being by Dr. Joe Dispenza

9 Recommended Books on Neuroplasticity

If you're interested in learning more and you have more than 20 minutes or so to dedicate to it, you might enjoy one of these books on the subject:

The Mind and the Brain: Neuroplasticity and the Power of Mental Force by Jeffrey M. Schwartz and Sharon Begley ()

9 Quotes on Neuroplasticity
Andrew Weil:
Before you go, check out these 9 interesting, engaging, and sometimes entertaining quotes about neuroplasticity.
Elizabeth Thornton:

"Among other things, neuroplasticity means that emotions such as happiness and compassion can be cultivated in much the same way that a person can learn through repetition to play golf and basketball or master a musical instrument, and that such practice changes the activity and physical aspects of specific brain areas."

Santiago Ramón y Cajal:

"Because of the power of neuroplasticity, you can, in fact, reframe your world and rewire your brain so that you are more objective. You have the power to see things as they are so that you can respond thoughtfully, deliberately, and effectively to everything you experience."

Craig Krishna:

"Any man could, if he were so inclined, be the sculptor of his own brain."

Norman Doidge:

"Meditation invokes that which is known in neuroscience as neuroplasticity; which is the loosening of the old nerve cells or hardwiring in the brain, to make space for the new to emerge."

Donald O. Hebb:

"Everything having to do with human training and education has to be re-examined in light of neuroplasticity."

Douglas Rushkoff:

"Neurons that fire together wire together."

Michael S. Gazzaniga:

"Brains are tricky and adaptable organs. For all the 'neuroplasticity' allowing our brains to reconfigure themselves to the biases of our computers, we are just as neuroplastic in our ability to eventually recover and adapt."

Susannah Cahalan:

"Our brains renew themselves throughout life to an extent previously thought not possible."

"Our minds have the incredible capacity to both alter the strength of connections among neurons, essentially rewiring them, and create entirely new pathways. (It makes a computer, which cannot create new hardware when its system crashes, seem fixed and helpless)."

A Take Home Message

I hope you've enjoyed this very brief journey through the subject of neuroplasticity! As you saw on this quick journey, it is a very large and complex subject, with new discoveries every day-often challenging what we thought we knew about the brain.

If you're interested in learning more, please check out the books, videos, and other resources noted above. I think the work on neuroplasticity is, in some ways, just beginning, so it's a great time to dive in!

What are your thoughts on neuroplasticity? Do you have an amazing recovery to share? How do you try to "rewire" your brain? Let us know in the comments!

Thanks for reading!

References

"A Consensus on the Brain Training Industry from the Scientific Community." (2014). Max Planck Institute for Human Development and Stanford Center on Longevity. Retrieved from http://longevity3.stanford.edu/blog/2014/10/15/the-consensus-on-the-brain-training-industry-from-the-scientific-community/

Ball, K. K., Berch, D. B., Helmers, K. F., Jobe, J. B., Leveck, M. D., Mariske, M., ..., & Willis, S. L. (2002). JAMA 288, 2271-2281. PMID: 12425704

Bergland, C. (2017). How do neuroplasticity and neurogenesis rewire your brain? Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/the-athletes-way/201702/how-do-neuroplasticity-and-neurogenesis-rewire-your-brain

Berlucchi, G., & Buchtel, H. A. (2009). Neuronal plasticity: Historical roots and evolution of meaning. Experimental Brain Research, 192(3), 307-319. doi:10.1007/s00221-008-1611-6

Campbell, C. (2009). What is neuroplasticity? BrainLine. Retrieved from https://www.brainline.org/author/celeste-campbell/qa/what-neuroplasticity

Cassity, J. (n.d.). The power of mindfulness: Reshape your brain for calm and compassion. Happify. Retrieved from https://www.happify.com/hd/the-power-of-mindfulness/

Cleary, I. (2015). Depression, anxiety and other conditions. Ian Cleary: Advanced Lightning Process Practitioner. Retrieved from http://iancleary.com/neuroplasticity-and-anxiety/

Demarin, V., Morović, S., & Béne, R. (2014). Neuroplasticity. Periodicum Biologorium, 116, 209-211. ISSN 0031-5362

Desphande, A., Bergami, M., Ghanem, A., Conzelmann, K. K., Lepier, A., Gӧtz, M., & Berninger, B. (2013). Retrograde monosynaptic tracing reveals the temporal evolution of inputs onto new neurons in the adult dentate gyrus and olfactory bulb. Proceedings of the National Academy of Sciences of the United States of America 110, 12. doi:10.1073/pnas.1218991110

Fuchs, E., & Flügge, G. (2014). Adult neuroplasticity: More than 40 years of research. Neural Plasticity, 2014. doi:10.1155/2014/541870

Hellerstein, D. (2011). Neuroplasticity and depression. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/heal-your-brain/201107/neuroplasticity-and-depression

Irving, G. A. (2016). Chronic pain and neuroplasticity. Swedish Medical Center. Retrieved from https://www.swedish.org/blog/2016/03/neuroplasticity

Joo, E. Y., Kim, H., Suh, S., & Hong, S. B. (2014). Hippocampal substructural vulnerability to sleep disturbance and cognitive impairment in patients with chronic primary insomnia: Magnetic resonance imaging morphometry. Sleep, 37, 1189-1198. doi:10.5665/sleep.3836

Kempermann, G., Gast, D., & Gage, F. H. (2002). Neuroplasticity in old age: Sustained fivefold induction of hippocampal neurogenesis by long-term environmental enrichment. Annals of Neurology, 52, 135-143. doi:10.1002/ana.10262

Mundkur, N. (2005). Neuroplasticity in children. Indian Journal of Pediatrics, 72, 855-857. doi:10.1007/BF02731115

Neimann, C., Godde, B., & Voelcker-Rehage, C. (2014). Not only cardiovascular, but also coordinative exercise increases hippocampal volume in older adults. Frontiers in Aging Neuroscience, 6, 170. doi:10.3389/fnagi.2014.00170

Nguyen, T. (2016). 10 proven ways to grow your brain: Neurogenesis and neuroplasticity. HuffPost Blog. Retrieved from https://www.huffingtonpost.com/thai-nguyen/10-proven-ways-to-grow-yo_b_10374730.html

Rodrigues, A. C., Loureiro, M. A., & Caramelli, P. (2010). Musical training, neuroplasticity and cognition. Dementia & Neuropsychologia, 4, 277-286. doi:10.1590/S1980-57642010DN40400005

Shaffer, J. (2016). Neuroplasticity and clinical practice: Building brain power for health. Frontiers in Psychology, 7, 1118. doi:10.3389/fpsyg.2016.01118

Shaw, C. A., & McEachern, J. C. (2001). Toward a theory of neuroplasticity. Philadelphia, PA, US: Psychology Press.

Sibille, K. T., Bartsch, F., Reddy, D., Fillingim, R. B., & Keil, A. (2016). Increasing neuroplasticity to bolster chronic pain treatment: A role for intermittent fasting and glucose administration? Journal of Pain, 17, 275-281. doi:10.1016/j.jpain.2015.11.002

Smith, G. S. (2013). Aging and neuroplasticity. Dialogues in Clinical Neuroscience, 15, 3-5. PMID: 23576885

Stroke-rehab.com

Su, Y. S., Veeravagu, A., & Grant, G. (2016). Chapter 8: Neuroplasticity after traumatic brain injury. In D. Laskowitz and G. Grant (Eds.) Translational research in traumatic brain injury. Boca Raton, FL, US: CRC Press/Taylor and Francis Group.

Taupin, P. (2006). Adult neurogenesis and neuroplasticity. Restorative Neurology and Neuroscience, 24, 9-15.

Vasconcelos, A. R., Yshii, L. M., Viel, T. A., Buck, H. S., Mattson, M. P., Scavone, C., & Kawamoto, E. M. (2014). Intermittent fasting attenuates lipopolysaccharide-induced neuroinflammation and memory impairment. Journal of Neuroinflammation, 11, 85-98. doi:10.1186/1742-2094-11-85

Vemuri, P., Lesnick, T. G., Przybelski, S. A., Machulda, M., Knopman, D. S., Mielke, M. M., ..., & Jack Jr., C. R. (2014). Association of lifetime intellectual enrichment with cognitive decline in the older population. JAMA Neurology, 71, 1017-1024. doi:10.1001/jamaneurol.2014.963

# data[].attributes.attachment_link.title
What is Neuroplasticity? Definition + 14 Brain Plasticity Exercises

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Sharing is caring. Our brains are truly amazing, aren't they? Have you ever watched one of those specials on someone who experienced amazing, unexpected recovery after a traumatic brain injury, stroke, or other brain damage? Some of those stories seem like the only explanation is magic!

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Inner Changes Psychotherapy and Counselling

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The PCL-5 is a self-report measure that assesses the presence and severity of Post Traumatic Stress Disorder ( PTSD) symptoms. Items on the PCL-5 correspond with DSM-5 criteria for PTSD.

This is a good screening tool for Post Traumatic Stress Disorder (PTSD). If you score highly on this PTSD test (28 or above) then do consider speaking to a health professional for a more detailed evaluation or PTSD treatment. If your score is high but doesn't meet the full criteria for PTSD, it is still worth seeking professional help as you may be suffering from some other form of trauma or other mental health condition such as anxiety or depression.

Instructions:

Below is a list of problems that people sometimes have in response to a very stressful experience. Keeping your worst event in mind, please read each statement carefully and then select an option that indicates how much you have been bothered by that problem in the past month.

Read each statement below carefully.

Select a rating based on how much the statement applied to you over the last month.

When you have completed all the questions click the Calculate Score button below.

Print the results.

If you are concerned about your score, discuss the results of this test with your doctor. Once you've confirmed that you have PTSD consider working with a Trauma Therapist.

NOTE: The results of this test are intended as a guide only. They are not intended to be a clinical diagnosis. No diagnosis is being offered. For a formal clinical diagnosis of PTSD speak with your doctor or other qualified health professional.

PCL-5 PTSD Assessment Test

Trauma Therapy

Nigel Magowan is a qualified and experienced UKCP accredited psychotherapist who offers Trauma and PTSD treatment in Manchester. He uses a three phase approach to recovery and combines psychotherapy with EMDR, Somatic Experiencing, Focusing, CBT, NLP and Mindfulness. He has experience of working with PTSD, PTS, and complex trauma/ developmental trauma/childhood trauma. Read more...

Assessment Tests on This Website

Generalised Anxiety Disorder Test (GAD-7)

Liebowitz Social Anxiety Scale (LSAS - SR)

PCL-5 Post Traumatic Stress Disorder (PTSD) Test

Rosenberg Self-Esteem Scale (RSES)

Yale-Brown Obsessive Compulsive Scale (Y-BOCS) - OCD Test

Zung Self-Rating Depression Scale (SDS) - Depression Test

Patient Health Questionnaire Quick Depression Assessment(PHQ-9) - Depression Test

Post Traumatic Stress Disorder Test (PCL-5).

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PCL-5 Post Traumatic Stress Disorder (PTSD) Assessment Checklist - Inner Changes Psychotherapy and Counselling

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PCL-5 PTSD Assessment Test The PCL-5 is a self-report measure that assesses the presence and severity of Post Traumatic Stress Disorder (PTSD) symptoms. Items on the PCL-5 correspond with DSM-5 criteria for PTSD. This is a good screening tool for Post Traumatic Stress Disorder (PTSD).

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HoNOS (Health of the Nation Outcomes Scales) was developed during the early 90s by the Royal College of Psychiatrists as a measure of the health and social functioning of people with severe mental illness.

The scales contain 12 items measuring behaviour, impairment, symptoms and social functioning. The scales are completed after routine clinical assessments in any setting.

Find out more:

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Reject Read More

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Health of the Nation Outcome Scales (HoNOS)

# data[].attributes.attachment_link.description
HoNOS (Health of the Nation Outcomes Scales) was developed during the early 90s by the Royal College of Psychiatrists as a measure of the health and social functioning of people with severe mental illness. The scales contain 12 items measuring behaviour, impairment, symptoms and social functioning.

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Dissociative Experiences Scale - II

a screening tool for The Dissociative Experiences Scale measures a wide variety of types of dissociation, including both problematic dissociative experiences, and normal dissociative experiences (e.g., day-dreaming). It is dissociative disorders, especially Dissociative Identity Disorder (Multiple Personality Disorder) and Dissociative Disorder Not Otherwise Specified (now known as Other Specified Dissociative Disorder).[1]:21, [2] People with Posttraumatic Stress Disorder also score highly on it. This is the second version of the scale, and it is easier to score than the original version. [1]:18-19 The Dissociative Experiences Scale is a self-assessment tool which is useful in determining whether a full clinical interview for dissociative disorders might be useful,[1]:21 and it has been translated into many different languages.[5]:128 The scale's authors have given permission for it to be copied for research or clinical use.[1]:22

This page requires that your browser be capable of running JavaScript.
In most browsers you can activate JavaScript using a dialog box somewhere under one of the menu bar options. Alternatively you can download a paper version of this screening tool.

DES-II

Instructions: This questionnaire asks about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. to answer the questions, please determine to what degree each experience described in the question applies to you, and select the number to show what percentage of the time you have the experience.
For example: 0% (Never) 10 20 30 40 50 60 70 80 90 100% (Always)
There are 28 questions. These questions have been designed for adults. Adolescents should use a different version. Download a printable version of this screening tool.

Dissociative Experiences Scale Scores Explained

High and Low DES Scores

High levels of dissociation are indicated by scores of 30 or more, scores under 30 indicate low levels. [1]:22 Successful treatment of a dissociative disorder should reduce the DES score when compared to the result before treatment began. [1]:23 Very high scores do not necessarily mean a more severe dissociative disorder is present, this is because the scale measures both normal and pathological dissociation.[1]:18

Dissociative Identity Disorder and the DES

Only 1% of people with Dissociative Identity Disorder have been found to have a DES score below 30. A very high number of people who score above 30 have been shown to have Posttraumatic Stress Disorder or a dissociative disorder other than Dissociative Identity Disorder.

Clinical Uses of the Dissociative Experiences Scale

If a person scores in the high range (above 30) then the DES questions can be used as the basis for a clinical interview, with the clinician asking the client to describe examples of the experiences they have had for any questions about experiences which occur 20% of the time or more. Alternatively, the Dissociative Disorders Interview Schedule (DDIS) or Structured Clinical Interview for Dissociative Disorders (SCID-D) can be used to reach a diagnosis.

References

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Dissociative Experiences Scale - II a screening tool for The Dissociative Experiences Scale measures a wide variety of types of dissociation, including both problematic dissociative experiences, and normal dissociative experiences (e.g., day-dreaming). It is dissociative disorders, especially Dissociative Identity Disorder (Multiple Personality Disorder) and Dissociative Disorder Not Otherwise Specified (now known as Other Specified Dissociative Disorder).[1]:21, [2] People with Posttraumatic Stress Disorder also score highly on it.

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Published on

This is an invited lecture from the AGM of the Royal College of Psychiatrists 2008. The topic is whether risk assessment scales and tools help clinicians who are assessing risk of suicide in vulnerable people.

1. Royal College of Psychiatrists, Annual Meeting, UCL, London, July 2008 Risk to Self in Psychiatry Do suicide/self-harm scales help clinicians? Alex Mitchell, Consultant in Liaison Psychiatry Leicester General Hospital / University of Leicester

2. Content / Questions * What guidelines exist? * How to assess risk of suicide/self-harm? - Role of scales / tools? - How to assess scales / tools? * How good are clinicians? - How much better are clinicians with tools? - Self-harm or suicide?

3. I: Guidelines

4. NICE Self-Harm Guidance (2004) * "Only use a standardised risk assessment scale to aid identification of those at high risk of repetition of self-harm or suicide." * "Don't use standardised risk assessment scales to identify service users of supposedly low risk who are not then offered services." Application of Scales =>

5. http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html Application of Scales =>

6. II: Self-Harm Scales

7. Many Scales SSI Scale for Suicidal Ideation(SSI; Beck et al., 1979) SIS Suicide Intent Scale (Beck, Schuyler, & Herman, 1974) LS Lethality Scales (LS; Beck, Beck & Kovacs, 1975) BHS Beck Hopelessness scale (Beck & Steer, 1988) HRDS Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) (Suicide item) BDI Beck Depression Inventory (BDI; Beck & Steer, 1988) (Suicide item) SPS The Suicide Probability Scale (SPS; Cull & Gill, 1988) is a 36- item self-report SIS The Suicidal Ideation Scale (SIS; Rudd, 1989) is a 10-item self- report scale MSSI The Modified Scale for Suicide Ideation ( Miller, Norman, Bishop, & Dow, 1986) is a revised version of the Scale for Suicide Ideation

8. Simple Scales * Kreitman & Foster "Edinburgh" Scale SAD PERSONS Scale (11 items) (10 items) - Previous Para-suicide S Sex - Personality Disorder A Age - Alcohol Abuse D Depression - Previous Psychiatric Treatment P Previous Attempts - Unemployment E Ethanol Abuse - Social Class V R Rational Thinking Loss - Drug Abuse S Social Support Lacking - Criminal Record O Organised Plan - Violence N No Spouse - Age 25-54 yrs S Sickness - Single, Divorced or Separated

9. Beck Suicide Intent Scale (15 items)

10. Measure Administration Predictive Study Setting Validity Psyc Medical Community other Self Interview Items Scale for Suicidal No Yes 21 Yes Yes Yes Yes Yes Ideation Suicide Intent Scale No Yes 15 Yes Yes Yes No No Lethality Scale No Yes 8 No Yes Yes No No HRDS No Yes 1 Yes Yes No No No (Suicide item) Becks Yes No 20 Yes Yes Yes No No Hopelessness scale BDI Yes No 1 No Yes Yes No Yes (Suicide item) Linehan reason for Yes No 48 No Yes Yes Yes Yes living

11. Difficulty Predicting Repetition

12. Possible Risk Factors for Repetition * Previous DSH [Hall, O'Brien et al., 1998] [Morgan, 1975] [Buglass & Hawton, 1974] [Wilkinson & Smeeton, 1987] * PPH [DeMoore & Robertson, 1996] [Slap, et al., 1989] * Depression [Kerfoot, McNiven et al., 1997] [Scott, et al., 1997] [Pierce, 1996] [Qari, et al., 1995] [Martin, et al., 1995] * Sociopathy [Kreitman & Casey, 1988] [Buglass & Hawton, 1974] * Poor problem solving [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] [McLauchlin, Miller et al., 1996]. * Poor social adjustment [Kerfoot, McNiven et al., 1997] * Hopelessness [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] [McLauchlin, Miller et al., 1996]. * Lack of confidants [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] * Internal locus of control [Tulloch, Blizzard et al., 1997] * Alcohol abuse [Pierce, 1996] [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974] * Child abuse [Wurr & Partridge, 1996] [Romans, Martin et al., 1995] [Boudewyn & Liem, 1995] * Poor parenting [Tulloch, Blizzard et al., 1997] * Physical violence [Gupta, Sivakumar et al., 1995] * Impulsiveness [Evans, Platts et al., 1996] [Slap, Vorets et al., 1989]. * Difficulty in sustaining relationships [Gupta, Sivakumar et al., 1995] * Family dysfunction [Martin, Rozanes et al., 1995] [Slap, Vorets et al., 1989]. * Obesity [Sansone, Sansone et al., 1995] * Deprivation [Inch, Rowlands et al., 1995] * Situational factors [Inch, Rowlands et al., 1995] * Psychological distress [Inch, Rowlands et al., 1995] * Male gender [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974] * Low social class [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974] * Single Marital state [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]

13. Moderate Predictive Test Point of Partial Rarity? Number of No Repetition Individuals Repetition True -ve True -ve True +ve True +ve False -ve False -ve False +ve False +ve Score on Hypothetical Predictive Test Optimum Cut-off value (hopelessness)

14. Poor Prognostic Test Number of No Repetition Individuals Repetition True -ve True -ve True +ve True +ve False -ve False -ve False +ve False +ve Score on Hypothetical Predictive Test Optimum Cut-off value (eg size of overdose)

15. 0 20 40 60 80 100 120 140 160 180 Ze ro O ne Tw o Th re e Fo ur Fi ve Si x Se ve n Ei gh t N in e Te n El ev e Tw n el ve Th irt e Fo en ur te en Fi fte e Si n xt Se ee ve n nt ee Ei n gh te N en in et ee Tw n Tw en en ty ty Tw -O en ne Tw ty en -tw ty o - Tw thr en ee ty Tw -fo en ur ty Tw -fiv e e Tw n t en y- si ty x Tw -s ev en e ty n Tw -eig en ht Beck SIS Scores 24-48hrs after Self-Harm ty -n in e Data from Allan House Th irt y

16. III: Evidence from Prediction Studies Leicester SH10 Study Edinburgh Scale (Kreitman and Foster) Beck Hopelessness Scale

17. Basic Demographics * There were 567 cases included in the study * The study period was between 18-April-04 to 27 June 2006 * The mean age in years was 39 * The follow-up period mean 254 days * 144 cases were followed for more than 365 days

18. Results Basic Repetition Details In the total sample * 130 cases repeated self-harm out of 567 = 22.9% repetition rate * There were 0.70 repeat self-harm attempts per year on average * Av time to repeat = 90 days If Follow up < 6 months * 223 cases were followed up for less than 6 months. * Of these 39 repeated = 17.5% repetition rate If Follow up > one year * 144 cases were followed for more than 365 days * 39 cases repeated = 27.1% repetition rate * There were 0.50 repeat self-harm attempts per year on average

19. III3: Leicester SH10 Repetition Results

20. Leicester SH10 (sub-sample) Repeater No Repeat Test +ve 84 120 PPV 41% Test -ve 3 44 NPV 94% 87 164 250 Prevalence Sensitivity Specificity 35% 97% 27% Predictive Summary Index 35%

21. Clinical Application of Predictors - Actual Risk Predictor If Yes If No RR Alcohol/illicit drug user 35.1 18 2.0 Difficult personal history 47.1 19 2.5 Housing problems 33.9 22 1.5 Intended to die 31.1 14 2.2 Mood/Perception 36.5 17 2.1 Past Medical history 34.9 20 1.7 Past Psychiatric History 32 10 3.2 Previous self harm 33.9 15.2 2.2

22. Kreitman and Foster Scale, 2002 Study * 3 yr study 1,331 patients * 180 repeaters within 365 days * Logistic regression analysis revealed only previous parasuicide contributed to self harm repetition.

23. Accuracy of Kreitman & Foster Scale Repeater No Repeat Test +ve 46 90 PPV 33% Test -ve 134 960 NPV 87% 180 1137 1317 Prevalence Sensitivity Specificity 13.6% 26% 84.4% Predictive Summary Index 20%

24. Beck Hopelessness Scale (20items)

25. BHS Meta-analysis Predict ed Predicte Repea high No d Low Reference Sample ted Risk Repeat Risk Colman et al (2004) Self-harm popn, 1yr follow-up 92 65 277 150 Hawton et al (2003) Self-harm popn, 1.7yrs follow-up 34 26 77 23 Keller and Wolfersdorf (1993) Inpatient popn, 1yr follow-up 10 8 51 15 Sidley et al (1999) 1 year outcome data reported 25 19 40 14 Tyrer et al (2003) Self-harm RCT 1 year follow-up 183 148 247 69 Adolescents followed for 1 year after hospital Goldston et al (2001) discharge 45 38 135 66 Adolescents followed for 6mo after hospital Huth-Bocks (2007) discharge 20 15 134 79

26. Accuracy of BHS Scale (n=7) Repeater No Repeat Test +ve 319 545 PPV 37% Test -ve 90 416 NPV 82% 409 961 1370 Prevalence Sensitivity Specificity (repetition baseline) 78% 43% 30%

27. 1 Post-test Probability 0.9 Baseline Probability 0.8 BHS+ (meta) 0.7 BHS- (Meta) 0.6 0.5 0.4 0.3 0.2 0.1 Pre-test Probability 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

28. 1.00 Post-test Probability 0.90 K&F+ 0.80 K&F- Baseline Probability BHS+ (meta) 0.70 BHS- (Meta) SH10+ SH10- 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

29. IV: Comparison with Clinicians (Unassisted) Alone Added Value

30. Accuracy of A&E Staff (high risk) Repeated No Repeat High Risk 207 764 PPV 21% Not High Risk 439 3469 NPV 89% 646 4233 4879 Prevalence Sensitivity Specificity (repetition baseline) 32% 82% 13%

31. Accuracy of A&E Staff (low risk) Repeated No Repeat High+Med 533 2722 PPV 26% Risk Low Risk 113 1511 NPV 87% 646 4233 4879 Prevalence Sensitivity Specificity (repetition baseline) 82.5% 35.7% 13%

32. Scales vs Unassisted Ability (Low Risk Strategy) 1.00 Post-test Probability 0.90 Unassisted (Not low risk) 0.80 Unassisted (low risk) Baseline Probability BHS+ (meta) 0.70 BHS- (Meta) SH10+ SH10- 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

33. Scales vs Unassisted Ability (High Risk Strategy) 1.00 Post-test Probability 0.90 Unassisted (high risk) 0.80 Unassisted (not high risk) Baseline Probability BHS+ (meta) 0.70 BHS- (Meta) SH10+ SH10- 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

34. V: Suicide?

35. BHS in DSH vs Suicide 1.00 Post-test Probability 0.90 BHS+ (Suicide) 0.80 BHS- (Suicide) Baseline Probability 0.70 BHS+ (meta) BHS- (Meta) 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

36. Accuracy of BHS Scale (n=7 for DSH) Repeater No Repeat Test +ve 319 545 PPV 37% Test -ve 90 416 NPV 82% 409 961 1370 Prevalence Sensitivity Specificity (repetition baseline) 78% 43% 30%

37. Accuracy of BHS Scale (n=4 for suicide) Repeater No Repeat Test +ve 46 1434 PPV 03% Test -ve 12 1067 NPV 99% 58 2501 2559 Prevalence Sensitivity Specificity (repetition baseline) 79% 43% 02%

38. IV: Extras and Questions

39. Predictive Scales after DSH - Power Repetition after DSH (Kreitman & Foster Scale) 70 Percentage Repeating 60 Number Repeating 50 Repetition (Number vs Proportion) 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Patients who score highly on the Kreitman & Foster scale are more likely to repeat, Positive Predictive items but the majority who repeat do not score highly

40. Advanced Suicide Intent Scales

41. Ranking (single Items) P-value Suicidal Plans or Conditional Threats? 1.65638E-05 Mood or Perceptions? 4.57034E-05 Previous Self-Harm? 0.000621875 Difficult Personal History? 0.001925556 Intended to die? 0.008459658 Housing problems? 0.113801724 Past Medical history? 0.171397338 Lack of social support? 0.202312118 Relationship problems? 0.234563323 Work or Financial problems? 0.267886875 Admission required (if so where)? 0.386619302 Past Psychiatric history? 0.391145703 Psychosis (odd thinking or beliefs)? 0.394990629 Antidote, sutures required? 0.411700936 Dementia (memory, odd behaviour)? 0.473154302 Appearance or Behaviour? 0.510764942 Unusual or risky circumstances? 0.730928415 Cognition or Insight? 0.903027575 Believed method was dangerous/fatal? 0.980425812 Alcohol or Illicit Drug User? 0.983364721 Depression (low interest, self-esteem)? 0.964452202 ICU/ITU or Resuscitation required? 0.910132669 Medical Complications or detoxification? 0.839234812 Personality (self-destructive, impulsive)? 0.755394419 Current Suicidal Intent? 0.675189743 Refuses assessment? 0.503519167 Delirium (poor orientation or attention)? 0.194075771 Hopeless or Suicidal Thoughts? 0.097861755 Attempts at concealment or Final acts? 0.068804974 Speech or Thoughts? 0.061774313

42. Combination Risk Suicidal Plans or Conditional Threats? + Difficult Personal History? = 64% (if no 18%) Past Psychiatric History + Intended to Die = 40% (if no 5%) Past Psychiatric History +

43. Alternative Cut-Off * The 10 Step form can act as an accurate risk predictor * Optimal accuracy with a 50% referral rate => - 80% rule out and 50% rule in * Using the simplest system (4 item) with 0/1 => - 93% rule out and 41% rule in (but we would receive 80% of referrals)

44. Summary of Factors Influencing Outcomes Factor Predicts No. Of Repeats Predicts Time to Repeat Suicidal plans/Threats Yes(1) No Mood/Perceptions Yes(2) No Previous Self Harm Yes(3) Yes(2) Difficult Personal History Yes(4) No Intended to Die Yes(5) Trend (p<0.1) Past Psychiatric History No Yes(1) Admission Required(Where) No Yes(3) Refuses assessment No Yes(4) Depression(low interest, No Yes(5) self-esteem)

45. 0 10 20 30 40 50 60 70 80 90 100 0 Re pe tit io ns 437 1 Re pe tit io n 90 2 Re pe tit io ns 25 3 Re pe tit io ns 7 Frequency of Repetitions of Self Harm 4 Re pe tit io ns 5 5+ Re pe tit io ns 4

46. 0 5 10 15 20 25 1 Da y 12 2- Rate 7 Da ys 14 8- 14 Da ys 9 15 -2 8 Da ys 17 29 -5 9 Da ys 13 60 -9 0 Da ys Frequency distribution of Repetition 16 90 -1 80 Da ys 23 18 1- 36 4 Da ys 23 36 5 Da ys + 3

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RCPsych AGM08 - Risk of Self Harm Evidence for Scales (July08)

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Published on This is an invited lecture from the AGM of the Royal College of Psychiatrists 2008. The topic is whether risk assessment scales and tools help clinicians who are assessing risk of suicide in vulnerable people. 1. Royal College of Psychiatrists, Annual Meeting, UCL, London, July 2008 Risk to Self in Psychiatry Do suicide/self-harm scales help clinicians?

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Window of Tolerance - a simple tool for emotional regulation

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POST TRAUMATIC STRESS DISORDER (PTSD), Causes, Signs and Symptoms, Diagnosis and Treatment.

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health mind body mind-body medicine conference psychology immunity disease

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The National Institute for the Clinical Application of Behavioral Medicine (NICABM) is a pioneer and leader in the field of mind-body-spirit medicine. As an ...

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A single moment can last forever in the memory . . .

Now when the memory is of something special, a time or an event that we hold dear, reliving the experience can feel almost as good as the actual moment did.

But when someone is remembering a traumatic experience, that memory can trigger a painful cycle of fear, anger, helplessness, and shame . . .

. . . and this, in turn, can slow the healing process for patients recovering from trauma.

So can traumatic memories be changed?

In the video below, Peter Levine, PhD shares some key insights.

Check it out - it's about three and a half minutes.

What techniques have you found effective in helping clients work with traumatic memories? Please leave a comment below.

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Working with Memory to Reframe a Traumatic Experience - NICABM

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A single moment can last forever in the memory . . . Now when the memory is of something special, a time or an event that we hold dear, reliving the experience can feel almost as good as the actual moment did. But when someone is remembering a traumatic experience, that memory can trigger a ...

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Relationship Inspired Learning and Development

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Trauma, Healing and The Brain: Community Learning Event, Dr. Gabor Mate

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Understanding PTSD's Effects on Brain, Body, and Emotions | Janet Seahorn | TEDxCSU

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Freedom from Your Painful Past with Dr. Gabor Mate

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[Glenn Parkinson] If you're avoiding people, you don't want to go out, you don't want to talk to people, you don't want to talk about your feelings, and you feel kind of numb. You can't numb out part of your emotions. You can't numb out feelings of fear, vulnerability, rage-all those things- without also numbing out feelings of love and tenderness and curiosity about people. All those things kind of get tamped down. Re-experiencing- if someone touches you, and this sort of sets off a physiological trigger for you somehow. Or if you're lying in bed with someone and feeling like you're not really sure when you wake up-well, who is that- or feeling vulnerable because you don't have control over your environment. All of these sorts of things can have an impact on someone's ability to relate to someone else-either the physical aspects of being sexual. Again, also we talked about sexuality as a sense of being free and losing control, and that's part of the pleasure of it. But if someone has difficulty losing control because they feel fearful or because they are trained not to, then it's difficult for them to have those experiences. And hyper-arousal-if you're sleep deprived and you're angry all the time, who wants to have sex, right? So again, that's a very generic sort of drop in the bucket, but because there is a lot of post-traumatic stress disorder in the population of combat-deployed military, it's really important to think about those aspects of it as well and the way in which that impacts people's ability to have social relationships in general, much less the much more deeply intimate and personal experience of being sexual with someone.

How can PTSD impact sexuality and intimacy?

Click here to see other video Q&As with Glenn Parkinson.

Click here to return to our BrainLine Military Ask the Expert feature.

Glenn Parkinson, MSW, MA works as the psychotherapist on the Traumatic Brain Injury service at Walter Reed National Military Medical Center. She works with active duty and retired military personnel and their families specializing in combat-related injuries.

Posted on BrainLine May 13, 2013.

Produced by Victoria Tilney McDonough and Erica Queen, BrainLine.

Glenn Parkinson, MSW, MA works as the psychotherapist on the Traumatic Brain Injury service at Walter Reed National Military Medical Center. She works with active duty and retired military personnel and their families specializing in combat-related injuries.

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How Can PTSD Impact Sexuality and Intimacy?

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Glenn Parkinson] If you're avoiding people, you don't want to go out, you don't want to talk to people, you don't want to talk about your feelings, and you feel kind of numb. You can't numb out part of your emotions.

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How childhood trauma affects health across a lifetime

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Childhood trauma isn’t something you just get over as you grow up. Pediatrician Nadine Burke Harris explains that the repeated stress of abuse, neglect and parents struggling with mental health or substance abuse issues has real, tangible effects on the development of the brain. This unfolds across a lifetime, to the point where those who’ve experienced high levels of trauma are at triple the risk for heart disease and lung cancer. An impassioned plea for pediatric medicine to confront the prevention and treatment of trauma, head-on.