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CTIPP - What makes a policy trauma informed? 

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CTIPP - What makes a policy trauma informed? 

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Checklist: What Makes a Policy Trauma-Informed?

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What makes a policy trauma-informed? CTIPP believes the following components can help ensure transformation occurs at every level of society to build a trauma-informed society that provides the necessary support for individuals, families, organizations, communities, and systems to adapt to adversity and stress in healthy and productive ways. ​

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Beth Tyson - The Adoptee Diaries - Navigating Childhood Trauma 

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Beth Tyson - The Adoptee Diaries - Navigating Childhood Trauma 

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‎The Adoptee Diaries: Truth, Trust, and Transparency: Ep. 6 Navigating Childhood Trauma & Adoption with Beth Tyson on Apple Podcasts

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‎Show The Adoptee Diaries: Truth, Trust, and Transparency, Ep Ep. 6 Navigating Childhood Trauma & Adoption with Beth Tyson - Sep 30, 2023

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“Trauma and psychosis: theoretical and clinical implications” - Morrison Et Al., 2005

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“Trauma and psychosis: theoretical and clinical implications” - Morrison Et Al., 2005

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“Full remission and recovery in a case of severe childhood psychosis after completion of a psychiatric day program” -Mubasher Et Al., 2023

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“Full remission and recovery in a case of severe childhood psychosis after completion of a psychiatric day program” -Mubasher Et Al., 2023

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Full remission and recovery in a case of severe childhood psychosis after completion of a psychiatric day program

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Psychotic disorders with childhood onset before age 13 are rare and may have worse prognosis than their adult counterparts, although early detection a...

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“Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life“ - Campodonico et Al., 2022

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“Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life“ - Campodonico et Al., 2022

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BMC Psychiatry 22, Article number: 213 (2022) Cite this article

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Abstract

Background

Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events. While there are some barriers to discussing trauma in clinical services, research has shown that disclosure is not only possible but also beneficial to both psychotic and traumatic symptoms. The current study is the first to evaluate service users' perception of the influence of trauma on the development and maintenance of their psychotic symptoms, as well as their views on how their life and mental health have been affected by traumatic events and their disclosure (or lack of).

Methods

Eleven participants with experiences of psychosis and trauma took part in semi-structured interviews.

Results

Consistently with previous literature, our participants reported high rates of interpersonal trauma, but had rarely had the opportunity to discuss any of these events. Using thematic analysis, we identified three major themes that have important implications for healthcare: factors that facilitate or hinder talking about trauma; consequences of talking or not; and relationship between trauma and psychosis. Participants generally benefited from talking about trauma and concerningly often associated the prolonged lack of opportunities to discuss traumatic events with negative feelings towards the self and with a deterioration of their mental health. Participants also recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

Conclusions

Our findings highlight the importance, as perceived by service users, of discussing trauma and looking at psychosis through a "trauma lens". These results stress the need to systematically assess trauma history and traumatic symptoms in psychosis and might potentially help to overcome clinicians' worries about discussing trauma with service users. Our findings underscore the need to change current practice and implement trauma-informed approaches to understand clients' difficulties and provide support.

Peer Review reports

Introduction

Offering a different perspective, Morrison et al. [ 13] suggest that psychotic and traumatic symptoms are caused and maintained by similar psychological mechanisms and fall on a continuum of trauma-related reactions. In support of this theory, research has shown that hallucinations can be considered a form of post-traumatic intrusion, where the content of psychotic symptoms relates to the traumatic experiences or to the feelings of humiliation, fear and guilt associated with them [ 14, 15]. Hallucinations and other positive symptoms of psychosis have also been linked to dissociation [ 16, 17], another trauma-related response, with researchers suggesting that several symptoms of psychosis are in fact a dissociative phenomenon [ 18, 19]. Another type of psychotic symptoms that have been associated with traumatic reactions are delusional beliefs, as paranoia and PTSD following trauma have been found to share similar cognitive underpinnings [ 20]. Some authors have recently suggested that some people with psychosis might also experience a particular traumatic reaction described as "psychosis-related PTSD" (PR-PTSD), where the symptoms of PTSD are caused by events related to the diagnosis and treatment of psychosis (e.g. sectioning) or by the psychotic symptoms themselves [ 21]. However, despite increasing evidence about the existence of PR-PTSD [ 22], this is yet to be accepted as an official diagnostic sub-type.

The evidence of a relationship between trauma and psychosis has led to the inclusion of recommendations to assess PTSD in national clinical guidelines for the management of psychosis [ 23, 24]. However, trauma-history and traumatic stress symptoms are often unrecognised [ 25, 26] and inconsistently treated [ 27], possibly due to a lack of trauma screening within routine services or to a minimisation of trauma by the individuals themselves [ 2]. A systematic review found that most people who use mental health services are never asked about traumatic experiences such as childhood abuse and neglect, and that people diagnosed with psychotic disorders are asked even less than other service users [ 28]. Practitioners' reluctance to enquire about trauma has been attributed to workload pressures and poor client engagement [ 29], and to concerns about offending or distressing the clients [ 30, 31].

Despite clinicians' concerns and individuals' reluctance to disclose trauma, different treatments are available that specifically target traumatic symptoms in people who experience psychosis, such as trauma-focused cognitive behavioural therapy for psychosis (TF-CBTp) [ 37], eye movement desensitization and reprocessing (EMDR) [ 38] and trauma exposure therapy [ 39]. Recently published systematic reviews suggest that these interventions for PTSD in psychosis not only are safe [ 40, 41], but they effectively reduce negative beliefs associated with traumatic memories, intrusive images and thoughts, hypervigilance and avoidance [ 42]. Treating PTSD in psychosis not only addresses the traumatic symptoms, but can also improve self-esteem and decrease delusions, hallucinations, anxiety, and depression (van den Berg & van der Gaag, 2012). Consensus has been recently reached about 16 essential principles of trauma-informed care in psychosis, including training on trauma-informed care for all staff, the adoption of a person-centred approach and the creation of an empathetic and non-judgmental environment [ 43]. This consensus might facilitate the consistent delivery of these interventions [ 43].

In support of these findings, qualitative research shows that promoting discussion of traumatic events in people with psychosis, even when individuals are hesitant, is possible. A study conducted with participants with first-episode of psychosis (FEP) and PTSD found that, although people might initially experience difficulty acknowledging that a trauma has occurred, it is possible to enhance their willingness to talk about trauma by giving them enough time and control over how trauma memories are shared [ 44]. Another study investigating the perspectives of young people with PTSD and FEP found that 86% of the participants showed improvement in both their PTSD and psychotic symptoms after talking about trauma, and reported that all participants found disclosure to be beneficial and worthwhile [ 45]. These qualitative studies offered privileged access to service users' experiences of trauma and disclosure, providing a unique depth of understanding which is difficult to gain from closed question surveys, and offering descriptive rather than predictive results [ 46]. These findings, although promising, need to be further supported by additional research looking at patients' perspectives of trauma.

Considering the high prevalence of trauma research in FEP, investigating the experiences of service users who have been diagnosed for a longer time would offer a more complete understanding of patients' perspective on the relationship between trauma and psychosis. Also, many qualitative studies in psychosis have so far focused on disclosure and recovery from psychotic symptoms, rather than specifically on traumatic symptoms or people's beliefs around the role played by trauma in influencing the development and maintenance of psychosis. Although the debate about what kind of events can be classified as traumatic is still ongoing, a recent meta-analysis has found that events currently recognised as traumatic by diagnostic manuals (e.g., involving actual or threatened death, serious injury, or sexual violence) are associated with only slightly higher PTSD symptoms than non-traumatic stressors [ 47, 48]. In the present study, we explore service users' experiences of trauma (without limitation to what participants could describe as traumatic), and we discuss their perspectives on how trauma and disclosure have affected participants' life and current mental health condition.

Methods

Design

A qualitative approach was chosen to explore participants' individual views, feelings and authentic experiences. Semi-structured interviews were used as they allow participants to freely disclose their thoughts without constraint and elaborate on their answers, and offer the researcher the opportunity to follow up on answers given by respondents in real-time, generating valuable conversation around a subject [ 46].

Participants

A sample of eleven participants was purposively recruited to complete semi-structured interviews as part of a larger quantitative research on post-traumatic reactions in people with psychosis. Participants were recruited if: 1) aged 16 or above; (2) able to provide informed consent; (3) experiencing psychosis as confirmed by relevant mental health professional; (4) experienced at least a difficult life event as defined by the Trauma and Life Events Checklist [TALE; 49]. Participants were excluded if: 1) experiencing dementia and/or other organic disorders; (2) had insufficient English to understand and complete the assessment; (3) had an intellectual disability which would impact the ability to complete the assessment. To create a group as heterogeneous as possible, the subsample of participants for this study was systematically recruited to differ in terms of: 1) age; 2) gender; 3) ethnicity; 4) levels of trauma symptoms as measured by the International Trauma Questionnaire [ITQ; 50]; 5) type of trauma anchored to the ITQ.

Measures

The Trauma And Life Events Checklist [TALE; 49] is a 22-item self-report measure specifically designed for routine trauma screening in psychosis services. It includes a list of common traumatic or stressful life events, as well as an item where participants can discuss traumas not covered previously. For each event that is endorsed, participants are asked if it occurred more than once and at what age(s). Three additional items ask participants which events are still affecting them and to what extent, using a scale from "not at all (0)" to "extremely (10)". Currently, the TALE is the only trauma checklist including psychosis-specific potentially traumatic events (e.g. traumatic reactions to psychotic symptoms, hospitalisations or unusual behaviours), showing moderate psychometric acceptability overall, with excellent convergent validity and reliability for sexual abuse [ 49].

The International Trauma Questionnaire [ITQ; 50] is a self-report assessment tool that evaluates whether someone meets the criteria for ICD-11 PTSD and CPTSD. It includes 12 items, 6 measuring PTSD symptoms (re-experiencing, avoidance, and sense of current threat) and 6 measuring DSO symptoms (negative self-concept, affective dysregulation, and disturbances in relationship). Each item is scored on a 5-point Likert scale ranging from "Not at all" (0) to "Extremely" (4), with possible totals for the PTSD and DSO symptoms subscales varying from 0 to 24. Impairment caused by PTSD and DSO symptoms is investigated through three items each. The criteria for PTSD are met when each relevant symptom scores at least 2 (moderately), and when functional impairment is also observed (at least one of the three items scores ≥2). The criteria for possible CPTSD are met when in addition to PTSD, the participant also presents at least moderate scores across each DSO symptom, as well as functional impairment. The ITQ has good diagnostic and psychometric properties and has been shown to effectively capture the distinction between PTSD and CPTSD [ 50].

Procedure

This research was carried out in accordance with the Declaration of Helsinki. Participants were invited from a pool of individuals with lived experience of psychosis, recruited as part of a larger study that had received NHS Research Ethics Committee and Health Research Authority approval (reference number: 18/NW/0469). After completing the previous study, participants were contacted via phone and offered the possibility to take part in this research. The researcher explained the study and agreed with them on a mutually convenient time and location (e.g., charity or Trust premises, private room at the University of Manchester, the participant's home) to take informed written consent and complete the interview. The semi-structured interviews lasted between 50 to 90 minutes and were conducted using a topic guide ( Appendix A). The questions were developed in collaboration with the research team. The topic guide was piloted with service users to ensure it was worded in a way that was easy to understand and not too distressing, and that the content was meaningful and relatable for people with lived experience of psychosis. Due to the iterative process of data collection and analysis, it became apparent during the research process that it was necessary to explore ideas not originally on the topic guide, like participants' opinion on what causes unusual experiences such as hearing voices. Interviews were audio-recorded using a digital recording device and then transcribed verbatim and anonymised at the earliest opportunity. Transcription was carried out by psychology students on placement who had been provided appropriate training and were then double-checked by the first author. Interviews were conducted until data adequacy was reached [ 51].

Analysis

Reflexivity statement

The first author (CC) is a white, middle-class, non-disabled female PhD student with an interest and background in working with trauma and people experiencing psychosis. CC believes that psychotic symptoms are strongly influenced by life experiences, especially by those events which have a traumatic nature. CC does not consider all psychotic manifestations as something intrinsically negative that need to be eradicated, but rather as meaningful attempts, conscious or not, to deal with a previous trauma. The other members of the research team (KB and FV) are also white, middle-class academics conducting research looking at the impact of trauma on psychosis, which might have influenced CC's understanding of the relationship between these two conditions. Although this study has been designed to investigate participants' point of view on the relationship between trauma and psychosis, CC was aware that some participants' might not think that such a relationship exists and she made sure to choose participants in a way that made the sample as heterogeneous as possible, rather than choosing participants depending on their perspective around trauma and their current mental health.

During both the data collection and analysis, CC attempted to acknowledge her preconceptions and personal feelings through constant discussion with the other team members. As mentioned above, all the participants in this study had previously taken part in previous research so CC had the opportunity to develop a positive working relationship with them. These relationships have given CC privileged access to people's stories, as they may have felt more confident in mentioning traumatic events or personal opinions that they had never spoken about before. As a result of their past experiences, some participants had strong negative feelings towards professionals. The existing relationship between CC and the participants, as well as the fact that CC has no experience as a clinician, made it difficult in the beginning to look at all the stories with impartiality. This was also affected by the fact that CC knows that trauma should be routinely assessed in clinical practice, but it is not. However, the other two authors have extensive clinical experience and offered their points of view during the analysis phase.

A critical realist [ 54] approach was used to analyse the data, which combines ontological realism and epistemological relativity. In other terms, we appreciate that the world has a concrete reality besides human constructions of it, but we also recognise that our understanding of the world is necessarily limited by our perspectives and standpoints within it. We acknowledge that our interpretations of what participants discussed are influenced by concepts that are socially constructed (e.g., schizophrenia and PTSD), and that complete objectivity is impossible.

Results

The demographics of the participants are displayed in Table 1. While Table 1. presents the traumatic event to which the ITQ was anchored, it is important to note that all participants reported complex and repeated trauma histories. On the TALE, participants reported having experienced an average of thirteen different traumatic events. Most of these events were repeated experiences of interpersonal abuse both in childhood and adulthood, including bullying, discrimination, aggression, or insults by a close person, or feeling unsafe and unloved during childhood. More than half of the participants had experienced childhood sexual abuse and two participants reported having experienced sexual abuse as adults. Almost all participants reported feeling scared or threatened by psychosis-related symptoms or by contact with mental health services. As observed in Table 1., most of the sample had ITQ scores suggestive of a PTSD or CPTSD diagnosis.

Table 1 Demographic and clinical characteristics of the sample

After conducting thematic analysis, three major themes were identified: 1. Factors that facilitate or hinder talking about trauma; 2. Consequences of talking or not; and 3. Relationship between trauma and psychosis. The following themes describe participants' experiences and their perspectives on what has facilitated or hindered trauma disclosure in the past and what could help to create the right environment in the future for discussing traumatic experiences. This is followed by a description of the most common consequences both in relation to talking and not talking about trauma, where disclosure normally resulted in positive outcomes and failure to discuss trauma led to isolation and the development of negative feelings towards the self. The last theme describes the relationship between trauma and psychosis as identified by the participants, in that participants recognised that not having the chance to share their traumatic stories aggravated their overall mental health and described how the content of their psychotic symptoms related to past traumas.

Factors that facilitate or hinder talking about trauma

Of the many factors that played a role in participants' willingness to talk about trauma, having people in their life that were trusted and considered willing to listen, played the most important role in terms of disclosure. Participants who had the opportunity to discuss trauma usually confided in family and support groups or tried to approach a professional. Disclosure to family and support groups was facilitated by perceiving a safe environment and being around someone trustworthy or who had been through similar events. Discussing trauma was also facilitated by having a supportive professional, who participants described as a person who is kind, patient and interested, who asks questions without being perceived as judgemental. Sylvia describes which characteristics in a professional facilitate trauma disclosure:

Most participants revealed that on many occasions they wished somebody had asked them about their difficult life events, as this was often the only push they needed to be able to share their stories and feeling less alone. However, when they felt ready to talk about trauma, they often did not have the opportunity to do so, or other people seemed distracted and not interested. Disclosure to family was often met by negative reactions including anger, disbelief and dismissal, while disclosure to support groups was sometimes regarded as disappointing or insufficient. Daniel describes his mother violent reaction to his attempt at disclosing a sexual abuse:

During hospital admissions, participants felt that they had no opportunity to disclose because of a range of negative views of professionals (perceived as too busy or as " the enemy "). Similarly, two participants reported not having the opportunity to talk when they were on probation following a prison sentence, as people around them already had a negative opinion of them and were not interested in listening. Sylvia describes how she felt when she got sectioned and realised that staff in the hospital was not interested in investigating deeper causes for her behaviour:

Among those patients who did not experience rejection, the fear that people would not believe them or would not understand the trauma or the participants' ways of coping with it, was enough to prevent them from discussing the event. At other times participants were simply not ready to talk about trauma as they had not processed it themselves, either because they were unable to recall the traumatic events or because they had spent too much time denying what happened. Another common hindering factor consisted in being too scared of possible consequences of talking about trauma. Participants often believed that bad things would happen if they spoke about the traumatic event (e.g., threat to them or family members), either because the voices (i.e. auditory verbal hallucinations) or the perpetrator of the abuse told them so. Vanessa explains she never spoke about trauma as she feared negative repercussions on her parents:

Consequences of talking or not

Participants identified many outcomes related to talking or not about trauma. Those who had the opportunity to discuss trauma reported experiencing positive consequences both for themselves and others. Many participants said that although talking about trauma is hard, when they were able to do so they felt as if a weight had been lifted off their chest. Similarly, some people remarked that discussing past experiences offers a chance of releasing negative emotions that would normally bottle up and become 'negative energy'. Walter acknowledges the difficulties of discussing trauma, but appreciates the benefits that might come from it:

Participants also found value in sharing their stories to help others feeling less lonely and desperate, and reported experiencing positive feelings when they thought they had been useful to someone else. In this respect, participants noted that knowing that someone else went through similar events, experienced similar feelings and survived, could be inspirational. For example, a participant said that the reason why they agreed to participate in this research, was that they hoped that their story would reach more people in similar situations. Luca explains his motivation for sharing his story:

Some participants who had not yet had the chance to talk about trauma, said that they would welcome the possibility to do so as it could potentially help them changing perspective on what happened and fully understand the consequences trauma had on their lives. Participants reported that not having the opportunity to discuss trauma mostly impacted the way they made sense of it. Not having anyone to talk to influenced their understanding of the reasons behind their maltreatment, which meant that for a long time they felt like they were to blame. Self-blame and guilt added to the wide range of negative emotions that they were already experiencing in relationship to trauma. For example, not being able to discuss trauma also led to feelings of shame, as participants considered themselves weak for feeling scared, angry or lonely, especially if they thought that abuse was 'normal' or deserved and they had no reason to be feeling that way. It was proposed that this way of thinking about trauma and themselves might have eventually led to the inability to cope with the traumatic event. Vanessa describes how she felt when she was blaming herself for her mother's death, and the relief she experienced when she could finally forgive herself:

Participants reported that not being able to discuss trauma had long-lasting consequences on their lives. They reported not feeling in control, because they often had to give up work and education, as trauma and its consequences affected their motivation and their ability to cope with daily tasks and be among other people. The idea of not having accomplished anything in life led to feelings of sadness and depression. Vanessa describes how the consequences of trauma made it impossible for her to hold on to a job:

Interpersonal trauma was more frequently associated with avoidance of social contact, as participants considered their loneliness a result of their past life events. Not being able to discuss traumas resulted in being cautious around other people and keeping distance for fear of being hurt or losing someone they cared about, leading to increasing isolation. Participants said they suffered because of their social withdrawal, and even when they wanted to connect with others, they reported not knowing how to do it, as interpersonal traumas resulted in difficulty expressing and feeling emotions, and confusion around the meaning of love and affection. Mary explains that she realises that she is the one keeping people distant, but she does not know how to stop doing that:

Relationship between Trauma and Psychosis

While almost all participants agreed that trauma impacted their whole life and that they were largely still affected by it, they had different thoughts around how it influenced their current mental health. While a few participants were unsure, many believed that trauma was the cause of their psychotic symptoms and psychosis-related diagnosis, and that if they had had the chance to discuss trauma earlier this could have prevented their current condition. One participant thought that professionals diagnosed them with psychosis only because they did not believe their trauma disclosure, and they were convinced that their life would have been much better if only they had received help when they were looking for it. Participants' mental health slowly or suddenly deteriorated as a direct consequence of trauma, or as a result of ignoring the event and its effects for too long. Symon explains how having the chance to discuss trauma when it first happened, could have prevented their current mental health status:

Even when the trauma did not cause traumatic or psychotic symptoms, it shattered the participants' confidence, coping abilities and mood, until they could not deal with daily tasks anymore and felt useless and hopeless. Feeling constantly scared as a consequence of trauma, as well as feeling continuously on the edge of a mental breakdown, wore participants down until something else traumatic happened and they could not cope anymore. Mary offers an example of how her everyday activities eventually became unmanageable:

Participants recognised specific links between trauma and the content and characteristics of psychotic symptoms. For example, memories of the trauma faded into visual hallucinations, and voices that screamed and cried often sounded like the participants at the time the trauma happened. They sometimes recognised that feelings of suspiciousness and 'paranoia' were also linked to their trauma, and so were some voices warning them off every time they left the house. Deborah explains her understanding of the relationship between her past traumatic experiences and current mental health:

However, the voices were not always perceived negatively. Despite being daunting, some participants recognised that the voices were probably just trying to keep them safe and to avoid new traumas. The voices would get anxious when the participants tried to talk about trauma, or they would directly order the participants to not talk about the traumatic events. On the other hand, a participant reported appeasing the voices to be able to cope with trauma, and that once they started dealing with the traumatic memories the voices also got better. Walter described the protective role played by his voices:

Discussion

This study investigated service users' perception of the role played by trauma in influencing the development and maintenance of their psychotic symptoms and their views on how traumatic experiences and their disclosure (or lack of) have affected their life and mental health. The study found that participants had high rates of interpersonal traumas and that discussion of these traumas could be facilitated by having appropriate conditions to do so. When provided with the right opportunity, mostly referring to having somebody trusted and interested in listening, talking about trauma usually led to positive outcomes for the participant and the people around them. On the other hand, not being able to discuss traumatic life experiences, together with feeling scared or not ready to disclose, affected the way participants made sense of the trauma and often led to negative feelings towards the self. Most participants believed that the prolonged lack of opportunities to talk about trauma aggravated their difficulties, and they recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

Consistently with what found in the literature [ 2, 28], our participants reported seldomly being asked about trauma history or traumatic stress symptoms, despite national clinical guidelines recommend trauma assessment in psychosis [ 23, 24]. Our research provided a richer description of the personal implications of not having the occasion to talk about trauma, grounded in participants' testimonies and personal experiences. In line with Tong et al.'s [ 44] qualitative research on FEP, our participants agreed that conversations about trauma can be uncomfortable, yet they welcomed the idea of a professional asking them about their experiences, as long as they felt safe and not judged. This supports the evidence that rates of disclosure are not influenced by patient characteristics [ 32], but rather by external factors such as the reactions of those to whom the traumas are disclosed. Our results not only further stress the importance of routine assessment of trauma in psychosis, but also match meta-analytical evidence that trauma disclosure is ultimately beneficial [ 55]. Negative reactions are particularly detrimental as not only they influence willingness to disclose, but they can also increase PTSD symptoms [ 56]. In our sample participants agreed that not talking was largely influenced by not having people in their life that were trusted and considered willing to listen, by previous negative reactions from family members or by poor relationships with professionals. Overall, our findings reflect and support the conclusions from qualitative research on trauma and FEP, suggesting that discussing trauma in psychosis is possible and beneficial.

Our findings that discussing trauma often resulted in positive consequences for the participants and others are in line with previous research suggesting that trauma disclosure can improve overall well-being [ 57]. For example, participants felt that telling their stories allowed them to process some of the associated memories and being able to use their experiences to help others get through similar events increased their self-esteem. These findings have important clinical implications as they suggest the value of using client narratives within services. By normalising and sharing positive experiences of patients who decided to talk about trauma, professionals can encourage disclosure. As both clinicians and service users gain confidence in the safety and benefits of discussing trauma, routine trauma inquiry initiatives would be facilitated.

The fact that participants who did not talk about trauma often blamed themselves for what was happening in their lives and felt weak for being scared or lonely, also finds support in the literature, which suggests that not being able to discuss trauma in psychosis can result in negative outcomes [ 33]. The role of self-blame here is particularly important, as research has found that in people with a history of trauma, internalising feelings of blame contributes to psychological distress [ 58] and has a deleterious impact on physical health [ 59]. Studies around self-blame in psychosis have so far focused mostly on caregivers rather than on service users [ 60]. Further research is needed to investigate the role of self-blame in relation to trauma and psychosis, to understand if self-blame arises as a result of prolonged non-disclosure or if the relationship is possibly more complex (e.g., bi-directional).

Similarly to previous research, participants reported that the content of psychotic symptoms was often related to their traumatic events and the negative feelings associated to them [ 14, 15]. When interviewed, participants reported experiencing many psychosis-related traumas, including being scared because unable to distinguish reality from fantasy, by their hallucinations or by going through several negative hospital experiences. These findings stress the need to move away from what is currently considered traumatic within the diagnostic classifications systems and adopt a wider and more ideographic understanding of what constitutes a traumatic experience. Events currently recognised as traumatic by diagnostic manuals (e.g., involving actual or threatened death, serious injury, or sexual violence) are associated with only slightly higher PTSD symptoms than non-traumatic stressors [ 47, 48]. Widening the definition of trauma could affect who is treated for trauma-related disorders, how treatment is understood and could reduce the risk of invalidating people's attempts of disclosing trauma. If more people who experience psychosis were treated for trauma, it might impact how their symptoms are conceptualised, as we know that flashbacks of an event can be difficult to distinguish from hallucinations [ 14, 15] and that the way these intrusive experiences are labelled determines the diagnostic interpretation of these symptoms as either a function of psychosis or PTSD [ 61].

While there is extensive quantitative evidence on the potential links between trauma and psychosis, including re-victimisation [ 62], our findings indicate that the views of people with psychosis are sometimes, although not always, congruent with these research findings. Consistently with studies that found that re-victimization increases the likelihood of having psychotic experiences [ 63], our results suggest that feeling constantly scared as a consequence of trauma, or feeling continuously on the edge of a mental breakdown, led participants to a point where they were so worn down that they could not cope with anything anymore.

Our findings on the relationship between trauma and psychosis, and the fact the participants reported wanting to discuss trauma rather than just be treated for the psychotic symptoms, fit well within the recovery movement that advocates for a broader and more individualised understanding of what recovery in mental health means [ 64], as well as with increased calls for the implementation of trauma-informed approaches within mental health care [ 65]. In the context of trauma in psychosis, this would not only mean reducing the psychotic symptoms, but also trying to understand these symptoms as potential reactions to traumatic life experiences, and therefore benefit from general support consistent with trauma-informed care as well as, in some cases, trauma-focused therapy. Trauma-informed care in psychosis, based on knowledge and understanding of how trauma affects people's lives, have widely agreed on principles [ 43]. Trauma-focused therapy has shown promising results [ 66], with no evidence that it could lead to re-victimization or the exacerbation of PTSD or psychotic symptoms [ 67]. For our participants, not being able to discuss trauma was potentially related to the development of their psychotic experiences, which has been found to be the case in other mental health conditions, as non-disclosure has been associated with higher PTSD symptoms and depression [ 68]. Trauma-informed approaches and trauma-focused interventions could be particularly useful and more acceptable for these participants who already see a connection between their past traumatic experiences and their symptoms of psychosis. TF-CBTp in particular, has been found to have promising effectiveness, as supported by case-series [ 37] and feasibility trials [ 69]. Prolonged exposure and EMDR have also been found to be effective in reducing both symptoms of PTSD and psychotic symptoms in people with experiences of psychosis [ 70]. These types of interventions have shown to improve both service users' experiences and working environments for staff, as they foster understanding, respect and trust between patients and professionals and avoid the risk of service users being retraumatised by 'trauma-uninformed' staff [ 65].

Limitations

It is important to remember that participants in this study had already contributed to previous research about trauma and were, therefore, more likely to be interested in the topic and willing to discuss their experiences, even if for the first time. This could potentially mean that those individuals who would not even consider discussing a traumatic event may not be represented and that additional challenges to disclosure could exist. It might also mean that the series of positive consequences associated with discussing trauma reported by our participants do not necessarily apply to all service users. Additionally, due to the diverse sample, potential moderating characteristics were not adequately represented to allow the exploration of subgroup differences (e.g., ethnicity and gender). As evidence indicates that minority ethnicities have a higher chance to experience coercive and potentially traumatic pathways into care [ 71], future qualitative research is needed to further our understanding of the experiences of trauma in minorities. Finally, while our results contribute to existing literature suggesting that many people with traumatic experiences and psychosis attribute their psychotic experiences to their traumas, we recognise that this study was not designed to test this putative mechanism nor any causal relationships. Although trauma seems to be one pathway to psychosis, there are people with experiences of psychosis who do not report any trauma [ 72].

Conclusions

The findings from this research highlight the importance, as perceived by service users, of discussing trauma. Our results suggest that similarly to findings in non-clinical populations, people with psychosis are willing to discuss trauma and think that disclosure might be associated with positive outcomes. On the other hand, not being able to discuss trauma was normally associated with negative outcomes. Despite not having the opportunity to discuss trauma previously, service users welcome the idea of discussing trauma and even hope that doing so might improve psychotic symptoms. Future research is needed to systematically investigate the connection between trauma and psychotic symptoms and explore the benefits of discussing trauma also with service users who have been diagnosed for a long time. By looking at psychosis through a "trauma lens" and implementing trauma-informed approaches to understand clients' difficulties and provide support, we might be able to see faster recovery and overall improved functioning and wellbeing.

Availability of data and materials

The dataset generated and analyzed during this study are not publicly available as interview transcripts contain sensitive and potentially identifying information but are available from the corresponding author on reasonable request.

Abbreviations

CPN:

Community psychiatric nurse

References

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Acknowledgements

The authors are grateful to all participants who took time to share their invaluable thoughts and experiences.

Funding

This review was supported by a doctoral research grant from the University of Manchester. The sponsors had no role in the study design, collection, analysis, or interpretation of the data, or the preparation and approval of the manuscript.

Author information

Authors and Affiliations

1. School of Psychology and Computer Science, University of Central Lancashire, Preston, Lancashire, UK

Carolina Campodonico

2. Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK

Filippo Varese & Katherine Berry

3. Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Zochonis Building, room 2.43, M13 9PL, Manchester, UK

Filippo Varese & Katherine Berry

Contributions

CC, FV and KB designed the study and created the topic guide. CC was responsible for data collection, data analysis and drafting the original manuscript. All authors agreed on the results, revised and approved the final manuscript.

Corresponding author

Correspondence to Carolina Campodonico.

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Campodonico, C., Varese, F. & Berry, K. Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life. BMC Psychiatry 22, 213 (2022). https://doi.org/10.1186/s12888-022-03808-3
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Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life - BMC Psychiatry

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Background Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events.

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“Childhood Trauma & Psychosis - an updated review” - Stanton et Al., 2020

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Author links open overlay panel Kate J. Stanton MD a , Brian Denietolis PsyD a , Brien J. Goodwin MS b , Yael Dvir MD a

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Key points

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Growing evidence supports the links between childhood trauma and psychosis, which include higher risk for psychosis, increased severity of psychotic symptoms, increased frequency of affective symptoms and substance use, and worse functional impairment.

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Biological factors explaining this link include gender, brain-derived neurotrophic factor, and other inflammatory markers.

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Psychological mechanisms explaining this link include dysfunctional cognitive schemas and affective dysregulation.

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Evidence

Summary

This article highlights recent advances in understanding the connections between childhood trauma experiences, psychotic symptoms, and the development and course of psychotic disorders. Cross-sectional and longitudinal studies have consistently demonstrated clear associations between traumatic life events in childhood and the development of psychosis in late adolescence. ¹ Although there is more to be discovered about the relationship between childhood trauma and psychosis, there is an abundance

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2022, Journal of Psychiatric Research

Studies estimate that childhood trauma triples the risk for the development of psychosis, even when controlling for variables such as intelligence, socioeconomic status, and genetic vulnerability (Arseneault et al., 2011; Varese et al., 2012). Further, childhood trauma accelerates onset, increases symptom severity, and intensifies cognitive and functional impairment in both schizophrenia (SZ) (Popovic et al., 2019; Stanton et al., 2020) and bipolar disorder (BD) (Cakir et al., 2016; Shannon et al., 2016; Farias et al., 2019). Despite higher prevalence and worse outcomes in these populations, researchers and clinicians may fail to inquire about childhood trauma due to a misconception that patients cannot provide reliable reports (Read and Fraser 1998).

Childhood trauma is common and associated with worse psychiatric outcomes. Yet, clinicians may not inquire about childhood trauma due to a misconception that patients cannot provide reliable reports. The goal of this study was to examine the reliability of self-reports of childhood trauma in psychotic disorders.

We examined the test-retest reliability of the Childhood Trauma Questionnaire (CTQ) in schizophrenia (SZ, n = 19), psychotic bipolar disorder (BD, n = 17), and healthy control (HC, n = 28) participants who completed the CTQ on ≥2 occasions over variable time periods (mean 19.6 months). We calculated the intraclass correlation (ICC) for the total CTQ score, each of the five CTQ domains, and the minimization/denial subscale for the three groups. For any CTQ domains showing low test-retest reliability (ICC < 0.61), we also explored whether positive, negative, depressive, and manic symptom severity were associated with CTQ variability.

We found high ICC values for the total CTQ score in all three groups (SZ 0.82, BD 0.85, HC 0.88). The ICC values for CTQ subdomains were also high with the exceptions of scores for sexual abuse in BD (0.40), emotional neglect in SZ (0.60), and physical neglect in BD (0.51) and HC (0.43). In exploratory analyses, self-reports of sexual abuse in BD were associated with greater severity of depressive symptoms ( β = 0.108, p = 0.004).

Patients with SZ and BD can provide reliable self-reports of childhood trauma, especially related to physical and emotional abuse. The presence of psychosis should not deter clinicians from asking patients about childhood trauma.

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Childhood traumas have been extensively associated with the development of psychotic disorders. However, our understanding of processes underlying this relationship remains poor. In order to address this issue, we examined which specific aspects of childhood trauma are significantly associated with a first episode of psychosis. 109 patients with first episode of psychosis and 145 controls representative from general population were recruited in three centers in France. Child experiences of care and abuses allowed obtaining information about types of childhood trauma, age at first exposure, identity of perpetrator, and social support. Odds ratio were calculated for each of these aspects, adjusted for age, sex, and education. Sexual and physical abuses (OR = 2.26 (1.19-4.32)), and separation from one or both parents (OR ranging from 1.94 to 3.17; all significant) are significantly associated with an increased risk to present a first episode of psychosis. Furthermore, separation from mother occurring before age of 4 (OR = 5.96 (1.24-28.77)), and sexual and physical abuses perpetrated by someone other than parents (OR = 4.61 (1.66-12.80)) were also associated with an increased risk of first episode of psychosis. Finally, social support was significantly associated with a decreased risk to develop psychotic disorders (OR ranging from 0.33 to 0.42; all significant). Together, these findings suggest that some but not all aspects of childhood trauma are related to a significant risk to develop a first episode of psychosis.

Childhood trauma, cannabis use and certain personality traits have been related to the development of psychosis. This study uses a sib-pair design to examine the association between childhood trauma and psychosis controlling for cannabis use and neuroticism.

We evaluated 60 patient-sibling pairs, conformed by patients with functional psychosis in the first five years of their illness matched with a non-psychotic sibling. In univariate analyses, patients and siblings were compared with McNemar tests and paired-sample t tests. A conditional logistic regression model of the risk of developing psychosis was built. The dependent variable of this model was the patient-sibling status (patient = 1, sibling = 0).

After controlling for cannabis use and neuroticism, the odds of suffering psychosis for subjects who experienced a childhood trauma were 7.3 times higher than the odds for subjects who did not experience a childhood trauma [95% CI, (1.06-50.01); P = 0.04]. Also, after controlling for experiencing childhood trauma and neuroticism, subjects who were heavy cannabis users had odds of suffering psychosis that were 6.4 times higher than the odds of the remaining subjects [95% CI, (1.2-35.2); P = 0.03].

Both childhood trauma and cannabis use were significantly associated with an increased risk of suffering functional psychosis. A neurotic personality also contributed independently to this risk. These findings might help improve the prevention of psychosis and the development of specific treatment strategies on this specific population.

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Childhood Trauma and Psychosis: An Updated Review

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Author links open overlay panel Kate J. Stanton MD a , Brian Denietolis PsyD a , Brien J. Goodwin MS b , Yael Dvir MD a Show more * Growing evidence supports the links between childhood trauma and psychosis, which include higher risk for psychosis, increased severity of psychotic symptoms, increased frequency of affective symptoms and substance use, and worse functional impairment.

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“Childhood Trauma & Psychosis - What is the evidence?” - Schafer & Fischer, 2022 

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“Childhood Trauma & Psychosis - What is the evidence?” - Schafer & Fischer, 2022 

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Dr. Melanie Greenberg - Understanding the Trauma BrainNeuroplasticity provides hope if you suffer from trauma or PTSD.

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Dr. Melanie Greenberg - Understanding the Trauma BrainNeuroplasticity provides hope if you suffer from trauma or PTSD.

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Key points

Trauma can affect your brain's emotion networks to make you overreact or under-react to stressful situations.

Trauma creates fixed neural networks that are isolated from other parts of your brain and resistant to change.

Avoidance behaviors and trying to suppress your trauma don't work and can create more damage.

Seeking psychotherapy, meditating, doing yoga, and taking medication can all help make your brain more flexible.

If you suffer from post- traumatic stress, you will likely overuse some parts of your brain and underuse others. The parts of your brain involved in monitoring for signs of danger and anticipating what could go wrong are overused. Because experiencing severe trauma can shut down other systems not involved in emergency responding, it is also likely that parts of your brain that are involved in enjoying the moment, celebrating your own successes, pursuing positive goals, relaxing, feeling gratitude or awe, or bonding securely with other people are underutilized.

Traumas Keep Your Brain Stuck in the Past

If you have PTSD, when you feel "triggered by an emotionally upsetting or physically taxing situation, you rapidly enter a state of "fight, flight, freeze" and may react with rage, run away or shut down. This is the result of ancient brain and nervous system wiring related to survival.

As a result of trauma, certain groups of neurons (those related to survival functions) may, over time, connect more strongly with each other while becoming more isolated from the rest of the brain. This can lead to a kind of rigidity in which the triggering of one part of a neural network makes it more likely that the whole set of neurons will be activated. These networks can become stuck in a pattern and resist taking in new information.

In the case of trauma, for example, your sense of a lack of safety or lack of self-worth may continue even when your current environment is not dangerous, and you are valued at your job or by your family and friends. It's as if the new information is not getting to the parts of your brain that store your trauma memory. When you suffer from post-traumatic stress, you are more likely to view current events through the lens of trauma, leading you to perceive things inaccurately and overreact or under-react. You can get stuck in fixed ways of thinking and feeling that are more reflective of the past than your present.

Traumas Make Your Strengths and Coping Tools Harder to Access

Weaker connections between neurons in a brain network may make it harder for your brain to perform certain functions, such as concentrating on a task without interruption or inhibiting unhelpful thought patterns or destructive impulses. Unprocessed trauma memories are thought to be stored in your brain in a way that is disconnected from the overall context. When triggered, they don't connect fully to the fact that your present is different from your past and that you have different abilities and choices now than you did then.

When you are triggered into a trauma state, you may not be able to connect with or utilize the strengths and resiliencies you can exercise in other contexts. The parts of your brain that help you assert yourself, calm down negative thinking, regulate emotions, make mindful choices, or realistically evaluate risk and reward may not have a strong enough connection to the "raw" trauma memory to be able to calm things down and redirect.

Neuroplasticity Means Your Brain Can Learn New, More Helpful Patterns

Traumas in childhood can affect the brain into adulthood. Yet your brain neurons have plasticity, which means they can continue to be changed by new experiences, even into adulthood and old age. You can learn to rewire your brain by making small changes repeated over and over again. You can practice new ways of thinking, new ways of making room for your feelings, and new ways of behaving that are more proactive and less avoidant.

At first, the new habits seem weak in comparison to your wired-in responses. You may be tempted to think they don't work and stop using them. But if you persevere, the neurons underlying these new habits will begin to get stronger. Perhaps you will be able to cope better with mild and moderate stress without being triggered. If you keep going for many months or years, even the severe triggering will begin to calm down as new network connections are built and strengthened.

Avoidance Perpetuates Trauma-Based Patterns; Facing Fears Helps You Unlearn Them

You may try to put your trauma memories and feelings into a mental box so you can avoid looking at them. You try to get on with everyday life as if the trauma never happened and don't deal with it. You may drink alcohol or abuse other substances to suppress anxiety or escape difficult feelings. You may become sexually compulsive or sexually avoidant. You may overwork, overeat for emotional reasons. become obsessed with thinness or exercise compulsively.

Although these strategies can work to suppress feelings for a while, they create new problems and can damage your health and self-esteem. They also don't work to suppress trauma permanently. Eventually, the trauma feelings break through. Sometimes a new stressor like being rejected in a relationship or being laid off from work can trigger them. A physical illness can make you feel weaker and more vulnerable like you did at the time of the trauma. You may overwork so as not to deal with the trauma but eventually face burnout. Life changes like having a child, a relationship breakup, being laid off from a job, or the death of a parent may trigger old trauma-related feelings. Loneliness may bring out the old feelings of being unworthy and unwanted.

If avoidance doesn't work, what is the alternative? Seeking therapy for your trauma is the best option. A trained professional can help you face your traumas in a controlled way and with support. Some therapies that are recommended for trauma include somatic therapy, EMDR (Eye Movement Desensitization and Reprocessing), cognitive-behavioral therapy, or internal family systems therapy. Doing regular yoga, meditating, having a healthy exercise practice, or taking medication like antidepressants can enhance the effects of therapy.

The most important goal is to develop a mindset of approach, rather than avoidance. You need to learn to approach difficult feelings and situations like conflict or intimacy in a mindful way and at your own pace. Trauma gives you an "all or nothing" mindset. A gradual, strategic approach is the antidote.

As you learn the habits of approach rather than avoidance, you will learn that you can function in the face of anxiety. You will learn that the trauma memory and related sensations are not the same as the actual event and can be tolerated. Eventually, you will begin to see yourself as a stronger and more capable person. Although you can't completely eliminate the trauma memory from your brain, you can connect it more strongly to your networks of resilience so that you, and not your trauma, are in charge of your life.

New knowledge about trauma and the brain is emerging and will continue to lead to new treatments. Psychotherapy assisted by psychedelics like MDMA is one such approach that shows initial promise. Understanding how trauma works in the brain and body is the first step to beginning a process of healing that can lead to lasting change. But don't try to do it all on your own. Seek the help of a caring and knowledgeable mental health professional who is trauma-informed.
To find a professional near you, visit the Psychology Today Therapy Directory.

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Neuroplasticity provides hope if you suffer from trauma or PTSD.

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University of  California- San Francisco: Trauma in youth leads to poor health in old age 

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University of  California- San Francisco: Trauma in youth leads to poor health in old age 

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Unhappy Family or Trauma in Youth Leads to Poor Health in Old Age

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Adverse experiences early in childhood and early life have been linked to lifelong health consequences.

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Beth Tyson - August Childhood Trauma Newsletter 

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Beth Tyson - August Childhood Trauma Newsletter 

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It's August, and the sights and sounds of back-to-school are joyously vibrating through my being! I don't know about you, but this summer has been a challenge in the parenting department. Children thrive in their routines and structure, and summer life does not have enough of that for my child because the baffling behaviors are off the charts!

As a former child trauma therapist, I feel the pressure to always know what to do as a parent, and when I don't I feel ashamed. So, cheers to a new school year, I am ready for it!

Thank you to all the teachers, school counselors, school nurses and other professionals who risk their lives and their sanity for our children. You all deserve a pay raise and more vacation time, in my opinion.

New parenthood can be traumatic. From the stress of the pregnancy on the body to any number of things that go wrong during the birth process, becoming a new parent is an overwhelming and potentially traumatizing experience for everyone involved.

This topic is important for me to speak up about because I struggled with anxiety and despair after the birth of my daughter, and I want every parent to know that you are NOT a failure if you are going through the same thing too. There is help available and there's nothing wrong with asking for support or seeking mental health treatment. Getting the help you need is BRAVE and absolutely the best thing you can do for your children.

But, even if everything goes smoothly with pregnancy and childbirth the first year or more of your child's life can be extremely stressful, and that's expected. According to the most recent research, this developmental phase from the beginning of pregnancy to one year postpartum is known by scientists as matrescence and patrescence. This vulnerable and natural stage of development, similar to adolescence, is experienced by anyone who becomes a parent, even through adoption or surrogacy.

During matrescence and patrescence it is common to experience intense feelings of anxiety, sadness, irritability, shame, and frustration. Yet, we often pathologize new mothers experiencing a human process, which can cause even more shame for their struggles as a new parent. This is important to discuss because feelings of shame can easily exacerbate hopelessness and despair during an already difficult phase.

At the same time, suicide is the leading cause of death in postpartum people (up to one year from giving birth). The risk factors include:

Being solely responsibly for the care of the child

A history of childhood trauma

Prior substance use

Intimate partner violence

Co-morbid psychiatric conditions

Lack of support from family or spouse

Demographics, like being young, lacking access to education, and being unmarried

When these deaths occur the impact on the baby's developing brain and nervous system can be devastating. However, I believe that normalizing the overwhelming experiences during early parenthood, and creating public policies that support new parents could reduce postpartum suicide and prevent some of the childhood trauma across our nation.

I have to say, before you read the full article, that I dislike the use of these gendered terms, and, unfortunately, the only research we have access to today is based on people who identify with their biological sex. More inclusive data and language is needed to have a full conversation on this topic.

This PACESConnection community is wealth of knowledge on Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs). The research on ACEs and PCEs is clear. When young children experience adversity it negatively impacts their long-term health, and when children experience positive relational and social experiences, it buffers them from the adversity of life. PACESConnection is an online, free membership community filled with trauma and mental health experts who share resources and guidance regularly.

PACEs Connection members include people living in rural, suburban, and urban areas and from a variety of different backgrounds, including health, education, criminal justice, social services, business, community activism, civic, and faith-based fields.

PACEs Connection members receive a Weekly Roundup with the latest PACEs, trauma, and resilience-related news, reports, research, and activities plus a features and new videos. Plus our new Weekender newsletter.

We post summaries and links to news, reports and research in the blog entries every day on the home page of PACEs Connection. That's where you'll find members' blog posts, too.

On the home page you'll also find the latest members who've joined the network, and recent comments from members.

You can also find calendar listings, videos, and an " Ask the Community " section (just below the blog entries).

Our Webinar Archive holds some of our most popular videos, especially our 'A Better Normal' Community Discussion Series.

Over the last few years I've had the pleasure of making friends and influential connections through the PACEs community. I highly recommend you check it out!

This month's Trauma Champion meshes perfectly with the topic of matrescence and patrescence.

Deborah's main focus is helping new parents understand and implement the process of attachment, and the important role it plays in the healthy development of the baby's brain and nervous system. When new parents have tools like Deborah created, it can increase attachment, which naturally will reduce anxiety in the baby. Less anxiety typically equals more sleep, which is a win for everyone involved!

She has been seen in publications, heard on radio interviews and webinars worldwide and receives rave reviews for her engaging and insightful presentations and keynotes for communities, schools, organizations and companies. She has the ability to make brain science both understandable and easy to implement into everyday life and loves seeing "aha" moments occur as she shares insights with those who care about making a positive difference.

The energy that the fall season brings is already ramping up! Pumpkin Spice Latte anyone? September feels like the start of a new year for many of us, especially teachers, parents, and anyone who works closely with children. And with this uptick in energy I am looking forward to new projects and speaking opportunities!

Exciting news! On September 19th I will be the keynote speaker for Kinship Care Month in Albany, NY for the New York State Kinship Navigator Program. I was honored to be invited to share about my children's book, A Grandfamily for Sullivan, and trauma-informed care for kinship families.

There are approximately 3 million grandfamilies, aka grandparents raising grandchildren, in the U.S. and that number is growing drastically due to the opioid epidemic. This population has a special place in my heart because I saw first hand, as an in-home trauma therapist, the unique pressures these families are under. Although we know there are huge benefits to placing children with relatives, there is still an enormous amount of trauma these families are coping with and they often lack the financial resources to care for the children. Relatives raising their kin need and deserve more support, and I am going to bring all of my latest trauma-informed skills to this keynote presentation, including my C.A.R.E.S Model for Connection After Trauma. If you're in NY state, I hope you can make it!

If you keep up with me on my LinkedIn or Facebook page (you do, right??) you might have heard that this month, in collaboration with Connect Our Kids, Unbelievably Resilient and the National Center on Adoption and Permanency, we are rolling out an interactive new curriculum called "Why Connections Matter" to every child welfare professional in the state of Mississippi!

Children in the U.S. foster care system often lose their biological family and their self-identity along with them, but it doesn't have to be this way! Every child has someone out there who knows them or wants to know them. These people have valuable information that can help children in foster care answer life's most important questions like, "who am I?" and "do I matter to anyone?"

Over the next few months I will be working with Dr. Michael Makara and his team from Hungary, to translate some of my content/webinars into Hungarian. This will be the first time my work has be translated into another language, and I'm so grateful to be able to support children in Hungary who are facing trauma on a daily basis without access to mental health care.

I am publishing another children's book! This new book will be for children between the ages 1-4 who experience separation anxiety for any reason, including trauma and loss.

Build child/caregiver attachment through co-regulation, safety, and trust

Calm the child's nervous system to try new things

Help young children recognize safe relationships and situations

Ease children into transitions to new environments and caretakers

Alleviate stress for caretakers

As I go through the creative process I will be posting ideas on my social media for opinions, suggestions, and general feedback. Definitely keep an eye out for fun updates and requests about the book. I can't wait to share the finished product with all of you!

As the new school year starts revisit my article about why transitions can be SO tough for children with trauma. A helpful rule of thumb is to schedule in 10 minutes each day to spend "do nothing time" with your children so they receive the gift of your presence, and sync up with your calm nervous system. Over time, this will teach their nervous system how to move in and out of distress with more ease. An incredibly valuable skill for resilient living.

Please reply to this email with questions or comments about my work or this newsletter. I love when I hear from you!

To schedule training, consulting, or speaking events on childhood trauma, ambiguous loss, and trauma-informed caregiving please reply to this email or to schedule time to chat!

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The August Childhood Trauma Newsletter: Matrescence, Patrescence, Infant Attachment, & Book Chat

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By Beth Tyson, MA - Childhood Trauma Consultant It's August, and the sights and sounds of back-to-school are joyously vibrating through my being! I don't know about you, but this summer has been a challenge in the parenting department.

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Lou Lebentz - Trauma Informed Practice Guide for Counsellors 

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Lou Lebentz - Trauma Informed Practice Guide for Counsellors 

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Dr.Anna Tanasugarn - 5 subtle signs of unprocessed attachment trauma 

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Dr.Anna Tanasugarn - 5 subtle signs of unprocessed attachment trauma 

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Key points

People with unprocessed attachment trauma often report similar behaviors or psychological symptoms that affect the quality of their adult lives.

Unexplained physical ailments may originate from having experienced early trauma.

Trauma-blocking behaviors occur by engaging in compulsive behaviors that momentarily distract from traumatic memories or pain.

To find a therapist, please visit the Psychology Today Therapy Directory.

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5 Subtle Signs of Unprocessed Attachment Trauma

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How these symptoms can affect the quality of our lives.

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Washington Post - Does Trauma Spill From One Generation To The Next 

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Washington Post - Does Trauma Spill From One Generation To The Next 

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The idea that trauma can be transmitted across generations - originating with long-dead relatives and passed down to future great-grandchildren - can be a difficult concept to grasp.

But with regular news of mass shootings, covid deaths, police killings and climate disasters, a growing number of therapists and their patients, particularly among the millennial and Gen Z cohorts, are turning their attention to the far-reaching impact of trauma, past and present.
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The Oscar-winning film "Everything Everywhere All at Once" and television shows such as "Transparent" have grappled with how trauma trickles down in families. Popular nonfiction books such as " What Happened to You?", by Oprah Winfrey and Bruce Perry, have taken the concept of intergenerational trauma "from the ivory tower to the general public," said Sandra Mattar, a clinical psychologist and specialist in trauma-informed therapy.

The medical community has taken note. In April, more than 100 psychiatrists, psychologists, medical residents and other physicians gathered virtually for a Boston Medical Center "Grand Rounds" education event focused on intergenerational trauma. Mattar, who led the session, said the high turnout reflects heightened interest in the subject.

"I believe that trauma is at the core of so many mental health problems," said Mattar, who also is director of training at the Immigrant and Refugee Health Center at Boston Medical Center.

The good news, experts say, is just as trauma can be passed through generations, so can resilience. But tapping into that resilience often requires a deeper understanding of the original source of the trauma and the routes of transmission through families and society.

Trauma in the genes

Intergenerational trauma can stem from biology, learned behaviors and even the collective experiences of a group. Some research suggests that trauma can affect a person's DNA and potentially influence the health of future generations far removed from the traumatic event.

Researchers have investigated whether Holocaust survivors and their children showed changes to what are known as "epigenetic markers," chemical tags that attach to DNA and can switch genes on or off, which in turn can influence inherited traits or diseases.

Advice: How to talk to your (skeptical) family about therapy

These studies, led by Rachel Yehuda,director of the Center for Psychedelic Psychotherapy and Trauma Research at the Icahn School of Medicine at Mount Sinai, compared blood samples of people who experienced the horrors of the Holocaust with those of Jews living outside Europe during the war.

Through molecular analyses, researchers found an important difference: Mothers exposed to the Holocaust showed changes in the activity of a DNA segment involved in regulating the stress response. Their children, who were not directly exposed, also showed these changes.

The implications of this research are far from conclusive but suggest that the environmental wounds inflicted on one generation may be transmitted to the next."Clearly there is a signal of something interesting happening on a molecular level with intergenerational trauma," said Yehuda, a professor of psychiatry and neuroscience. "It will be a while before we figure it all out."

It's not the traumatic experience that is passed on, it's the anxiety and world view of the survivors, said Ed Tronick, a developmental and clinical psychologist at the University of Massachusetts Chan Medical School in Worcester. Many Holocaust survivors developed a view that the world is a dangerous place where terrible things can happen anytime. Their children intuitively sensed this fear. "Children are like anxiety detectors," Tronick said, and they pick up and adapt to these cues.

Even the great-great-grandchildren of enslaved people can experience the anxiety their parents feel about the danger of sending them out into the community. In response to parents' behavior, a child's "body has already begun to experience the world as dangerous, even though he doesn't understand the dangers at that young an age," Tronick said.

Researchers have found that a range of toxic environmental and social exposures during pregnancy, whether it's ingesting drugs and alcohol, or the stress of living in poverty, can also be transmitted in utero.

Imprints of abuse

Studies show that an abusive childhood can profoundly affect future generations.

Researchers interviewed volunteers from the Nurses' Health Study about the levels of abuse inflicted on them in childhood - whether they were hit with a belt, left with bruises, or sexually or verbally abused.

The imprint of this violence took a lasting toll on the women's children, the researchers found: Depression rates were 1.7 times higher and chronic depression 2.5 times higher among the children of women who experienced severe child abuse compared with children of mothers who had not endured such abuse.

"Childhood abuse has a profound impact on adult mental health, which can then affect family members," said Andrea Roberts, the study's lead author and a senior research scientist at Harvard T.H. Chan School of Public Health.

Bessel van der Kolk, author of the best-selling book " The Body Keeps the Score," characterizes trauma not merely as an event in the past, but also as something having a lasting imprint on the mind, brain and body.

In an interview, van der Kolk said intergenerational trauma can be tracked in the ways children adjust themselves to their parents' behavior. "When your mother freezes in response to your laughing, you learn not to laugh in front of your mom," he said.

Collective trauma

"Collective" intergenerational trauma and " racial trauma " refer to the psychological distress passed through generations as a result of historic events, including colonization, slavery and other forms of oppression.

This type of trauma reaches far beyond individuals and families and is a shared experience among a particular group, such as descendants of the 120,000 Japanese Americans and Japanese nationals who were detained in incarceration camps during World War II.

Such trauma can manifest in many ways, from heightened anxiety, depression and insomnia to other mental and emotional health problems.

Thema Bryant, a specialist on healing from trauma and president of the American Psychological Association, said many people must cope with multiple forms of trauma at the same time.

She said her own view of the world was filtered through her experience growing up in Baltimore with descendants of the transatlantic slave trade and a World War II veteran grandfather with PTSD. She's also endured a lifetime of racism and survived sexual assault. "I'm both a survivor of trauma within my lifetime and of intergenerational trauma," Bryant said.

In the memoir " What My Bones Know," Stephanie Foo confronts a punishing personal history of abuse and, after being diagnosed with complex PTSD, explores how trauma can be inherited through generations.

"We are all products of our history," she said in an email interview. "I don't really think it's surprising that we carry our fears, traumas, tics and insecurities and pass them on to their children to some degree, whether it's a depression-era recipe for potato salad or a deep-seated fear of abandonment."

Foo's great-grandmother and grandmother survived the Japanese occupation of Malaysia during World War II and a brutal guerrilla war with Britain known as the Malayan Emergency.

"I personally believe that because my great-grandmother and grandmother had to hustle desperately to survive," Foo said, "that has contributed to the hustle and creativity I've possessed in building my own career and survival skills here in America. It's probably also contributed to my intense anxiety."

Helping people cope with generational trauma

It often requires a holistic approach to break the grip of generational trauma, experts say.

Awareness: Jason Wu, a Bay Area psychologist and child of refugee parents,said the first step is building awareness. A patient may have internalized the belief they're not good enough, "but upon unpacking it, they can see how their parents', and maybe even their parents' parents', constant criticisms and lack of warmth or praise is the source of this belief."

Mind-body therapy: Somatic, or body-based therapies such as yoga, have been found to be effective for trauma. Increasingly, expressive arts therapies employing movement, music or visual arts, are being used to help patients find more adaptive ways to cope, said Cécile Rêve, co-founder of ARTrelief, a center that provides these arts-based therapies.

Reframing: Foo said it was important to reframe the damaging stories she'd been fed as a child. "My mother's voice saying, 'You're worthless, you're unlovable, you're stupid,' " she said. "I think the essence of healing has been the effort to rewrite that narrative to something more loving, forgiving and kind."

Breaking the cycle: Studies suggest that even children who did not experience nurturing parenting can overcome this history if, as adults, they consciously adopt positive parenting strategies with their own children.

Activism: Directly addressing the sources of trauma, such as gun violence or racism, through activism and advocacy are also powerful tools for overcoming its grip, said Bryant, the APA president.

Talk about it: How trauma is talked about in families can also be important. "Is it never discussed and therefore labeled as unspeakable? Or is it one part of the family's story that is owned and claimed by each family member?" asked Arielle Scoglio, an assistant professor of health studies at Bentley University in Waltham, Mass. "The second response dispels shame related to the trauma and integrates it into a narrative that is flexible."

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How does trauma spill from one generation to the next?

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The idea that trauma can be passed across generations can be a difficult to grasp. But just as trauma can be passed through generations, so can resilience.

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(Mis)understanding trauma-informed approaches in mental health - Sweeny & Taggart (2018)

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(Mis)understanding trauma-informed approaches in mental health - Sweeny & Taggart (2018)

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Mis understanding trauma informed approaches in mental health

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NHS - Safe & Therapeutic Environments Checklist 

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Safe and Therapeutic Environments Checklist

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NHS - Trauma-Informed Service Assessment Tool

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NHS Camden & Islington - A Trauma Informed Organisational Strategy

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NHS Camden & Islington - The Trauma Informed Model 

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My Care Academy, Elearning - Introduction to Trauma Informed Care Approaches 

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NWCI & Quality Matters - Gender-sensitive Mental Health: Developing Policy and Services Which Meet the Particular Needs of Women and Girls 

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Cambridge University Press - Looking through the wrong side of prison bars: The psychology of injustice

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Cambridge University Press - Looking through the wrong side of prison bars: The psychology of injustice

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Notes

1 Wakefield and Uggen (2010, p. 401).

2 Reiman and Leighton (2016).

3 The terminology used to discuss incarcerated persons has been changing; see Shalby (2019). I have tried to use terminology that is more neutral.

4 Foster and Hagan (2015).

5 Western and Pettit (2010, p. 9). Mears and Cochran (2018) make the same point: "Individuals in prison have substantially worse educational ... histories as compared to the general population" (p. 30).

6 Page, Piehowski, and Soss (2019).

7 Epstein finally met a kind of justice in prison when he (apparently) took his own life, but as chronicled so diligently by Julie Brown (2021) his wealth and influence kept him out of the reaches of the law for decades.

8 De Carvalho and Bantim (2019).

9 For a broader discussion of prison riots, see chapter 12 in Wooldredge and Smith (2018) and Wooldredge (2020).

10 Kulig, Pratt, and Cullen (2017) provide a reasonably balanced discussion, arguing that psychologists should be more demanding regarding replication of results, particularly in the case of studies such as the Stanford prison experiment. Le Texier (2019) provides a more damning discussion of Zimbardo's prison study.

11 Kim, Losen, and Hewitt (2010).

12 Kearney et al. (2014).

13 Scott-Hayward and Fradella (2019).

14 Schweitzer and Nuñez (2017).

15 Franklin (2017).

16 Woolard (in press).

17 Reiman and Leighton (2016).

18 Wheelock and Uggen (2008).

19 Heller, Jacob, and Ludwig (2011).

20 Geller et al. (2009).

21 Carson and Golinelli (2013).

22 Zorbaugh (1929) and Shaw and McKay (1942).

23 Ellen, Lacoe. and Sharygin (2013).

24 Stuckler et al. (2011).

25 Graif, Gladfelter, and Mathews (2014).

26 Graif, Gladfelter, and Mathews (2014, p. 1141).

27 Nikulina, Widom, and Czaja (2011).

28 Freeman (1996) and Lochner (2004).

29 Lally, Mangione, and Honig (1988) and Schweinhart, Montie, and Xiang (2005).

30 Lochner and Moretti (2004).

31 Hjalmarsson, Holmlund, and Lindquist (2014) and Hjalmarsson and Lochner (2012).

32 Carson (2018).

33 Archer (2004).

34 See Choy et al. (2017) and Schwartz, Steffenmeier, and Ackerman (2009).

35 Campbell, Vogel, and Williams (2015, p. 199).

36 Carson (2018, Table 6).

37 Han (2018).

38 Tonry (2014); see also Kearney et al. (2014).

39 Tucker (2014, p. 135)

40 Barnes and Motz (2018).

41 Jan (2017).

42 Kearney et al. 2014).

43 Aizer and Doyle (2015).

44 Aizer and Doyle (2013).

45 Mendel (2011).

46 Sedlak and McPherson (2010).

47 Human Rights Watch (2012).

48 Beck, Harrison, and Guerino (2010).

49 Dierkhising, Lane, and Natsuaki (2014).

50 Dumond (2000).

51 For example, see Trulson et al. (2010) for juveniles and Steiner and Wooldredge (2008) for adults.

52 For a review of this literature, see Foster and Hagan (2015).

53 Lee, Porter, and Comfort (2014).

54 Wildeman, Turney, and Yi (2016).

55 Turney (2015).

56 Amato (2000).

57 Wakefield, Lee, and Wildeman (2016).

58 Wakefield, Lee, and Wildeman (2016, pp. 11-12).

59 Haskins (2014).

60 Geller et al. (2009).

61 Haskins (2014).

62 Ewert, Sykes, and Pettit (2014).

63 Eason (2010).

64 Nance (2016).

65 Katsiyannis et al. (2018).

66 There is a lack of systematic and comparable statistics on recidivism across nations, but Fazel and Wolf (2015) provide a tentative picture.

67 Durose, Cooper, and Snyder (2014).

68 Cullen, Jonson, and Nagin (2011).

69 Foucault (1995).

70 For examples, see Western et al. (2015) and Western (2018).

71 Western et al. (2015, p. 1541).

72 See Gaes (2019) for a discussion of research on prison privatization.

73 See Melossi and Massimo (1981).

74 Katzenstein and Waller (2015, p. 639).

75 Katzenstein and Waller (2015).

76 Van Zyl Smit and Dunkel (2018).

77 For example, see Dyer (2000) and Eiser (2017).

78 Dickens (1970, p. 324).

79 See Alber (2007) for a more comprehensive discussion of how Dickens incorporate the prison in his novels.

80 Surprenant (2019, p. 124).

81 Piff et al. (2012).

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Looking through the wrong side of prison bars: The psychology of injustice | BPS

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Notes 1 Wakefield and Uggen (2010, p. 401). 2 Reiman and Leighton (2016). 3 The terminology used to discuss incarcerated persons has been changing; see Shalby (2019). I have tried to use terminology that is more neutral. 4 Foster and Hagan (2015). 5 Western and Pettit (2010, p. 9).

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A trauma-informed practice

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A trauma-informed practice | Classroom resources | Jigsaw.ie

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Dr. Sandra Bloom - Trauma Informed Workplaces 

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Trauma-Informed Workplaces with Sandra L. Bloom, M.D.

Episode Summary

"Trauma-informed workplaces offer a sanctuary of safety and support, a place where people can bring their whole selves and be valued for who they are." - Sandra L. Bloom, M.D., CTIPP Board Chair, and Founder of Creating PRESENCE

Episode Notes
Content advisory: Sexual assault and suicide (:9:13 - :19:58)
What does it mean to be "trauma-informed," and why should organizations make their workplace more trauma-informed? How can it improve a team member's (and the organization's!) well-being, safety, productivity, fulfillment, and growth? How do you build, implement, and sustainably maintain trauma-informed workplaces? Who is responsible for such endeavors within the organization? How do I get started?

We aim to answer those questions and more with our podcast on creating and maintaining trauma-informed workplaces, featuring CTIPP's Board Chair, Sandra L. Bloom, M.D.

Dr. Bloom is a Board-Certified psychiatrist, a Temple University School of Medicine graduate, and an Associate Professor of Health Management and Policy at the Dornsife School of Public Health, Drexel University. A pioneer in the trauma-informed care field, she is the Past-President of the International Society for Traumatic Stress Studies. She has spent over three decades researching, developing, and promoting trauma-informed practices, particularly in workplace settings.

Her work emphasizes the importance of creating safe, supportive, and empowering environments for individuals who have experienced trauma. Her approach to trauma-informed care is comprehensive and holistic, recognizing that the impacts of trauma extend beyond an individual's physical and mental health

#TransformTrauma is a Campaign for Trauma-Informed Policy and Practice (CTIPP) podcast. Through coalition-building, advocacy, and policymaking, we're building a national movement that integrates community-led, trauma-informed, resilience-focused, and healing-centered prevention and intervention across all sectors and generations. Learn more at CTIPP.org.

Episode Transcription

APPROXIMATE TRANSCRIPT, POWERED BY AI
CONTENT ADVISORY: SEXUAL ASSUALT & SUICIDE: 9:13-19:58
Hello and welcome to the transformed trauma podcast. My name is Whitney, and I am the director of trauma-informed practice and Systems transformation with the Campaign for Trauma-Informed Policy and Practice, or CTIPP. And I'm here with Jesse, our executive director. And we're thrilled today to have the opportunity to chat with Dr. Sandra Bloom as our guest, to talk about being responsive to trauma in our systems and in particular, our workplaces, and to learn a bit about Dr. Bloom's background beyond what we discuss here, as well as to check out her books and other amazing work. Please be sure to check out the description of this episode. So welcome, Dr. Bloom. We're delighted to be with you today.

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Well, thank you, Whitney. And thank you Jesse, it's good to be here.

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And to begin, since you do have such a rich and storied career, Jesse and I thought a great starting point would be to invite you to share a bit about what you would consider to be the key parts. Of the story that brought you here with us today, the things that called you to this work, as well as any striking learnings or, AHA moments that emerged along the way.

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I'd be happy to, but I have a long story because I'm old. I want to give you kind of a context for what my story is. I started out in psychiatry when I was a teenager, first as a secretary on Temple Hospital's psychiatric unit, and then as a psychiatric technician on that same unit. As we were preparing for this conversation, I was thinking about what I was immersed in way back then, which is in the 1960s that then became part of my life story. And I think what I was immersed in was what psychiatry was in the first part of the 20th century, and it was largely influenced by the most important psychiatrist of the day, a guy named Adolf Meyer, who was at John Hopkins.

He talked about what he called "common sense psychiatry". He was himself an immigrant, and he talked about how human beings were programmed to adapt to all kinds of changing conditions.Some people developed mental disorders as a result of adaptive failure and the inability to adjust to whatever was going on in their lives. He emphasized that the boundary between the mentally well and mentally ill is fluid because normal people can become ill if exposed to sufficiently severe trauma.

He thought that an untoward mixture of noxious environment and psychic conflict causes mental illness. He said "It's the story that counts in a person". So that was knowledge that was embedded in the way people thought in those days that I was exposed to. Even though I didn't know formally about Adolf Meyer and common-sense psychiatry, it was embedded in my teachers. Later I learned that he had trained a psychiatrist named Trigant Burrow, who was one of the founders of the American psychoanalytic association and had been analyzed by Carl Jung in Switzerland. And Trigant was really the unacknowledged founder of group therapy, unacknowledged because he gave up successful analytic practice and started his own alternative community because he came to believe that it was a society that was sick.

He and his colleagues and friends lived in this community for 30 years, trying to figure out what was wrong with our entire species. And he said, "Individual discord is but the symptom of a social disorder....It's society that is the patient".

So those ideas were influencing me even though I didn't know it at the time. What I did know, which was explicit when I was working as a mental health tech and then as a medical student and then as a psychiatric resident through the 1960s and 70s, was the main school of thought, which was called social psychiatry. So, it was the main branch at the time when I was training, and it focused on the interpersonal and cultural context of all of the problems that we were seeing and what it takes to create mental well-being for people. So that was part of the conversation. And this all came about because of World War II.

When the war was over, there was a burgeoning understanding that, well, we have to look at everything in the culture because this must never happen again. We had just almost destroyed the whole world, and the nuclear bomb had gone off, and it was really a scary, important time like today. William and Karl Menninger, the Menninger brothers were two psychiatrists who founded the Menninger clinic, famous in Kansas. Karl Menninger's book, The Human Mind was the first psychology book I read as a teenager. In 1945, William Menninger wrote that "every institution in American society must evaluate its program in terms of the contribution to individual and group mental health and that it was vital to determine the more serious community caused sources of emotional stress". Wow, 1945 and there is still so much left undone, right

The people that taught me, were writing about that, talking about that, and teaching us about that social injustice. By 1982, George Albee, who was a psychologist focused on prevention, said "to argue that there are a number of separate and discrete mental illnesses, each with a separate but undiscovered cause, obscures or blocks consideration of the possibility that most emotional disturbances are a result of dehumanization, powerlessness and victimization by social cruelty". That is already forty years ago and one of the reasons for pointing that out for your listeners is that it illustrates how knowledge keeps getting lost. It keeps getting disregarded. We've known about the impact of trauma as long as there's been recorded history We can go all the way back to Mesopotamian literature, a lot of Greek literature and abundant references in Shakespeare. It doesn't matter where you go. There's always an emphasis on the importance of trauma and what it does to people and yet it keeps being forgotten.

So, there's always a danger today that it will be forgotten again, and that's part of what I want people to understand. So, although I was immersed in all this, I understood this was part of the context of my experience throughout my training. But it really wasn't until 1980 when my colleagues and I had created our own psychiatric unit in a semi-rural community about an hour north of Philadelphia, and I had been asked to see a young woman, a teenager, who was the daughter of a nurse that I had worked with. And in my first book, I call her "Dawn." Her mom sent her to me because she had accused a man on a college campus of rape. And the police investigated, and it had not happened. And even listening to her story, it didn't make sense. Even to her, it didn't make sense and I didn't know what to make out of that. WeI started doing regular weekly psychotherapy and having been trained in social psychiatry and dynamic psychiatry, you get people's story, and you develop a relationship with them, and then you kind of see as you go what they need and how to help. I worked with her for several years, probably three or four years, and then she left to go to graduate school after she had finished college.

During that time, there were times, usually whenever she was out on a date, where she would call me as an emergency, where she would be really upset, and I couldn't always understand what it was she was upset about. She'd be crying, and I'd calm her down and just listen and talk to her, and then she'd say, "I'm okay now, and I'll see you at the next session". I didn't really think much about those episodes or what they meant. And then in 1985, I got a call from her mother asking if she could bring her in to be hospitalized because she was suicidal. They were now in another state. I said, of course, or yes. But I was kind of staggered because I thought she was all better.

When they arrived and I walked into the room to do the psychiatric evaluation, it was her, the person I knew, but in another way, it wasn't her. It was the weirdest thing I had encountered up until that time and I had encountered so"me pretty weird things. But she was moving like a little child, and it was very dramatic. And I remember saying to her, "who are you?" And she gave her name. And then I said, "how old are you?" And she said, "I'm seven". This was somebody I thought I knew as well as I knew anybody in my family. This was not a stranger.

What then emerged over time, in the course of her hospitalization, which was just a couple of weeks, was that she was an incest survivor. And I was staggered. I was shocked that I had missed it all this time. I had been in psychiatry a long time, and I just could not believe that I didn't know or even suspect this incredibly important information. And her mother was able to confirm a lot of the surrounding details of what my patient was telling me, enough to undo any skepticism I had about what she was telling me.

Now, looking back, I think there were some other things that kind of prepared the groundwork for being able to accept the terrible things that happen to children. I started seeing her in 1980. In 1983, a tragedy occurred in the relatively small community we were practicing in. The hospital where our unit was located was small with a President of the Board and a very active ministerium in the town.

In 1983, two boys handcuffed themselves together, took LSD, and set a recording going so they could say goodbye to all their friends and relatives. At the same time they could express their hatred for all the people that they hated, which they did. They then handcuffed themselves together and jumped into a quarry to their deaths. One of them was the son of a prominent local minister. About a couple of weeks later, the girlfriend of the boy who was the minister's son, killed herself. She was the daughter of the President of the Board of the hospital. Naturally this tragedy got enormous coverage locally. A reporter from Philadelphia Magazine came up to do an investigative report on these three adolescent deaths because it wasn't as routine as it has become for teenagers to kill themselves.

It was really mysterious as to what was going on. I had met the one boy who was the minister's son once because the school had called me in to see if there was anything I could do to help him. I think the school had a sense that things were really going downhill, so they forced this young man to come into a room with me. But he wasn't about to talk to me about anything, I don't know that I had ever experienced anybody so filled with hatred as he seemed to be and I said so to the school people, I had no idea what to do to help him and we had no legal grounds to really do anything. He hadn't overtly threatened suicide or homicide or anything else that would put someone's life in danger. But after the deaths what I saw then was that this trauma affected the entire community, the whole hospital community, the school - everybody because everybody was interconnected, all the churches, all the families. It was a system trauma.

So in retrospect, I think that's what set me up for the things that began to unfold later when I then started to see people in our psychiatric unit who came in with every kind of conceivable problem. We had an open, voluntary unit because another thing your listeners should know is that there were in those days, in many general hospitals, open, voluntary psychiatric units so you could get care if you were really in a crisis. You could get away from home for a while and get into a place where people would listen to you and give you an opportunity to tell your story. We used a lot of art therapy and psychodrama and movement therapy so early on we were integrating the expressive arts because that was what was done at the time, not because we knew how effective all of those modalities were for trauma, but because that was part of what I had been trained to expect, where the arts were really important. And so, when I created my own program, I did the same thing.

So we started asking everybody about their history of childhood trauma and other traumas, and we were profoundly shocked because everybody, virtually everybody, had a sad and often abusive history. And sometimes we had captured the history, but we just didn't know what to do with it. And at other times, we hadn't asked the right questions. And of course, it is also true that it is painful for people to talk about their past trauma, particularly if it begins in childhood, so they would actively avoid telling us. We were absolutely floored at the amount of sexual abuse that people experience as kids, men, and women. It was astonishing. We had all been taught it was really rare, that sexual abuse hardly ever happened to anybody. Several years later, the same reporter for the Philadelphia Magazine, Stephen Fried, came up again to the same area, the same neighborhood, to investigate a local police chief who had been convicted for pedophilia and was in prison. It was never proven, but there was some suspicion that the two boys, or at least one of the boys, that had killed themselves, had known this guy. So it remained a question in my mind, but that would certainly explain what I saw back in 1983 and didn't understand.

So by 1991, we were in a team meeting trying to figure out how we had all been changed by this information and my friend and colleague, Joe Foderaro, who sadly died last year, said "we've stopped asking people what's wrong with them, and now we ask what happened to them and that's changed everything". We had stopped focusing on what their diagnosis was and thinking that in some way we could medicate it all away, but this was really hard information to take on board and to recognize about our culture.

I had been trained at Temple Hospital. So Temple is in the middle of one of the most impoverished neighborhoods in the country, mostly African American at this point, with a history as a community. It had been a very highly industrialized area, where people after the civil war who had been enslaved, came up to the northeast to find jobs and the jobs were there. The factories were abundant and they needed a workforce, and people moved in near their workplace and developed prosperous neighborhoods.

But then over time, as the industry left and went overseas, people were trapped. They couldn't get away - there weren't any jobs anymore. If you were white, you could get out to the new and growing suburbs, where there were workplaces and new housing. But if you were black, the Civil Right Movement hadn't even happened yet, so you were really stuck there. The people who originally taught me how to be a mental health tech were all African Americans - they were my colleagues and my friends, even though I was much younger. Segregation still existed as it still does but not in the hospital. So I wasn't as aware of what people were going through, But when I entered medical school and my residency my patients were largely African-Americans living in poverty, trying to make a living as best they could, trying to protect their children from the encroachment of drug dealers and pimps. They were all my patients once I started actually training, and then I would find out what their lives were like, and that was excruciating. So I had this division. I looked at what was going on at Temple, and I said, oh, there's nothing I can do about these social problems. This is so huge. I can't get people jobs. I can't get them out of these impoverished situations where kids are eating lead paint.

One of my teachers was the person that discovered the connection between lead paint and brain damage in children. All of the psychiatrists that taught me were active in the Civil Rights Movement, in the feminist movement, in the LGBT movement. One of them was John Fry, who was the guy that was the first psychiatrist to go to an APA meeting with a mask on and talk about how being gay was not pathological. So they were my teachers. But I didn't think I could impact the social problems people had in any way because the problems were so big and so social. So when I finished my residency I went out to the far distant, all white suburbs expecting I'd be able to do something there. And that's when we found trauma. That's when we really discovered that this is everywhere. There's different kinds of trauma, but exposure to adversity and trauma is everywhere. And that was overwhelming.

And so now bridging into the workplace because I know that's what you guys want to get to. I want to talk a minute with what happened to us as clinicians because we all got burned out. There were various physical illness that developed among us, mental illness, divorces, affairs, boundary violations - any number of signs that we were not doing well. We seemed to be okay before we started letting in all this knowledge about what people had really been through. So recognizing the degree of pathology in the culture was very disturbing, and that you have to look at yourself and you have to look at your own issues, and you are compelled to look at what happened to you as a kid and an adolescent and as an adult. You had to look at the relationships you were in. You had to do your own work. It wasn't about "us" and "them". It was really us. All of us in a culture that had become incredibly pathological. So that's the very long answer to what you asked me, and I'll pause and take a breath for a minute.

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Yes, Sandy, thank you for sharing all of that. And it's incredible to hear about how so long ago we were talking about how macro sociological systems impacted the individual and how one of the things that we do at CTIPP is really try and flip the narrative. Has become where burden and onus of trauma and resilience seems to be. Put so much on the individual that we've lost sight of how broader systems are impacting the individual. You brought up issues around redlining, around sexual abuse and just the magnitude of abuse, neglect and dysfunction that exists in people's lives.

Which reminds me also of the ACEs study, the Adverse Childhood Experiences study, and what Dr. Anda and Dr. Felitti found in their groundbreaking study in the 90s as well. I am curious, as you did that work at your own workplace. You sort of left us off there since 91 when all of that work took place. You've now developed models and have become a real international leader in terms of how this applies to all workplaces. We're not just talking about psychiatric care settings. We're not just talking about people that have as advanced degrees and knowledge sets as you are. We're sort of talking about creating human workplaces all over, in all industries, all across the world. And so, I'm curious if you can sort of pick back up there about how all of this applies to the broader workplace in all settings.

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Sure. I think what we have to reckon with is that. There really is no meaningful vision of health, that we have mistaken what we call normal for health. The two are radically different. So, we don't have a vision of what's a healthy individual, what's a healthy group, what's a healthy society. No, there's no vision of that, that's not portrayed really anywhere except on Star Trek, so without that, you don't know what you're aiming for.

And being human beings, our greatest strength is that we are very adaptive. It's also our greatest weakness because you can see it day by day. We are adapting to the most pathological behavior at every level of our system including our national and state governments. It's unbelievable when you turn on the television, but we are adapting to it. We are adapting to astonishing levels of cruelty and hatred being accepted as normal.

Well, how can this be? How can we be getting sicker and sicker and sicker and more and more and more violent? Well, I'd say we're building on about 12,000 years of intergenerational exposure to trauma and adversity. It's not new. It's been around as soon as people stopped being hunter gatherers and settled down. We have been making war on each other ever since.

So, it means on the ground now, today, that the people running our systems, no matter what system you look at, from the federal level right down to the workplace are people who have been exposed themselves in some way to adverse childhood experiences, because we know from an abundance of research that most people in our culture have been exposed to adversity and trauma.

And then there's all of the interpersonal violence that people are exposed to. You know, we know from the national studies that 46% of women and 42% of men have been exposed to one or more types of interpersonal violence in their lifetime.

We know that the more childhood adversity you've had, the more likely you are to suffer from a mental illness - any mental illness. We know that the Secret service has investigated that people don't just snap. These school shooters, church shooters, these people that are creating havoc, they don't just snap. The common theme is that they have experienced loss, failure, public humiliation in the days or weeks before they attack other people. None of this is mysterious anymore.

We know where all of this is coming from, but our values have become radically altered.

We are no longer grounded as Americans in terms of shared values, purpose and meaning. The only thing that seems to really mean anything is money. And that's been going on as long as I've been alive. The cultural emphasis has shifted so that the only thing of value is in accumulating wealth and that if you're not doing that, then you really don't have much value. So, the result of that is that we've created a society where violence is now a constant threat to everyone everywhere and we forget that it's all completely preventable.

We have to stop being bewildered by what is happening and what's causing it. We know what's causing it. It's violence beginning in childhood, then further exacerbated by interpersonal violence and injustice of all kinds. We have to recognize that there are different levels of safety. And this came out of our work. It was clear that it isn't just physical violence that's an issue. There's also psychological violence, social violence, moral violence and cultural violence. And our culture has become violent in all those ways and it's increasing. It's not decreasing. And that means every workplace has to establish some kind of system of meaningful interlocking values that everyone is held accountable to. And every workplace then has to have what are called "universal precautions". With COVID that meant wearing a mask and universal precautions around violence are really focused on every level of safety and becoming more aware of our own responsibility in creating safety in the workplace.

We really have to be thinking about not just physical safety, but the cruelty that is being used as a standard for how to treat people. Systems are under stress, become increasingly authoritarian, and in doing so they are likely to become increasingly cruel and controlling. And human beings do not thrive in those kinds of environments. So, we have to be really thinking about the values that are important. Everybody has to take responsibility for this. Every person must recognize that silence is dangerous. When you see something going on that is unsafe, you need to speak up. You need to collectively get other people involved to stop it.

Whenever there is cruelty, injustice, really bad kinds of behavior, don't stay silent. And yet that's what people do whenever they see bullying, they often go, "Oh, I'm not going to deal with that because the bully is going to attack me". Well, that's probably true if you do it by yourself. So, you have to organize. You have to respond collectively. When you see the destructive behavior going on, recognize that it's really dangerous- people can end up being hurt, and it might be you if you don't speak up.

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Wow. I'm so struck by everything you've shared, and I really appreciate that you've highlighted the need to really shift toward a different set of shared values and to coalesce around common values that will help us take collective action. And I think that one of the reasons we together today is because at CTIPP we've created a toolkit to really try to support folks who are seeing these challenges and are the need for change and are wondering about where their spot in this movement is.

And as we've been talking about today, we know that while the onus really does need to be on the system so that folks don't have to adapt to a dysfunctional and unhealthy and harmful way of being to survive, we also recognize that it's through individual and collective advocacy and action that this kind of change really will push organizations and systems out of the current power dynamics and to disrupt the status quo so that they will really be motivated to shift their ways of thinking and being and doing and relating. And so, in that toolkit, we give some thoughts and resources.

And yet, of course, we know that sustainable change implementation, of course looks different in different settings. And as much as we might wish that this was a formula we could give, there's really no checklist where we can say, okay, start here, do exactly this and you'll be able to expand into this trauma-informed, preferred future.

So, with all of that said, I think I'm curious to know from you for someone who is listening and is really wondering about either their place in this movement or what they might be able to do themselves. To model the model. In addition to really calling in and calling out when they see that violence happening, I wonder how you might help them think about action steps that they can take to catalyze or contribute to that broad, sweeping, and sustainable, trauma-informed change in their own workplace setting. Whatever it might be, whatever their role is.

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Well, I think about my own experience that I've been talking about, and the first thing we really had to do was get educated. We joined the International Society For Traumatic Stress Studies in order to find out what in the world were people doing. It didn't get organized until after Vietnam. It was really the Vietnam War that brought the issue of PTSD onto the table. Learning about it is critical, and there are all different ways to do that. There are books, many training programs and there is online material. My colleagues and I created a new online training program for organizations that was released during the pandemic called Creating PRESENCE. And we use the word to embody a set of values, Partnership, and Power, Reverence and Restoration, Emotional Wisdom and Empathy, Safety and Social Responsibility, Embodiment and Enactment, Nature and Nurture, Culture and Complexity, Emergence and Evolution. So those 16 words basically enable us to talk about anything.

There's an Introductory Track for everybody in an organization. And then it divides into a Leadership Track, a Clinical Track, a Direct Service Track, and an Indirect Service Track so that everybody gets educated in slightly different ways depending on what their job is and a lot of universal precautions that are embedded within the training program. And because it's mine, we can modify it to any kind of industry, we can do whatever we want with it. I don't have to report to anybody else. It's kind of exciting to see what's happening. We've begun to get our first certified programs in that educational process, but that's just the beginning.

Because then it gets down to figuring out how to use the knowledge. And that really is where people have to recognize that silence is dangerous, that they have to speak up and educate each other and basically incorporate what they come up with as a result of the knowledge acquisition into their policies and practices, depending on what is going on in the workplace.

But that means that every department must look at how we are trauma-informed and how we are, not trauma-informed? How are we actually creating more stress for people? What are our workplace practices? How can we continue to do the work we have to do and create what we need to create but not endanger people in the ways they're currently being endangering? And it's a process just like it was for us. It's a process of gradually understanding and coming to grips with counterproductive workplace practices. It's hard work and it is not for amateurs. It's really hard to do because you have to look at your own experiences with adversity and trauma. There's no way around it.

First, you have to look at your own families and it doesn't mean you don't love them, but it does mean there are intergenerational things going on that have been going on for, perhaps, thousands of years. It's not your parents or your grandparents. The knowledge of this way of treating each others was passed on to them. So I think we have to be clear, firm and compassionate about the past and about our ancestors and what they've tried to do and where they failed and start things anew if we're going to save the planet.

I mean, what's at stake now isn't just our individual lives. It's really about whether life is going to continue on Earth. There's a lot of doubt about that because of all the damage, the wounding, the trauma we've inflicted on nature, on the environment, and our separation and dissociation from our natural environment as if we were somehow superior to all other species. And what we know now is a "no". We are complexly interdependent with every other living creature. We live in a new age that was declared in 2016 by geologists. It's called the Anthropocene Age. We are the first generation of humans where the future of the planet is going to be determined by the choices human beings make.

That's huge. And we are making incredibly bad choices everywhere. And I'm going to contend that the reason we're making those really bad choices is because of these thousands of years of multigenerational trauma that we have only really understood anything about in the last couple of decades. So, there's a big burden on all of us living today and on the future generations. We have to pass the baton. We have to give these young people the knowledge they need that has been lost in the past, that's now been found again, and try to guarantee that it won't be lost again.

And that's our challenge. How do we keep it going?

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We lead with the hope and belief that we can make the decisions to continue the well-being of each other and the planet as a whole. I mean, that's what keeps us in this work, right, is understanding that we may not have known exactly what had led to all of these horrible decisions for millennia in the past, but as we understand what has been driving these behaviors, we can make new behaviors and that will take all of us.

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But I'm curious, as someone who has been in this work for so long and as someone who could have gotten out of the work, done other things that may have been more individually beneficial, what has kept you in the work? What keeps you motivated and continuing to do work, continuing to innovate and continuing to drive this movement forward?

And I think, as you expressed it earlier, it's hope and love. I am really scared that we are going to destroy life and that motivates me. It's love of the planet, it's love of life, it's love of people, despite what a difficult species we are. I love my dog and I don't want to see all the animals killed; I don't want to see the elephants no longer there. I don't want that to happen. And in the little tiny bit that I can do to keep hope alive and keep love alive, I think "What else is the purpose of being alive if it's not that?" And I have been very fortunate in my life. I have a great deal to be grateful for. I have not suffered most of what the people that I've worked with have suffered. And that being the case, I think I have a moral obligation to do whatever I can to reduce the suffering in any small way I can. I don't like to see people suffer. I find it really. poisonous, toxic to watch people make other people suffer. And so I think that's what keeps me going is "What's going on is not right. And together we can prevent it".

We know enough now and If we get together to work collectively, we could stop this. We can change the destiny of where humanity is going for now. We can't do it alone and we can't do it in one generation, but we can do it. We need transformative experiences. And so I'm trying to keep learning things, keep kind of pushing away the veils that are in front of reality, but not let that reality drag me under. How to keep hope alive, how to keep love alive, how to engage with other people like both of you, to move this human evolution in a different direction than the direction it is currently and obviously set upon. That's really what we're trying to do.

That's the big-ticket item: can we consciously, deliberately evolve into a different form of being a human being, where life is really valued, where love is the most important thing in the world, not money, and where we respect other forms of life and each other. What other purposes are there for being alive if not that?

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What you just shared is pretty darn profound. Right? And I really appreciate that you capture that. This is a long game. Sometimes I think people might get disillusioned, and yet we know that this is something that those of us doing this work, we likely will never get to see, really, this come to fruition, this shift, this healthy, compassionate, equitable, connected world that we want to see. And yet we know the steps to take.

We know what must happen for humanity and all organic life and nature as we know it to continue to exist. And I think that's just a lot to sit with. And I imagine that our audience is just reeling taking that all in. And there's so much that you've shared today. We've gone into corners of the meso, the micro, the macro, all of it. And as we just wrap up this conversation, I'm curious to know what final things are on your heart or mind that we haven't asked about that you think are important to share with our listening community.

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And I think it's important for people to step up to the plate, being a baseball fan, that everybody has a role to play. And if you are depressed, if you feel lost, if you feel like you have no role to play, it's because you haven't found your purpose yet. And your purpose is part of what we're talking about. So you need to get on board. We need everybody in this. We need everybody's participation. There is some way, even if you are working at a very low level in the workplace, you can affect the people that you work with. And just like COVID spreads, so do good things. The good things that we do are every bit as contagious as the bad things. And so everybody has a choice every day, every minute of the day, whether you're going to do something for the good or not, whether you're going to speak up or not. And so those are my final requests, I think, to send out there.

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Love that call to action. And for anybody who is curious to find out more about the different types of steps you could take, we would invite anybody to check out CTIPP.org, check out the materials we've put out there. We're going to include Dr. Bloom's materials in the description of this episode for exploration as well. And Dr. Bloom, we're just so thrilled to have had the opportunity to be in community with you today. We're grateful for your continued commitment to and leadership in this work and just really appreciate you sharing the insights and wisdom from your extensive work in making change with us here today. Thank you so much.

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Trauma-Informed Workplaces with Sandra L. Bloom, M.D.

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"Trauma-informed workplaces offer a sanctuary of safety and support, a place where people can bring their whole selves and be valued for who they are." - Sandra L. Bloom, M.D., CTIPP Board Chair, and Founder of Creating PRESENCE

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Developmental Science Article - Hitting Children Leads to Trauma, not better behaviour 

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Developmental Science Article - Hitting Children Leads to Trauma, not better behaviour 

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[This post is about the practice of hitting children to modify their behavior, usually referred to as "spanking." I choose not to use that term here, in part because I feel it minimizes the seriousness of bodily violence against children, and also because the term has been co-opted to refer to a type of consensual sexual play. Instead, I use other terms like "hitting," "physical punishment," and "corporal punishment." Also content notice: There are references to violence and slavery in this post.]
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Almost every caregiver has experienced that emergency that makes them want to impulsively discipline their child. For example, your child chases a ball into the street, directly into traffic, unaware of the oncoming truck. You bolt after them, grab them by the arm, and rush both of you to the sidewalk. You've just saved your child from getting injured, or worse. You're terrified and possibly angry, too. For some adults, this intense activation leads them to strike a child.

"Now, why would you hit them?" Elizabeth Gershoff said to me when we discussed the effects of physical force on children. Gershoff is a professor of Human Development and Families Sciences at the University of Texas at Austin. For the past 20 years, along with collaborators at other universities, she has been a leading researcher documenting the harmful effects of hitting children for "discipline."

"I agree we need to get the child out of the street," she continued. "But the child is already scared to death. They see your fear on your face and hear it in your voice. You're already communicating the seriousness of the behavior by your emotional expression, your words, and your tone. Those are thetools you already have to express that they cannot run into the street, that they could get badly hurt, that you're scared, and that if they can't keep their feet on the sidewalk, then they'll have to go inside. There are many ways you can deal with the situation that do not require hitting them."

"If you have to hit somebody, you have lost control," she said.
Why do adults still hit children?
Hitting a child is a failure of the adult in many ways, Gershoff told me. Sometimes adults misunderstand a child's behavior and ascribe the wrong intention to it. They think the child was purposely trying to make them mad, get back at them for something, show they don't care, or even take advantage of them. But most often, what an adult calls "misbehavior" is actually just a mistake on the part of the child, Gershoff said. For example, a preschooler may not know that it's not okay to write on a wall. To them, that big, white expanse looks like a large canvas or the easel they use at school, and they were simply inspired to color it. It can be helpful for adults to learn more about what children are capable of at different ages and channel a child's inspiration in appropriate directions. (See some resources below.)

What many people won't admit is that hitting a child can provide an emotional release and a fleeting sense of power for the grown-up. An adult may feel frustrated that they've lost control of the child, but when they strike the child, the child stops what they're doing and usually starts crying. The adult feels vindicated by getting the child's attention, and their pent-up frustration or anger is released. They believe "it worked," and the strategy becomes reinforced. Many parental feelings are masked by anger-fear, alarm, loss, grief, shock, shame, etc.-and lashing out can momentarily transfer the uncomfortable energy onto the child-a much less powerful target.

Sometimes physical punishment results from an adult's failure to supervise and plan responsibly-and maybe the feelings of shame and regret that come up when things go wrong. "Our job is to make a safe environment for children," said Gershoff. "Why was the child near the street to begin with? Why is the pot on a stove in a position where the child can grab the handle? Why is the electrical socket uncovered? We adults are responsible for making a safe environment for children." Of course, not every misstep can be anticipated; no parent can make the world 100% safe for their child. When accidents do happen, then, it's the responsibility of the adult to respond in a way that doesn't involve physical or emotional harm.

Most people who use physical force were on the receiving end of it when they were children. Studies show that children who are physically punished are more likely to perpetuate the practice as adults, believing that it's not only normal but necessary for raising children properly. Even the small percentage of pediatricians who still support this kind of hitting-in direct opposition to the official position of the American Academy of Pediatrics-tend to be the ones who were hit as children.

"When a child hits a child, we call it aggression.
When a child hits an adult, we call it hostility.
When an adult hits an adult, we call it assault.
When an adult hits a child, we call it discipline."

- Haim Ginott, Child Psychologist and Psychotherapist

The use of physical force against children has deep roots. Throughout history, children were objectified as sub-human, the property of adults to do with as they pleased. Maltreatment was the norm, and children were "civilized" by routine beatings and worse. In the U.S., it wasn't until 1974 that child abuse was made illegal. Even then, it was restricted to actions (or failures to act) that caused "serious harm" or death to a child; physical force that did not cause a visible injury, and was intended to "modify behavior," remained legal. The distinction, though, often falls to the eye of the beholder-a judge or other representative of the state.

Some communities are more apt to rely on physical punishment. Conservative Christians historically believed that children were inherently "depraved" and "filled with the devil," requiring harsh treatment to become proper adults. Today's Christian leadership is divided on the issue. James Dobson, therapist and founder of the Christian group, Focus on the Family, advocates the physical discipline of children as long as the adult is "calm" and hugs the child afterward. But two religious denominations, the United Methodist Church, and the General Assembly of the Presbyterian Church, passed resolutions encouraging parents to use discipline that does not involve corporal punishment.

A 2015 Pew Research Center survey showed that in the U.S., Black families use physical methods to punish their children twice as often as White or Latinx families. "Black parents have legitimate fears about the safety of their children," writes Stacey Patton, professor at Howard University and author of Spare the Kids: Why Whupping Children Won't Save Black America. "And the overwhelming majority believe physical punishment is necessary to keep Black children out of the streets, out of prison, or out of police officers' sight...a belief [that], however heartfelt, is wrong." She asserts that physical punishment is not a Black cultural tradition; it's racial trauma.

Charles Blow, New York Times columnist and author of Fire Shut Up in My Bones, concurs. He acknowledges that some people believe that it is better to be punished at home by someone who loves you than someone outside the home who doesn't. But that is a "false binary between the streets and the strap," he writes. "Love doesn't look like that."

Stacey Patton considers physical punishment through a historical lens: "We cannot have discussions about corporal punishment in Black communities without talking about history," she writes. Many Black Americans are descendants of enslaved people who were abducted from West Africa. According to historians and anthropologists, there is no evidence that parents in West African societies used physical force on their children. In fact, they believed that children were gods or reincarnated ancestors, arriving from the afterlife with spiritual powers for the good of the community. Hitting a child could make their soul leave their body. But the slave trade increasingly stole younger and younger people, and by the time abolition was imminent, the average age of captives was between nine and twelve. It was impossible for young people to carry child-rearing traditions from their homeland, and once they were in America, adults were under tremendous pressure to make their children docile and compliant in front of white people in order to survive. Today, a number of Black parenting experts advocate for families to break intergenerational cycles of trauma and adopt constructive ways to guide children without physical punishment.
Why do people who were hit as children often become hitters themselves?
A common psychological defense our minds employ is to act out the hurt we've experienced at the hands of others by perpetrating it on other people later, even with those we love. This happens when haven't become aware of our painful feelings or fully examined them.

Trauma experts explain why this happens. Children depend on the adults around them for survival. This dependency takes the form of attachment, something I wrote about in a previous post. So when children experience pain from the person who's supposed to keep them safe, it's one of the worst kinds of harm they can experience. Their nervous system, designed to keep them safe, begins to get sculpted around the constant threat, creating brain circuitries that are vigilant, reactive, and dysregulated. At the same time, their attachment system needs to keep them in the relationship, so it devises all kinds of excuses: "It's not that bad;" "I deserved it;" "It made me a better person," etc. In other words, children dissociate from their feelings of pain and fear.

Kier Gaines, a therapist, social media influencer, and father of two, describes the dynamic in an Instagram video that went viral. "The men that were a generation before us, got raised by the men that were a generation before them, and those men didn't really know warm love....Before you take on a family," he says, "go see somebody about your past. Go see somebody about the trauma you've endured throughout your life, and start healing."
Hitting children, even for "discipline," is a form of trauma.
Some adults cling to the excuse that a single swat on the bottom, or one slap on the head, can't be that bad, and is necessary to "teach them a lesson."

"Is there any kind of hitting that works to change behavior?" I asked Gershoff.

"There's no situation that I can imagine where physical punishment is useful or necessary," replied Gershoff. "It doesn't teach children to behave well. It's not effective for reducing aggression, or teaching self-control or prosocial behavior, or any of the things parents hope to teach children. It's not effective in either the short- or the long-term."

Physical punishment is one of the most intensely studied aspects of parenting. Hundreds of studies over five decades have concluded that it's harmful to children in just about every measurable way. Children's behavior, emotions, intellectual functioning, and physical health all suffer. Gershoff's most recent 2016 meta-analysis with Andrew Grogan-Kaylor, professor of social work at the University of Michigan, analyzed 75 studies involving 161,000 children. Three important conclusions were drawn:

First, consistent with earlier research, the analysis found no evidence that physical punishment changed the original, unwanted behavior.

Second, there were 13 significant harmful effects of the practice:

Poorer moral reasoning

Increased childhood aggression

Increased antisocial behavior

Increased externalizing behavior problems (disruptive or harmful behavior directed at other people or things)

Increased internalizing behavior problems (symptoms of anxiety or depression)

Child mental health problems

Impaired parent-child relationship

Impaired cognitive ability and impaired academic achievement

Lower self-esteem

More likely to be a victim of physical abuse

Antisocial behavior in adulthood

Mental health problems in adulthood

Alcohol or substance abuse problems in adulthood

Support for physical punishment in adulthood

Third, these outcomes were similar to effects of childhood trauma. A landmark set of studies in the 1990s documented that exposure to certain kinds of childhood experiences-including physical and emotional abuse or neglect, sexual abuse, domestic violence, family mental illness, incarceration, and substance abuse-causes great harm lasting into adulthood. And the more adverse experiences a child has, the greater the impact. The effects include increased risk for serious physical diseases like cancer, diabetes, heart disease and COPD as well as early death, mental illness, suicidality, lower educational and professional attainment, and even reduced income. As a result of these findings, a ten-question screening tool known as the Adverse Childhood Experience (ACE) Checklist is now widely used to identify risk for mental and physical illnesses due to ACEs, in the hope of providing early intervention and treatment.

Gershoff and Grogan-Kaylor analyzed a subset of seven studies from their meta-analysis that compared the use of physical punishment to physical abuse and found that the impact was indistinguishable. Both physical punishment and physical abuse led to more antisocial behavior and mental health problems in childhood as well as increased mental health problems in adulthood. In a separate study, Gershoff and colleagues reanalyzed a subset of the original ACEs data and also found that physical punishment was associated with the same mental health problems in adulthood as physical and emotional abuse. In addition, it created an even greater likelihood of suicide attempts and substance abuse than physical and emotional abuse alone created.

Brain imaging studies also show a link between physical punishment and trauma. In a 2021 study, researchers showed 147 12-year-olds pictures of fearful and neutral faces while their brain activity was imaged in a functional MRI (fMRI) machine. Compared to children who were never physically punished, children who were physically punished had greater activity throughout the brain when viewing fearful faces. They also had more activity in regions of the brain related to threat appraisal, emotion regulation, and evaluating the mental state of others. Importantly, the pattern of their brain activity was the same as children who had been physically abused. When children have harmful interpersonal experiences, they become hypervigilant to the emotional expressions of others, because fearful or angry adult faces can be a cue that something bad is likely to follow. This study suggests that children who are physically punished are running the same brain circuitry as children who have been abused.

Data like this shows that the attempt to distinguish between physical punishment and physical abuse is no longer legitimate. What we now know is that inside the child, the response is the same. According to Gershoff, "Research like this may help parents understand that when they're hitting their children, they're causing fundamental damage to the child's brain-not because they're hitting them in the head. They're hitting them in other places on their body, and it's causing a massive stress reaction every time. And it gets worse every time it happens. That stress ramps up and ramps up and causes physical and mental health problems." As a result, Gershoff and colleagues, and many other scientists, call for physical punishment to be identified and screened for as an additional ACE.
Other countries are far ahead of the U.S.
Worldwide, three out of four (close to 300 million) children two-to-four years of age are punished with violence regularly, including physical punishment or verbal abuse from parents or caregivers. In some countries, children as young as 12 months are regularly hit, according to a 2017 UNICEF study.

But momentum is growing to outlaw corporal punishment of children in all settings, including home and school. (The term "corporal punishment" is used internationally, and in the U.S. it refers to physical punishment in schools. It's defined as the intentional use of physical force to cause pain or discomfort, or non-physical force that is cruel or degrading.) Currently, 63 countries have a full prohibition on corporal punishment, inside and outside the home. The map below shows the status of each country. ( This link takes you to the interactive map, where you can find more details about each country's progress.)

In U.S. homes, though, physical punishment remains legal in every state. Even in the case of abuse, some judges will excuse it if it was intended to "discipline" children, under a "parental discipline exemption."

As for schools, corporal punishment is outlawed in 31 states and the District of Columbia, but it remains lawful in 19 states, in both public and private schools. Gershoff consulted with Congressman Don McEachin and Senator Chris Murphy on a bill to ban corporal punishment in schools, Protecting Our Students in Schools Act. "It didn't get momentum," she told me. "I don't think people realize it's still happening in schools, but nearly 100,000 kids get paddled with boards each year in school, primarily in states in the South."

Even without progress at the government level, public opinion and practices are gradually changing. A U.S. study of 35-year-old parents conducted every year from 1993 to 2017 asked the question, "How often do you spank your child(ren)?" The graph below shows the decline in the percentage of parents reporting any spanking at all, from about 50% in 1993, to about 35% in 2017.

Recently, a colleague and I were facilitating a parent meeting at a school, squeezed into child-sized chairs in a circle, when an older woman rushed in, late, and breathless. After she settled into her chair, she shared: "I'm taking care of my two grandchildren while my daughter is in jail," she said. "I hit my own kids, and I know that's wrong. But I don't know what to do instead." I was moved by her vulnerability and her determination. One of the most important jobs we have as parents and caregivers is to protect our children from our worst selves. I could see her commitment to stopping the intergenerational transmission of violence.

Parenting is hard. We love our children, we nurture their gifts, and we teach self-control and acceptable behavior. There are many positive, gentle, respectful ways of guiding them forward that begin with our own awareness, education, and self-regulation. This is a larger topic for another post, but as a starting point, I've listed a few of my favorite resources below.

"It took us until 1994 to ban violence against women," Gershoff told me in closing. "Now we look back and wonder why anyone ever thought violence against women was okay. I think we're in the middle of a similar gradual shift regarding hitting children. We'll eventually get there, but we haven't quite had the sea change yet. I'm hoping it will come."

"...There is no ambiguity: 'All forms of physical or mental violence' does not leave room for any level of legalized violence against children. Corporal punishment and other cruel or degrading forms of punishment are forms of violence and the State must take all appropriate legislative, administrative, social and educational measures to eliminate them."

- United Nations Committee on the Rights of the Child

"Parents, other caregivers, and adults interacting with children and adolescents should not use corporal punishment (including hitting and spanking), either in anger or as a punishment for or consequence of misbehavior, nor should they use any disciplinary strategy, including verbal abuse, that causes shame or humiliation."

- American Association of Pediatrics

"Physical discipline is not effective in achieving parents' long-term goals of decreasing aggressive and defiant behavior in children or of promoting regulated and socially competent behavior in children....The adverse outcomes associated with physical discipline indicates that any perceived short-term benefits of physical discipline do not outweigh the detriments of this form of discipline....Caregivers [should] use alternative forms of discipline that are associated with more positive outcomes for children"

- American Psychological Association

Alternatives to hitting:
A secure attachment and an authoritative parenting style set the foundation for closer relationships and cooperation - see my earlier blog posts for more.

In addition, there are lots of wonderful resources on Instagram and TikTok. Look for people who advocate gentle parenting, positive parenting, or respectful parenting. Here are some of my favorites on Instagram:

@respectfulmom, @mrchazz, @biglittlefeelings, @babiesandbrains, @dr.katetruitt, @the.family.coach, @wildpeaceforparents, @greatergoodmag, @ceciletuckercounselling, @kiergaines, @thedadgang, @the.dad.vibes, @laura._.lovee, @gottmaninstitute, @parentingtranslator, @parenting_pathfinders, @dr.annlouise.lockhart, @dr.siggie, @parentstogether
Books:

No Bad Kids: Toddler Discipline Without Shame by Janet Lansbury

The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child's Developing Mind

by Daniel Siegel and Tina Payne Bryson

How to Talk So Kids Will Listen & Listen So Kids Will Talk, by Adele Faber and Elaine Mazlish

Between Parent and Child, by Haim Ginott

The Secrets of Happy Families: Improve Your Mornings, Rethink Family Dinner, Fight Smarter, Go Out and Play, and Much More, by Bruce Feiler

What to expect of children at different ages: On hitting and trauma:

Many good resources are available at the Trauma Research Foundation

The Body Keeps the Score, by Bessel van der Kolk

What Happened to You? By Bruce Perry and Oprah Winfrey

For Your Own Good, by Alice Miller

Spare the Kids: Why Whupping Children Won't Save Black America, by Stacey Patton

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Hitting Children Leads to Trauma, Not Better Behavior - Developmental Science

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This post is about the practice of hitting children to modify their behavior, usually referred to as "spanking." I choose not to use that term here, in part because I feel it minimizes the seriousness of bodily violence against children, and also because the term has been co-opted to refer to a type of consensual sexual play.

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Trauma & Play Therapy - Paris Goodyear-Brown

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Trauma & Play Therapy: Holding Hard Stories | Paris Goodyear-Brown, MSSW, LCSW, RPTS | TEDxNashville

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Chefalo Consulting - Complete Guide to Trauma Informed Organisational Implementation 

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Chefalo Consulting - Complete Guide to Trauma Informed Organisational Implementation 

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Childmind Institute- Multilingual Trauma Resources 

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Childmind Institute- Multilingual Trauma Resources 

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Multilingual Trauma Resources - Child Mind Institute

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Free trauma resources to aid parents, educators, and other adults in talking to children and adolescents about potentially traumatic events.

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Whitney Marris - Practice & Systems Transformation : Guide to Trauma Informed Meetings, Discussions & Conversations 

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Whitney Marris - Practice & Systems Transformation : Guide to Trauma Informed Meetings, Discussions & Conversations 

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By Whitney Marris, Trauma Therapist and Director of Practice & System Transformation, and Laura Braden Quigley, Director of Communications and Outreach

Trauma-informed conversations create and maintain conditions where participants fully engage with one another with respect, authenticity, and openness.

CTIPP has created this short guide to help facilitators navigate this process and re-establish a healthy space if the discussion becomes unfocused and unproductive.

CONSIDERATIONS & PRINCIPLES

The following is grounded in six principles to guide a trauma-informed approach: safety, trustworthiness/transparency, peer support, collaboration/mutuality, empowerment and voice/choice, and cultural/historical/gender issues.

Facilitators can support an environment where everyone feels they may communicate openly by letting people know what to expect and what is expected of them (trust and transparency), which might include:

Logistics or ways someone can participate (E.G., through text, unmuting audio, etc.)

Procedures, or what the experience during and following the discussion might entail (E.G., someone is expected to take notes, one person from breakout groups will be asked to report to the larger group, etc.

Role clarity (E.G., as the facilitator, what you will be doing - "It's my job as a facilitator to _______," "Time-sharing is a priority for me, and I will be working to ensure everyone has the opportunity to speak," etc.)

Community agreements to which each person is expected to hold themselves accountable (see example below)

People sharing their journeys is a gift. It is essential to enter facilitation with reverence (safety) for the wisdom, adaptive capacities, insight, and other gifts that each person's lived experience has played a role in shaping.

It's critical to remain respectful and encouraging of the experiences participants share. Sharing lived experiences can create enriching connections that deepen the conversation. Encourage folks to "speak from I, think from we" (empowerment and voice/choice) to avoid anyone speaking for others or making generalizations. It can be helpful to utilize open-ended questions that invite deeper insights, and you can encourage participation through questions like:

It's also important to stay focused and rooted in the purpose of the discussion. This work has many dimensions, and many are relevant to discuss! In those moments of "distraction," use your best judgment to determine whether the diversion advances or is helpful to the purpose of the discussion.

Simply restate the purpose of the conversation, invite consideration around whether the discussion is getting to the heart of the topic, and gently redirect the discussion back to the original topic.

And last but not least, safety extends to you as the facilitator. It's important to reflect honestly on your willingness to stay with opinions that may differ from your own and sit with uncertainty or unresolved conflict.

If you notice something coming up for you that might interfere with the group process, simply say to yourself:

It's not my responsibility to 'fix' this for the group; I must sit in this discomfort and hold space for all to participate.

Noticing and discussing differences allows us better to understand one another and the issues at hand.

It's not about me.

See also: Mindfulness practices to befriend discomfort

Each participant comes to the discussion with unique experiences. In alignment with a trauma-informed approach, it is crucial to maintain awareness that such experiences may have been shaped by trauma and adversity (universal precaution). As a facilitator, you must use this awareness to:

Notice nonverbal signals that participants are dysregulated or distressed (E.G.., people suddenly turning their cameras off after a comment is made, body language that is closed off, multiple people looking distracted or having side conversations, etc.)

Intervene when someone's trauma response leads to them attacking the person rather than the inequity, injustice, or broader issue at play

Naming the tension and allowing space for people to label and explore their feelings about what is happening in the process, then working together to re-establish an environment to support meaningful, authentic engagement and participation

Check in with the person/people you noticed may have been impacted and support them in doing what they need to do to remain in the space

In moments where you notice escalation/activation, it can be helpful to lead a guided embodied/movement-based activity, followed by taking a brief break

Strive to stay solution- and strengths-oriented with discussion prompts that probe strengths and creative thinking around moving toward what we want rather than away

It can be tempting to follow up on someone's share with a profound comment that intends to commend the courageousness of sharing their story. While we recognize that intent is "good," we can validate without our lens distorting (safety, empowerment, and voice/choice) their true meaning:

Demonstrating gratitude: "Thank you for sharing with the group."

Lifting courage: "It was courageous of you to share that. I appreciate you trusting us with your truth."

Shining a light on character strengths: "Wow - that sounds really hard. I think you've shown a lot of courage in your approach."

It helps when facilitators maintain consistent and clear communication

Be mindful of your body language (E.G.., if you nod or snap your fingers to acknowledge one contribution, consider doing the same for all contributions, etc.)

Notice your tone and remain aware of how you are holding yourself accountable for holding space for and valuing all perspectives shared

Trauma-informed facilitators should manage time thoughtfully, ensuring everyone has the opportunity to be heard (and the option to pass) (empowerment, voice, and choice; collaboration and mutuality). Make sure everyone knows the various modes to participate (E.G., chat function, unmuting audio, being on video, etc.), and if you notice an imbalance, support more equity through statements like:

Awkward silences can be uncomfortable and essential because each of us processes and makes meaning of information differently. Allowing people the time and space to put their thoughts together and consider whether/how they might like to contribute is an integral part of facilitating group conversations.

If you ask a question and it is met with silence, consider counting-slowly!-to four before moving on to something else (anything longer than four seconds can like rejection). If things remain silent, stay anchored, and say something like, "I wonder what's happening that's making it hard for us to have this conversation. What do you all think?"

This is more likely to generate meaningful discussion and engaged participation than simply asking the question again by phrasing it differently or staying silent until someone speaks up out of a sense of obligation.

Trauma-informed conversations maintain awareness of facilitator-to-group power dynamics and identity-based dynamics (cultural, gender, and historical issues) that mirror power imbalances, inequities, and oppressive norms in broader society.

Traditional group facilitation can preserve and perpetuate white body supremacy culture, so we should strive to create "brave" spaces rather than "safe" ones to avoid harm and oppression.

Remember, your role as a facilitator is to create and maintain conditions in which participants may fully engage with one another (collaboration and mutuality; peer support; empowerment, voice, and choice). Simply by being in this role, you are moving with power and privilege. While you may have expertise or experience that you feel moved to share, consider how that signals approval/disapproval for a particular way of thinking, being or doing and how that may chill authentic, diverse discussions.

By giving the group the responsibility of shared leadership, you can leverage your wisdom to make connections between what has been shared and invite participants to address wonderments, share thoughts, and suggest actions.

SAMPLE COMMUNITY AGREEMENTS

Inviting everyone to participate while allowing everyone the right to pass

Demonstrating respect by:

Giving our attention to the person who has the floor

Creating space for others' perspectives, experiences, ideas, and contributions

Prioritizing impact over the intention

Preserving confidentiality and privacy

Choosing and using our words with the intention

Engaging with curiosity and compassion rather than shaming others or making assumptions by "calling people in" rather than "calling people out" ()

Using inclusive language that is accessible to people with varying levels of knowledge and familiarity with the topics being discussed

Taking space and making space by paying attention to how frequently, how long, and how quickly we participate

Speaking from our own experiences by using "I" statements rather than generalizations

Engaging in ongoing self-reflection and taking care of ourselves in whatever way makes sense for each of us

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Guide to Trauma-Informed Meetings, Discussions & Conversations

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By Whitney Marris, Trauma Therapist and Director of Practice & System Transformation, and Laura Braden Quigley, Director of Communications and Outreach

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Posttraumatic growth following a drug-related death: A family perspective: Daniel O’Callaghan, Sharon Lambert, Nora Conway & Nollaig Frost

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Posttraumatic growth following a drug-related death: A family perspective: Daniel O’Callaghan, Sharon Lambert, Nora Conway & Nollaig Frost

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Abstract
This paper explores the experience of posttraumatic growth in families who have lost a family member to a drug-related death. Seven family units (17 participants) were interviewed, and interviews were analyzed using reflexive thematic analysis. Analyses revealed themes that reflected positive adaptation and growth, including (a) reframing the loss, (b) open dialogue and social support, and (c) reclamation of purpose. Themes are presented in this paper for their pertinence in understanding how best to negotiate adaptation through complicated grief. The paper concludes that posttraumatic growth can occur once families begin a process of acceptance and receive support through the journey.

Introduction

Positive adaptation following the loss of a loved one is a deeply personal journey influenced by diverse personal characteristics and environmental factors (Jordan & Litz, ). The grieving experience is inherently complicated, and healing trajectories can be shaped by an individual's existing or underlying vulnerabilities, relationship to the deceased, gender, age, social supports, spirituality, and the cultural script that guides their society (Kaltman & Bonanno, ; Tedeschi & Calhoun, ). Research suggests that "normative" grieving patterns begin with intense emotional reactions that begin to reduce after six months (Zisook et al., ), but the circumstances surrounding death play a significant role in determining the trajectory of the healing process and, consequently, adaptation strategies.

The findings from Titlestad et al. () in Norway and Feigelman et al. () in the United States have provided an in-depth understanding of the healing trajectories of families bereaved by DRDs with international implications. In 2021, Lambert et al. conducted a study examining DRD bereavement in an Irish context. The study explored the impact of complicated grief on the family system and intra-family dynamics following the DRD of a family member. The authors interviewed multiple members of each family together, and highlighted outcomes such as familial relationship breakdown, the renegotiation of relationships, family shame, and isolation from their community. On an individual level, the study reflected international findings that highlight stigma, helplessness, internalized feelings of shame, guilt, and physical health difficulties as outcomes (Lambert et al., ; Titlestad et al., ). However, while the Irish study demonstrated the negative social and health implications of a DRD, it did not highlight potential healing trajectories for these families.

Materials and methods

Approach

The current research is part of a study by Lambert et al. () which examined the impact of DRD bereavement on families in Ireland. In this paper, we investigated how the families recruited and interviewed by Lambert et al. () experienced posttraumatic growth following a DRD, aiming to provide a phenomenological understanding of potential healing trajectories. In identifying an appropriate qualitative framework, we wanted to ensure that the family unit, at the center of the phenomenon, was the primary focus. Furthermore, we wished to consider the personal nature of bereavement and the individualized impact of disenfranchized grief. As such, reflexive thematic analysis emerged as a tool to explore common patterns and experiences across the data, while also allowing the authors to account for potential biases throughout the process (Braun & Clarke, ).

Participants & sampling

As per Lambert et al.' () recruitment, this study included 17 family members bereaved by DRDs representing seven families across seven interviews ( Table 1). As a method of purposive sampling and to ensure transferability of the findings, contact with an independent organization, which supports families affected by drug dependence, facilitated the recruitment process. Staff within the organization approached family members with information leaflets including details of the study's aims and the professional qualifications of the interviewer. Family members subsequently self-selected to contact the research team by phone, by email, or allowing a staff member to contact the team on their behalf. Those who expressed such interest received a detailed information pack inviting them to participate. These packs outlined the study parameters, potential uses of their anonymized data, the role of the research team in working with the data, and information about their role in the interview process. All who received this information pack decided to participate and invited members of their own family to be involved in a focus group interview. There were no incidents where participants sought to withdraw from the study at any point.

Posttraumatic growth following a drug-related death: A family perspective

As primary inclusion criteria, participants had to be active members of a family support organization, and to have experienced the DRD of a family member. In line with the requirements of the ethics committee at the researchers' home institution, persons who were under 18, recently bereaved (under twelve months), and those who disclosed an active addiction or mental health issue were excluded from the recruitment process. Follow-up support services from the support organization were available to any participants who wished it after taking part in the research.

Participants included four males and thirteen females, (six mothers, three fathers, one brother, five sisters and two nieces). The study investigated the deaths of seven men (two of whom were brothers) and one woman, between the ages of 19 and 46. Four deaths occurred by accidental overdose involving opiates and benzodiazepines and three were suicide by hanging. At the time of interview, time since death ranged from one year to 27 years. One family was from the south of Ireland, two from the southeast, and four from the east.

Data collection

As per the methodology of Lambert et al. (), a semi-structured interview schedule guided six focus group interviews alongside one in-depth individual interview with a mother parenting alone. Six interviews took place in the family home, and one occurred in the office of the support network. The semi-structured nature of the interview allowed for the exploration of unanticipated topics while ensuring thematic consistency across cases. The interview schedule contained five open-ended core questions that were supported by general interview protocol such as paraphrasing, follow-up questions, and prompts: (1) "Can you tell me a little about yourselves?," (2) "What do you think are the impacts on your family of experiencing a drug-related death?," (3) "Do you think your experiences are the same or different to those who lose a family member in other ways?," (4) "Have you any recommendations for what is needed to support families who have experienced this loss?" and (5) "On a scale of 1-10, how difficult was this interview for you?."

Adopting this flexible interview format allowed participants to provide a continuous narrative about their experiences at a comfortable pace. Overall, the interviews provided information about the impact of experiencing a DRD, challenges, supports, and future recommendations. However, a recurring, yet unanticipated, concept that emerged throughout the data was the journey of healing which highlighted how families had adapted in the time since death. Interview lengths ranged from 1 hour and 11 minutes to 2 hours and 40 minutes. The second author conducted all interviews and used a recording device to record the interviews, which were subsequently transcribed verbatim.

Data analysis

The analysis followed Braun and Clarke's () framework for reflexive thematic analysis with findings presented in adherence to O'Brien et al. () standards for reporting qualitative research. All authors have experience in working with marginalized populations and we considered this methodology as the most systematic, yet flexible, tool to bring our skills and values in research to the data. The authors followed six steps as recommended by Braun & Clarke's protocol: (1) familiarization with the data, (2) coding the transcripts, (3) generating initial themes, (4) reviewing emergent themes, (5) defining the themes, and (6) writing up the findings. At times, there was back-and-forth movement between phases when discussions encouraged revisions of certain emerging concepts. To ensure credibility, transferability, confirmability, and dependability of the results, we followed recommendations cited in the four-dimension criteria for assessing rigor in qualitative research outlined by Forero et al. ().

All authors familiarized themselves with the data by reading and re-reading the anonymized transcripts. The first and third author coded the transcripts utilizing NVivo qualitative analysis software and adopted a-priori approach to deconstruct the data and develop nonhierarchical codes, followed by a second round of coding. To ensure dependability and inter-coder reliability, this process was followed by open discussions between the first, second, and third authors about the coding, potential discrepancies, and how to synthesize the codes across the entire data set. As new codes began to decrease in frequency over time, all authors made an informed decision that data saturation had been achieved. The authors moved to initial theme generation with specific focus on any required changes, additions, or biases. Through rigorous reorganization, initial codes from all transcripts transitioned into preliminary themes. All authors reviewed and named the themes, and the first author drafted the report with input and feedback from each coauthor.

Roles and reflexivity

In line with Dodgson's () recommendations for qualitative research, we adopted a reflexive approach to the analysis to ensure that the process was confirmable, clear, and methodical. Prior to coding the data, all authors met to discuss and reflect on the anonymized transcripts. This discussion encouraged an open dialogue about how our experiences may influence our thoughts, pre-formulated assumptions, and ideas about the content. To reinforce the credibility of the analysis, the authors who coded the data wrote reflective memos and journals to keep a record of emerging thought processes. Each coauthor brought individual experiences to the research team, and to account for potential influences in interpretations, we engaged in reflective practice to minimize the risk of biased analysis.

As drug use is a sensitive topic often associated with criminality, we ensured that the terminology used in the coding and write up was sensitive, appropriate, and non-stigmatizing. The second author conducted all interviews, as they have professional experience working therapeutically with families through addiction services. To augment the credibility of the research process, this individual was considered the most suitable to conduct sensitive interviews while being cognizant of their own prior assumptions. This researcher was the only person present alongside the participants during interviews, and peer debriefing occurred during initial discussions about the data.

To understand bereaved families' experiences with participating in engaged research, and to continue to develop suitable practices, participants were given an opportunity to provide feedback on the research process. The feedback was exclusively positive as participants spoke appreciatively of the therapeutic value of the interviews: "It was most positive for me as I bottled a lot of anger and resentment over the death of my son, and this was the first time that I ever spoke about his death openly," and about the opportunity to potentially help other families through their own experience: "The most positive aspect for me was the knowledge that recounting my son's life and death might in some way help in the future."

Ethical considerations

The departmental ethics committee within the authors' home institution granted ethical approval for this research. All components of the research process adhered to the guidelines within the Code of Ethics of the Psychological Society of Ireland (PSI). All participants in this study were briefed, informed how their data would be used, provided informed consent, and offered follow up support the support network. Participation in this study was voluntary, confidential, and family members could withdraw from the study up to 6 weeks post-interview. Once the final report emerged, withdrawal from participation was no longer viable. Data for this research was stored in an encrypted data repository provided by the university.

Results

The analysis revealed varying degrees of individuals' posttraumatic growth in the aftermath of a DRD and identified three core themes: (a) Reframing the Loss, (b) Dialogue and Social Support, and (c) Reclamation of Purpose. The findings suggest that each of the participants experienced a profound sense of loss and pain following the death of their loved one, but most reported a sense of personal growth and healing. By making sense of the death through various active engagements, bereaved family members expressed that they were able to come to terms with the loss.

Reframing the loss

The period of active addiction before death was tumultuous for families. Years of uncertainty, stigma, and hopelessness permeated throughout the family system and left heavy emotional scarring as they lived in constant fear for the safety of their loved one, and sometimes for themselves. Following the death, this fear alleviated as the unpredictability surrounding the location of loved ones, issues with police, looming threats, and death began to fade. Participant 6 described finding comfort in knowing her son was now safer than he once was:

He could have ended up getting killed on the streets and he didn't suffer, so I am happy with that...I wouldn't have liked to have seen him found dead outside somewhere or over a lot of drugs or one thing or another.

Although she initially felt guilty about experiencing relief, all this mother truly wanted for her son was peace. She understood his life in addiction was painful for him and would not provide such comfort. As a mother, she experienced a prevailing sense of helplessness in this role that transformed to solace post-death in knowing her son was no longer suffering:

I am happy with where he is "cos, you know," if he was here and going on with heroin and the life that he was leading, I'd say he was going to end up in really bad crime and drugs and that. So, if he is where he is and in no pain and happy, sure that's all a mother wants for their kids.

In the data, there was a distinguishable difference between living one's life and simply trying to survive chaotic circumstances. Positioning loved ones in "a better place" and references to "God's will" was commonplace as family members drew on their faith to bring peace to their loved one, make sense of the death, and reach acceptance. Finding meaning in the loss in the context of fate also provided some solace for her husband (Participant 5). They had lost their son 27 years prior, and although the memory of the death remained, he was eventually able to reframe the loss in such a way that helped him transcend the grief:

I have come to accept (son's) death but maybe it was something that was meant to happen. His life wasn't going to change, you know? And I think he was happy to go...It was meant to happen or something, that's what I keep saying to myself.

This family's experience echoed many of the other participants' struggles with their loved one's active addiction. Families spoke about harrowing emotional experiences following the death, but they did find peace in knowing that their loved one's hardship, and the uncertainty about their health, had ceased. Participant 1's comments mirrored these sentiments: "I know he didn't want to die. But to me, I think he'd be happier up there because he wasn't going to have a good ending."

One father (Participant 4) only permitted himself to begin healing after a prolonged period of self-blame for his son's DRD. In holding himself accountable for the loss of his son, this father's guilt negotiated his healing trajectory, as he did not consider himself within his own right to grieve. Nine years on, he eventually came to understand that his son's behavior was beyond his direct control. Over time and with the support of his daughter (Participant 3), a greater awareness unfolded that his son's death ended the associated hardships. This realization facilitated the eventual relief of his guilt and felt that even in his last moments; their son was trying to protect them: "Personally, I think that my son had an insight into where his life was going, and he didn't want to bring that to us. So, we lost him to the street, there's no two ways about that." As an overall family unit, they experienced posttraumatic growth by supporting each other, but the journey to self-acceptance was very much individualized even within the family structure.

Despite the emotional trauma associated with his son's addiction, Participant 4 managed to absolve himself of guilt and remembered his son with fondness. Such memory reconstruction was challenging for others as some participants struggled with identity fluidity. Conflicting memories of loved ones from life before addiction and the suffering experienced during addiction generated confusion when trying to reframe the loss. Efforts to align these versions of their loved one proved difficult for some, such as Participant 16: "You have to go back and pick out the bits you loved about him and knock out the other bits, that was very confusing." Emerging from this conflict was the concept of a double loss, where families felt they lost their loved ones to addiction and, consequently, experienced an exacerbated grief following their death. Participant 2 stated: "We always talk about this, she didn't just grieve for [our brother] when he died, she grieved for [our brother] when he went on drugs."

Dialogue and social support

Bereavement support groups, where the unique grief associated with a DRD was recognized, offered an empathic space where families could unburden their sense of shame and helplessness. Many found comfort through interaction with others who had experienced this unique loss and sense of seclusion. For Participants 8 and 9, parents who had lost two sons to DRDs, the support groups fostered a deep sense of resiliency, self-preservation, and vitality. This mother (Participant 9) demonstrated that as parents, they moved from prolonged self-blame toward healing after engaging in support groups:

We blamed ourselves for years but then through the family support we got a little bit of learning that it wasn't our fault at all... And I always say we are the lucky ones, because God knows where we would be today without the support we have gotten from the groups. You know people that have encouraged us to look at things differently, with a different view, and that's what we do.

Reframing the loss helped the family move toward positive adaptation, but family support groups mediated this journey. Both family members spoke at length about how the clarity and guidance they received helped them to navigate the painful journey of loss: "Dialogue, to us, is the most important thing." A key outcome of this engagement was that the parents found greater self-compassion, and Participant 8 reflected on recognizing the importance of their own well-being: "I am no good to anyone if I am not well. I can't do anything for myself if I'm not well, so our whole objective now is to keep ourselves as well as possible, so we keep going to our meetings." Opening a dialogue with other families created a space of deep reflection where different perspectives, sensitivity, and a culture of mutual understanding fostered posttraumatic growth.

Upon reflection, Participant 14 came to understand that constructing her entire world around intense support provision consumed her quality of life: "If you focus on your children all the time when they are in addiction, you are never going to get well yourself." However, the parental instinct to care for one's child took precedence, and many parents experienced a sense of failure, questioning their parental self-efficacy when their loved one passed. As acute stress had already compromised the health of many family members prior to the death, learning the value of prioritizing one's own health was instrumental to recovery. Engagement with support groups guided families through the process of rebuilding their sense of self-worth and strengthening familial bonds. Open dialogue and reflection facilitated the development of emotional practices to build resilience and maintain wellbeing during daily functioning. In gaining a new perspective and renegotiating their sense of self-worth, families were able to pass on the value of their reflections to others, as shown by Participant 3:

It brings great peace into your life. We often speak to people. We have had a bereavement group here for the last 4 years. We often say to people, when they realize that their children are not able to stay in this world anymore it is better for everybody, you know it's hard to come to that you know, to that realization but we have come to it. That they are not meant to be there, their time to go you know and prolonging it doesn't really help.

Speaking to others in the groups who are all at various stages of their recovery cultivated a community of learning where people with similarly complex experiences could establish supportive relationships, validate their grief, and share coping mechanisms. Participant 17, who had lost her older sister three years earlier, described how she found "reassurance from hearing other people's stories." Participant 10, whose son passed away 21 years prior to the time of interview, showed considerable posttraumatic growth following engagement with bereavement services and reflected on the value these groups would have had at an early stage: "One good thing is all the work I've done on myself through the family support. I probably should have got that done 20 years ago." This mother still had unprocessed trauma even 20 years post-death and demonstrates that there are benefits to social support that cannot be offered solely by the passing of time.

Although group-based social therapy fostered posttraumatic growth for most families who were in a position to access it, the individualized nature of grief demonstrates that this solution may not work for everyone. Participant 6 expressed her personal discomfort with support groups:

I went but I didn't like it, for the simple reason I don't think [group member] should've ever mentioned her son's name. She should have never been telling us stories about her son. But yeah, that kind of group was all about that. When I found I was passing that same person on the street I'd say "Jesus I know all their business."

Her desire to keep details about the death confidential may reflect the stigma and shame that families burdened by their loved one's addiction must live with. For those who had not previously engaged with a bereavement group, the thought of having to speak openly about their anguish tempered their orientation toward counseling. Participant 6 mentioned that dealing with the grief was something done internally: "It's a struggle that a family has to work through themselves, there's no outsider can help you." Speaking about her distress magnified her sense of vulnerability and unease, particularly with respect to engaging in open dialogue about personal issues with strangers from the locality. Evident from her concerns, understanding how participants define their own parameters of anonymity is a crucial component of developing individualized support packages for individualized grief processes.

Reclamation of purpose

During their loved one's active addiction, one constant for family members among the uncertainty was their role as a parent, caregiver, or sibling. Fathers, mothers, and other family members found their identities and roles fractured by a loss that trapped them in cycles of guilt, but many participants demonstrated how they reclaimed and continued these roles in diverse ways. Through self-determination to maintain their identities post-death, many achieved a constructive reorientation of their grief experience to make sense of the loss and find a new purpose in life. Participant 1 spoke about how she continued her role as a mother, taking care of her son even after he had passed away: "I would drive out to the grave, it was like I was making his bed, I would pat the whole thing down and fix it and everything." As she continued to care for her son while conducting tactile actions to maintain her sense of maternal identity, this role constancy helped her to contend with grief.

While some conducted personal rituals in memory of their loved one, others channeled their energies into loss-inspired activism. Participants 10 and 11 (mother and daughter) cultivated a sense of purpose through advocacy work and drug awareness campaigns, where their new roles as activists served the dual purpose of honoring their loved one while also supporting them to find meaning in the loss. Participant 10 and her daughter reconstructed their lives by becoming proactive in their community, supporting others in similar circumstances, and creating a legacy in honor of their loved one:

I felt that I was doing something, for [my son]. Yeah, I just poured all my life into it...I was doing voluntary work up there for a year, family support up there for a year. I then got the job as [houseworker], and then they got funding for a family support worker, so I was doing that as well.

Over time, participants who attended group support services transitioned their roles and purpose within that framework from solely seeking support to concurrently providing support to others. Participant 8 reflected on how they used their stories and coping efforts as opportunities to support fellow attendees the way others had supported them in the past, developing a communal environment among people who felt isolated from their respective communities:

It reminds us of how important it is to stay well and maybe our story might help people and we might be able to encourage people, but we know ourselves [it's difficult] when somebody comes in and they are only starting off on their journey.

At the time of the interview, Participant 7 had not engaged in any advocacy work but spoke at length about her experience with her own addiction years prior. She stated that the death of her brother acted as a catalyst for her desire to use her first-hand experience of the different social supports to guide and mentor others through recovery:

I'd like to do that, to let people know that social workers are not there to hurt or harm them. I've been through a process. So, if an individual comes in now that's new, I can sit down and I can guide them the best I can and say try it this way. There is good information coming back from my mouth to them.

Forging a new identity by taking up new active engagements nurtured posttraumatic growth. Participant 5 spoke about the benefits of "breaking the cycle," where falling into inactivity and languishing made it difficult for him to transcend the loss and overcome his grief. He described intense mental anguish in the early years following his child's death:

I didn't handle it very well...I started drinking, not every day drinking that's not the way it was, but I was drinking more than I was, I felt I couldn't grieve the way I wanted to.

His family (Participants 6 and 7) emphasized the importance of participating in activities as it alleviated their own sense of helplessness and gave their life a sense of order. This value was pertinent in the case of Participant 6, as while she did not feel comfortable in family therapy, focusing on extracurricular activities provided her with a sense of purpose: "I'll tell you what I excelled with over the death as well-with crochet, because my whole focus is gone into it." She encouraged her husband to engage in similar activities, demonstrating an intra-family support network that was vital to recovery. This family experienced posttraumatic growth in diverse ways and at a different pace, but as a family unit they all engaged in other activities that they were passionate about, as Participant 5 highlights:

I nearly used to fish every day [before son's death]. I got to a stage one time it was like déjà vu. Every day was the same, day in day out, and I was getting depressed about [son's death], so I got my fishing rod and just threw it in...I did that for a few days to break up the monotony of every day being the same because I was doing everything the exact same every morning.

DRDs can result in the breakdown of family dynamics, but some of the participants in this study spoke about the strengthening of intra-family social bonds. With less emotional distance among family members and a willingness to communicate openly, Participant 3 strengthened her bonds with her parents: "There are a lot of positives that came out of it. Like, I'm very, very close to mom and dad because of (brother's) passing as well." When speaking to her father in the interview she noted that he is more empathetic and emotionally available: "I think that a positive thing with you Dad is that you have softened, you are easier to talk to."

Discussion

Finding peace for their loved ones was a priority for families. Death offered a stillness from the tumultuous nature of addiction, but families could not begin to process their own grief until they psychologically separated their loved one from chaotic circumstances. Many participants reframed their loss in the context of fate, with spiritual references to God and "a better place." While their personal sadness did not remit and remained intense, drawing on their faith to position their loved one in a happier place provided a sense of solace with their loved one's best interests at heart. For those who did not reference religion or spirituality, the fact that their loved one was at peace acted as a form of comfort. Using the various spiritual and emotional tools at their disposal was an essential component of posttraumatic growth and services should aim to support families in drawing from these. Closing this chapter acted as a catalyst for families to finally transition their priorities from their loved ones to themselves. This research was conducted in a predominantly Christian country and future research could examine how spirituality and religion within various cultures may facilitate positive adaptation with reference to how drug use is culturally perceived.

Support between members of the same family proved valuable for participants, but family members within the same unit often grieve in different ways. Lambert et al. () reported that some families experienced a breakdown of relationships following the death. Intra family support that addresses complex needs and emotions in socially excluded populations should aim to be trauma informed with professionals educated in how to navigate the intricacies of family dynamics, assisting them in developing emotional tools to support one another during daily functioning. Within the development of targeted support frameworks, it is important to consider individualized response plans alongside familial projects as some participants felt uncomfortable about disclosing information in a group setting. All families in this study were registered with a family support network at the time of interview, but not at the time of death. National support efforts should consider how to bring practice-based frameworks to those who require it, especially considering some families in the current study reflected on how the knowledge of available supports and their value would have been beneficial to them many years ago.

The current study has also yielded similar findings to recent literature exploring the lived experience of bereaved parents who lost children to chronic illness (Dutta et al., ), where parents developed new meaning structures by positively reappraising their trauma through rituals and fostering a new outlook on life. Many of the successful coping strategies in the current study involved reclaiming a sense of what was lost after the death, such as parental/sibling identity, community participation, or emotional connection to the deceased. Reestablishing their identity was vital to positive adaptation, and family members maintained their bonds with their children through religion and physical actions such as candle lighting and grave maintenance. Others engaged in advocacy work to keep their loved one's memory alive. The value of rituals to empower one's sense of identity and purpose was a key finding of the current study and coincides with literature from other traumatic deaths (Dutta et al., ). Wheeler () found that parents coped with the loss of their child to suicide by preserving memories, conducting rituals, and engaging in reflective processes to maintain bonds with their children.

For DRD bereavement, Titlestad et al. () and Feigelman et al. () specified meaning making as a tool for making sense of the loss. Martela and Steger () suggest that people achieve meaning making when understanding that an individual's life matters, it has value, and that it has a broader purpose in life. By becoming active members in their own community, engaging in new hobbies, or focusing on their own well-being, the pain of bereavement shifted from paralyzing to transformative as family members in the current study established a newfound sense of purpose. Some family members found their roles within support groups transitioning from simply being supported to providing support and guidance to more recently bereaved families. This new role helped them find meaning and purpose in the loss where they once felt disenfranchized.

Recent meaning focused narrative interventions have shown promise in supporting families living with a child with chronic illness (Dutta et al., ). While their research deals with pre-loss interventions for anticipatory grief, the framework has success in implementing a narrative e-writing tool through a therapist facilitated smartphone app to assist meaning-making processes for families. In improving psychological and spiritual wellbeing for families, the tool resulted in increased hopefulness for their own future and the quality of social support available to them. Given some of the similarities between positive adaptation strategies for DRDs and other traumatic deaths, future research could seek to conceptualize a similar support tool for families bereaved by a DRD that incorporates meaning making as a supportive intervention.

Overall, the families in this study found their identities and sense of community shattered by DRDs, and experienced posttraumatic growth through various active engagements that helped them to find purpose and meaning in the loss. Services should aim to support the strengthening of intra-family bonds where possible, while also assisting family members to make sense of unfamiliar and complex grief reactions. Some coping strategies associated with other traumatic deaths are similar, and the development of DRD supports could employ transferable elements of existing frameworks. Furthermore, support efforts must assist the bereaved in reconnecting with themselves and their communities while keeping themselves actively involved in fulfilling engagements. Policy and practice should consider these families in the specialized responses to complicated grief associated with other special deaths. For example, specific services in Ireland support suicide bereavement, but there are currently no extensive formal networks that specifically address DRD bereavement.

Strengths and limitations

A strength of this study lies in its in-depth methodology and approach that allowed participants to voice their experiences, which are seldom heard voices in empirical research. In analyzing the experiences of families of which the members were interviewed together, the analysis allowed for a comprehensive overview of how these participants experienced posttraumatic growth, both individually and as a family unit.

This study included a purposive sample, and all participants were white Irish in a similar urban socio-economic position. Future directions for this research may benefit from a more culturally diverse sample to address any potential differences that were not identified. Future studies could also look to explore intersectionality of experiences with addiction while experiencing social exclusion, considering groups such as the traveler community and other ethnic minority groups. This study included DRDs due to accidental overdose and death by suicide. Researchers should consider the possibility of comparing bereavement experiences and healing trajectories among those who are bereaved from accidental overdose death, intentional overdose death, and other drug-related causes of death, and whether grief and health outcomes differ in a considerable manner. Finally, future research could investigate individuals' and families' experiences of posttraumatic growth in more discrete-and narrower-post-death time intervals, as the participants in this study represented a broad range of years since the death of their loved one.

There is a need for targeted supports to help those bereaved by DRDs, not only in the immediate aftermath of the death but as an ongoing support structure to facilitate adjustment. Services could implement bereavement screening to ascertain the specific psychosocial needs of families grieving DRDs. These could be coupled with information sessions where participants are provided with an opportunity to understand the nature of group support and how the sessions are facilitated. Specialized interventions are warranted to help those dealing with complex, disenfranchized grief reactions.

Participant

Time (years) since bereavement

Relationship to the deceased

Disclosure statement

With respect to the above-named paper submitted to Death Studies, the authors wish to confirm that the publication has been approved by all coauthors, and authors have no conflicts of interest.

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Posttraumatic growth following a drug-related death: A family perspective

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Abstract This paper explores the experience of posttraumatic growth in families who have lost a family member to a drug-related death. Seven family units (17 participants) were interviewed, and interviews were analyzed using reflexive thematic analysis. Analyses revealed themes that reflected positive adaptation and growth, including (a) reframing the loss, (b) open dialogue and social support, and (c) reclamation of purpose.

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ACAMH - ACEs – Adverse Childhood Experiences : Topic Guide 

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ACAMH - ACEs – Adverse Childhood Experiences : Topic Guide 

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Hogg Foundation for Mental Health - Bruce Perry & Oprah Winfrey discuss “Three Things to Know about Mental Health & Trauma” 

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Hogg Foundation for Mental Health - Bruce Perry & Oprah Winfrey discuss “Three Things to Know about Mental Health & Trauma” 

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Three Things to Know About Mental Health and Trauma

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Dr.Soren Kaplan - Your Childhood Traumas Can Empower Your Future Success 

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Dr.Soren Kaplan - Your Childhood Traumas Can Empower Your Future Success 

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Your Childhood Traumas Can Empower Your Future Success

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Difficult life experiences build strengths that can propel you forward.

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AMA Steps Forward - Collective Trauma Toolkit: Respond Effectively as an Organization

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AMA Steps Forward - Collective Trauma Toolkit: Respond Effectively as an Organization

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Department of Education - Partner Pack : Ukraine Supports 

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Department of Education - Partner Pack : Ukraine Supports 

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NICABM - How a Caregivers Trauma Can Impact a Child’s Development 

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NICABM - How a Caregivers Trauma Can Impact a Child’s Development 

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How a Caregiver's Trauma Can Impact a Child's Development [Infographic]

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You see, during times of stress, the body releases the hormone cortisol. As you may know, that's one of the ways our body helps us cope with physically or emotionally difficult situations. So how can this happen? We created an infographic you can use with clients to help them visualize how trauma can get passed on through caregivers.

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This is so relevant for teachers, parents, guardians and professionals trying to understand behaviour being displayed by children who have experienced developmental trauma.

It is more challenging for learning to be achieved and participation to happen if children do not first feel safe, connected, regulated and cared for.

In often a constant state of ‘flight or fight’, these children are not looking for attention, they are looking for connection

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HSE/TVG - Examining the impact of 5-Step Method, trauma-informed, and Traveller cultural awareness training on community healthcare workers

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HSE/TVG - Examining the impact of 5-Step Method, trauma-informed, and Traveller cultural awareness training on community healthcare workers

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Cork - Our Vision for a Trauma Sensitive City 

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Cork - Our Vision for a Trauma Sensitive City 

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Cork Our Vision for a Trauma-Sensitive City City-Wide Trauma Awareness, Sensitivity and Healing through Relationships

Trustworthiness Transparency

Safety

Peer Support

Collaboration and Mutuality

Empowerment, Voice and Choice

Cultural Sensitivity

Cork Trauma Sensitive City

Cork Trauma Sensitive Cities Strategy 2022 - 2025

City-Wide Trauma Awareness, Sensitivity and Healing Through Relationships

Foreword We know that trauma can affect any one of us at any time in our lives. Many of us will develop ways to cope with these experiences as they arise, and our lives will continue without any long-term consequences. During these times we may be supported by members of our family, our friends, or others in our community. These connections and the role of one supportive relationship must not be underestimated. We know that for some of us, the significance of these experiences is such that we will need to reach out and access specialist support to help us to recover from the impact of trauma. These experiences can impact not only our physical and mental well-being but also our relationships. Together we have an opportunity as a city to be courageous and transform how we understand and respond to Trauma. This strategy affords us as a city an opportunity to develop a 'trauma lens 'which can be applied across all our services. The Covid-19 pandemic highlighted for us all the impact of collective trauma, and while we were all in the same ocean, we were not all in the same boat. Covid 19 has illustrated the role and impact of trau- ma, particularly for those who are already affected by inequalities and have experienced Adverse Childhood Experiences (ACES). Importantly, this strategy helps us to understand the roles we all play, and the difference we can all make by simply being more compassionate and more understanding of each other. By shifting our perspectives firstly as individuals, collectively within our organisations and as a city shifting our focus from the narrative of 'What is wrong with you?', and instead asking 'What has happened to you?' As a city, we want to promote a culture where people experience empathy and kindness and are empowered to access the services they need for support. We want to provide services and policies that build and strengthen trusting relationships. This strategy aims to develop a bespoke trauma framework at a city-wide level that will support statutory, community and voluntary organisations, in addition to local communities. At its core is the development of principles and practices which further Cork City becoming Trauma-sensitive. This framework comprises a number of overarching goals including the development of a bespoke training programme and toolkit that will be developed for, and offered to, all partner organisations. Further, this strategy is the beginning of the development of a road map for Cork City charting our courageous and exciting journey towards becoming Trauma-sensitive City. Thank you Ann Doherty CE Cork Council

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Foreword Lord Mayor The introduction of this Strategy and E- training module could not be more timely. We have witnessed so many shifts and changes in our world over the past 24 months, COVID-19 and the more recent events in Ukraine have brought the impact of trauma to the forefront of our minds. We have all become far more mindful of the potential impact trauma can play on the lives, health, and well-being of people. Simple acts of kindness, and help, can have a positive impact on the lives of those affected by trauma. Across Cork, we have seen how individuals, communities and groups have come together to help others, including offering sanctuary to those who have fled from conflict. It is these kinds of actions both individually and collectively which underpin how we can live in a Trauma-sensitive way. Responding in a trauma-sensitive manner can influence our overall well-being, it promotes belonging, kindness, safety and trust. Here in Cork want to see public services, third-sector organisations, communities and individuals embracing this strategy and embedding it into their daily practice. This brave call to action challenges us all to work towards ensuring our interactions with each other and the people we serve are based on a trauma-sensitive approach. Through this collective action we can all make a difference in building a city that is Trauma-sensitive Lord Mayor Cllr Deirdre Forde

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City-Wide Trauma Awareness, Sensitivity and Healing Through Relationships

Executive Summary Trauma and adversity are a growing public health concern (Thorley, 2019). Van Der Kolk (2014) noted that childhood trauma had been identified as one of the most important public health challenges facing societies today. Bellis (2021) in his address at the Five Nations Adverse Childhood Experiences (ACEs) Meeting noted that the cost of trauma to the health and justice systems across Europe is approximately $581 billion dollars per annum. Previous research reports that our earliest experiences in life inform the foundations for lifelong health, well-being, and quality of life (Thorley, 2019; Romero et al, 2018; Liming et al ., 2014). Notably, responsive relationships and supportive family and community environments have been shown to shape a child's future well-being, development, educational engagement, and health (Romero et al ., 2018), and are indeed key to positive life outcomes (Campbell et al. , 2016). Several nations across the globe have accelerated their respective trauma/ACEs movement significantly in recent years. Countries including Scotland and Wales have implemented impactful trauma-focused frameworks with great success. These frameworks have been reported to decrease social isolation, improve educational outcomes, and build resilience in young people (Skuse & Matthew, 2015). Cities including Plymouth (UK), Lancashire (UK), Tennessee (US) and Tarpon Springs, Florida (US) have begun the journey to implementing Trauma Informed Practice at a city and community level. Mental Health Ireland and Alcohol Action Ireland (2021) advocate that cultural changes must take place within our public and social systems to reflect the impact of trauma. They call for a multi-agency, multi-pronged approach to trauma-sensitive services. The Government of Ireland report prepared by the Department of Health, ' Vision ~ A Mental Health Policy for Everyone' (2020) gives a very clear mandate regarding the provision of Trauma-Informed Service Delivery Principles and specifically states that staff in every part of mental health organisations change their language, behaviour and policies to take into consideration the experiences of those who have trauma histories, including staff members themselves. This mandate needs to transcend all organisations, where at an organisational and individual level people are given an opportunity to reflect and retrain using a 'trauma-sensitive lens'. In "Cork: Our Vision for a Trauma-Sensitive City" we are providing a framework and opportunity for us collectively as a city, collaboratively at an organizational level as well as at an individual level, an opportunity to embrace and adopt a trauma lens in the work that we do and the lives that we live. Fundamentally, taking a population-level, trauma-sensitive approach means * developing proactive systems that aspire to prevent trauma from occurring in the first place * promoting protective factors for all * recognising the behaviours that may be the result of trauma and intervening appropriately, and * helping people who are suffering adverse consequences in a trauma-sensitive way. At the most basic level, trauma is the presence of toxic stress in the body, leading to the overproduction of cortisol, which in turn activates our innate fight/flight/freeze/fawn response and occurs without the buffer of a secure relationship (Mulcahy, 2018; Siegel, 2012). t Stress, when mild, can promote healthy development; however, when stress is prolonged and unpredictable and occurs in the absence of a 'buffer' or caring relationship, can have a negative impact on how our brains and bodies function and how we view the world around us. (Hornor, 2015). Fundamentally, healing and recovery from trauma occur through responsive

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and nurturing relationships (Brooks, 2019; Treisman, 2018). This strategy aims to promote the role we can all play in our relationships with each other. We in Cork city aspire to have an understanding that trauma is everyone's business, and we all have a role to play in providing support. In shaping a vision for our city, Cork Trauma-Sensitive Cities Steering Committee have been working, learning, and reflecting in collaboration with other cities and trauma-sensitive organisations over the past 24 months. This is to ensure we fully comprehend the science of trauma and how it relates and translates to the local city context, in order to better understand what a trauma-sensitive approach should look like for Cork City. This strategy provides a framework for the city to develop pathways and opportunities to ensure as a city we are adopting a trauma-sensitive approach, which will involve a comprehensive change in the manner in which we develop and deliver services and programmes across the city. This will ensure that all partners can demonstrate a basic understanding of trauma and consider the implications for people experiencing trauma in their planning and delivery and where appropriate utilise trauma- sensitive responses (Kimberg &

Wheeler, 2019; SAMSHA, 2014)). Sandra Cogan Williamson Chair Cork Trauma- Sensitive City

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City-Wide Trauma Awareness, Sensitivity and Healing Through Relationships

Contents Foreword . ..................................................................................................................................................... 1 Ann Doherty, CE Cork Council................................................................................................................1 Foreword Lord Mayor ................................................................................................................................ 2 Lord Mayor Cllr Deirdre Forde.................................................................................................................2 Executive Summary . .................................................................................................................................. 3 Sandra Cogan Williamson, Chair Cork Trauma- Sensitive City...........................................................3 Cork Trauma Sensitive City Steering Group Members 2019 to Present..............................................6 Section 1 ....................................................................................................................................................... 7 1.1 Vision: Growing Cork as a Trauma-Sensitive City..........................................................................7 1.2 Mission: to promote city-wide trauma awareness, sensitivity, and healing through relationships.............................................................................................................7 1.3 Values and Principals of becoming Trauma- Sensitive.....................................................................7 1.4 What is a Trauma-Sensitive Approach?..............................................................................................7 Section 2 ..................................................................................................................................................... 10 2.1 Introduction.........................................................................................................................................10 2.2 Definition of Trauma and Trauma-sensitive Practice.....................................................................11 2.3 Adverse Childhood Experiences.......................................................................................................12 2.4 The one good adult/ The key person.................................................................................................12 2.4.1 What difference does One Good Adult make?.............................................................................13 2.5 Types of Stress Response: Positive, Tolerable and Toxic Stress......................................................13 2.6 A City focused on partnership, prevention and upskilling............................................................14 2.7 Strategic Goals......................................................................................................................................15 2.8 Steering Committee.............................................................................................................................15 2.9 Training & Workforce development:................................................................................................16 2.9.1 Training - Dr Karen Treisman........................................................................................................16 2.9.2 Trauma Responsive Schools Pilot Programme:............................................................................18 2.9.3 Munster Technological University Trauma Awareness Training:..............................................18 Section 3 ..................................................................................................................................................... 19 3.1 Systems development.........................................................................................................................19 3.1.1 Tier 1: General Awareness...............................................................................................................19 3.1.2 Tier 2: Trauma Champions.............................................................................................................20 3.1.3 Tier 3: Strategic Planning and Organisational change using a Trauma lens............................20 3. 2 Pledge/Memorandum of Understanding MOU.............................................................................21 Section 4 ..................................................................................................................................................... 22 4.1 Research/Evaluation............................................................................................................................22 Phase 1: -Review of extant literature in the field, globally and in Ireland. - 2019-2022..................24 Phase 2: - Research design based on the findings of Phase 1 - 2021-2022........................................24 Phase 3 - Implementation -2022-2025...................................................................................................24 Phase 4 - Evaluation of Bespoke Cork City Trauma Lens/Model/ Framework - 2025...................24 Section 5 ..................................................................................................................................................... 25 5.1 Conclusion............................................................................................................................................25 References: . ................................................................................................................................................ 26 Appendix 1 ................................................................................................................................................. 29 MEMORANDUM OF UNDERSTANDING ........................................................................................ 30 Pledge to become a trauma-sensitive Organisation .......................................................................... 31

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Cork Trauma Sensitive City Steering Group Members 2019 to Present Dr. AnnaMarie Naughton Health Service Executive Ingrid O'Riordan School Completion Programme Dr. Judith Butler Munster Technology University Katherine Harford Cork Healthy Cities & Lets Grow together Dr. Mary T. O Mahony Health Service Executive Sandra Cogan Williamson Cork City Council Garda Timothy O'Donovan An Garda Siochana Adrienne Rodgers Cork City Council David Lane Health Service Executive Dr. Jennifer Hayes Health Service Executive Dr John Sheehan (Former Lord Mayor) Cork City Council & General Practitioner (GP) Judy Cronin Health Service Executive Cllr Mick Finn (Former Lord Mayor)

Cork Education and Training Board & Cork City Council Cork City Council & Health Service Executive

Rebecca Loughry Dr. Sharon Lambert Siobhan Goulding

University College Cork Department of Social Protection Cork Education and Training Board Mercy University Hospital Munster Technology University Matt Talbot Adolescent Services CLG Munster Technology University

Ruth Griffin

Margaret McKiernan

Honor Carroll

Edel Foley

Dr. Annie Cummins

Kerry Brennan Mick Devine

Cork Simon Community

Tabor Group

Traolach O'Callaghan

TUSLA

Eileen O'Shea

Cork Traveller Visibility Group

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Section 1

1.1 Vision: Growing Cork as a Trauma-Sensitive City A trauma-sensitive city approach is a commitment to all citizens, not just children. It endorses and supports relationships, practices and environments that promote safety, predictability, empowerment, and control (Nicholson et al ., 2019; Jedd et al ., 2015). Trauma Informed Practice (TIP) and a trauma-sensitive approach support a deeper understanding and awareness of the prevalence and role that trauma plays in people's lives, and that healing comes from responsive relationships. Through the integration of this knowledge and understanding into the fabric of our daily way of working, we promote resilience and understanding (Butler, 2020). 1.2 Mission: to promote city-wide trauma awareness, sensitivity, and healing through relationships. This strategy aims to develop and establish a bespoke trauma framework at a city-wide level that will serve to support statutory, community, voluntary organisations and local communities in the development of principles and practices with regard to becoming trauma-sensitive. This framework will comprise the development of a bespoke training programme and bespoke toolkit that will be developed for, and offered to, all partner organisations at an individual and city-wide level. The mission is to promote city-wide trauma awareness, sensitivity and healing with a focus on relationships. 1.3 Values and Principals of becoming Trauma- Sensitive For Cork City to become trauma- sensitive, we must * realise the widespread impact of trauma and understand potential paths for recovery; * recognise signs and symptoms in our citizens who are involved with the systems that operate within the city; * respond by fully integrating knowledge about trauma into our policies, procedures, practices, and * seek to actively resist re-traumatisation (Trauma and Justice Strategic Network; SAMSHA, 2014). A city that holds a trauma lens at its core holds the values of trauma-sensitive practice as one that is 1) safe, 2) person-centred, 3) kind in its responses, 4) works collaboratively and 5) is empowering and recognises 6) resilience within a person, family, and community . (Adapted from Envisioning Plymouth as a Trauma-Informed City). Treisman (2018) advocates, we need to create services that consider, acknowledge, and integrate our understanding of adverse adult experiences, adverse community experiences, adverse cultural experiences and adverse organizational experiences 1.4 What is a Trauma-Sensitive Approach? A Trauma-sensitive recognises the prevalence and impact of trauma, the role trauma plays in people's lives and most importantly, advocates that healing from trauma is through relationships. (Butler, Clerkin & Cummins et al ., 2022) Fundamentally, a city-wide approach to understanding the prevalence and impact of trauma across the lifespan necessitates understanding the impact of adverse childhood experiences (ACES) and trauma within organisations and communities, along with the interaction and experiences of the individual within those structures.

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The Substance Abuse and Mental Health Services Administration, (SAMHSA, 2014) posit that Trauma- informed Practice is a strengths-based framework that is underpinned by six core principles which are; 1. Safety 2. Trustworthiness and Transparency 3. Peer Support 4. Collaboration and Mutuality 5. Empowerment, Voice and Choice, and 6. Cultural, Historical and Gender Issues (Pemberton & Loeb, 2020). "Research would indicate that exposure to adverse experiences is common, the psychological impact of these adversities varies from person to person. There are many people in our communities who have experienced adversities at a level that drastically impacts on their day to day living, including access to and use of public services. Creating an inclusive community requires us to think that how we can improve access to services to those who have experienced psychological trauma. Cork City's journey to become a trauma aware city is an exciting development with the potential to improve outcomes and experiences for both the public and staff working in public services" Dr Sharon Lambert University College Cork The physical, psychological and emotional safety of service users and staff are prioritised, by: * people knowing they are safe or asking what they need to feel safe * there being reasonable freedom from threat or harm * attempting to prevent re-traumatisation * putting policies, practices and safeguarding arrangements in place Safety

Transparency exists in an organisation's policies and procedures, with the objective of building trust among staff, service users and the wider community, by: * the organisation and staff explaining what they are doing and why * the organisation and staff doing what they say they will do * expectations being made clear and the organisation and staff not overpromising Service users are supported in shared decision-making, choice and goal-setting to determine the plan of action they need to heal and move forward, by: * ensuring service users and staff have a voice in the decision- making process of the organisation and its services * listening to the needs and wishes of service users and staff * explaining choices clearly and transparently * acknowledging that people who have experienced or are experiencing trauma may feel a lack of safety or control over the course of their life which can cause difficulties in developing trusting relationships

Trustworthiness Transparency

Peer Support

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The value of staff and service user experience is recognised in overcoming challenges and improving the system as a whole, by: * using formal and informal peer support and mutual self-help * organisation asking service users and staff what they need and collaboratively considering how these needs can be met * focusing on working alongside and actively involving service users in the delivery of services Efforts are made to share power and give service users and staff a strong voice in decision-making, at both individual and organisational levels, by: * validating feelings and concerns of staff and service users * listening to what a person wants and needs * supporting people to make decisions and take action * acknowledging that people who have experienced or are experiencing trauma may feel powerless to control what happens to them, isolated by their experiences and have feelings of low self-worth Move past cultural stereotypes and biases based on, for example, gender, sexual orientation, age, religion, disability, geography, race or ethnicity by: offering access to gender-responsive services leveraging the healing value of traditional cultural connections incorporating policies, protocols and processes that are responsive to the needs of individuals served ( Working definition of trauma-informed practice - GOV.UK (www.gov. uk)

Collaboration and Mutuality

Empowerment, Voice and Choice

Cultural Sensitivity

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Section 2

2.1 Introduction Cork is the second largest city in Ireland with a population of 210,000 citizens. Cork is the only Irish city currently recognized by UNESCO for its excellence in the field of learning and was one of just 12 cities globally, and 3 in Europe, presented with the inaugural UNESCO Learning City Awards in 2015. Cork City is a World Health Organisation (WHO) Health City since 2012. As a city, we have a proven track record of strong interagency collaboration and project delivery. This was particularly evident during the Covid 19 pandemic, where 16 Community area teams ensured that individuals, families, and communities were supported and nurtured throughout the pandemic. A City-Wide Community response forum was established led by Cork City Council. The trusting relationships that have been established over years of collaborative working ensured that as a city we supported our citizens through a very uncertain time. In Cork, we recognise that trauma can occur at any time in the lifespan, so we need a broad, inclusive approach to being trauma aware, compassionate and supportive. We also recognise that some of the most vulnerable members of our community are at far greater risk of trauma. Our aim is to work towards increased awareness of trauma, and the impact of trauma in the context of social inclusion and connection. As a city, we are embedding ACE Awareness & Trauma-Sensitive Practice through a Whole Systems Approach in partnership with agencies and the community and voluntary sector. This approach is supported by national and international literature from neuroscience, public health and psychology. Cork Healthy Cities commissioned 'Cork City Profile' - a statistical and geographical profile of Cork City Local Authority area that focused on health and inclusion. The profile provides an in-depth examination and insight into the social determinants of health that influence the health of citizens. Further analysis from POBAL maps identified that 29% of the 519 small areas in Cork City are defined as being disadvantaged or very disadvantaged. Geographical disadvantage continues to be a key challenge facing Cork City. Cork City Council retained the Revitalizing Areas through Planning, Investment and Development Programme (RAPID), and adapted it to be reflective and responsive to the needs of the RAPID areas by embedding it within the Local Community Development Committee (LCDC) structures. Despite improvements in outcomes across a range of measures, there remains a distinct spatial component to the distribution of disadvantage within the city, with a concentration of deprivation and associated factors across the RAPID areas of the City and in particular north of the river. To address poverty and disadvantage it is essential that we have a multi-agency planned response, focusing on upstream approaches to health and wellbeing that are proactive and holistic. The 4 designated RAPID areas in the city have a DP score between -13.2 and -16.6. (Cork City Local Economic and Community Plan). The existence of trauma poses a threat to individuals and communities. Trauma occurs across all economic, cultural, racial and social groups, which can form a rootless trajectory that may be experienced by children worldwide (Brooks, 2017). Various cohorts are typically more susceptible to experiencing ACEs and trauma such as those encountering socio- economic disadvantage (Nicholson et al ., 2019). Due to increasing social and cultural factors (Nurius et al. , 2013), researchers devised the notion that communities that are vulnerable and marginalised are at a higher risk of experiencing trauma, including members of the Traveller community (Hughes, 2019; Coogan, 2019), members of the homeless community (Lambert & Gill-Emerson, 2017), children in poverty (Murray & Morgan, 2019), and children in direct provision (The College of Psychiatrists of Ireland, 2017; Fazel, Wheeler & Danesh, 2005.

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Cork City recognises that to achieve this ambitious and courageous goal of becoming a city that is Trauma- sensitive we need to embrace and embed a new approach to how we meet people. We are planting the seeds that will grow a city that is kind and inclusive. This is about caring, creating trustful relations and having in mind that difficult children do not exist, but many children are living under difficult conditions.

As a City we recognise that relationships are key, responsive relationships and supportive family and community environments have been shown to shape a child's future well-being, development, educational engagement, and health (Romero et al ., 2018), and are indeed key to positive life outcomes (Campbell et al. , 2016). "As Cork continues to prosper as a Healthy City, a Learning City and a City of Sanctuary, it is crucial that an awareness and understanding of childhood trauma and the lifelong impacts of adverse child- hood experiences (ACEs) underpins its evolution. Putting children, young people and families front and centre in in service delivery across all organisations will strengthen the roots of Cork's family and community life. Educating people working in the various sectors about ACEs through a self-guided learning continues the ground-breaking work already done to raise awareness in the city and will help lead to a Cork that is more inclusive, understanding and responsive to the needs of the more vulnerable among us." Cllr Mick Finn, CETB and Former Lord Mayor Of Cork 2.2 Definition of Trauma and Trauma-sensitive Practice For the purposes of this strategy, trauma is defined at its core as an event(s), or a series of circumstances that are experienced as physically or emotionally harmful or life-threatening. It may overwhelm a person's ability to cope and function which has a lasting adverse effect on their mental, physical, social, emotional, and/or spiritual well-being (Trauma and Justice Strategic Network; SAMSHA, 2014). Put simply, trauma is about the harmful experiences that people experience and the legacy of the impact.

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2.3 Adverse Childhood Experiences Adverse Childhood Experiences (ACEs) is a term coined by researchers, Vincent Felitti, Robert Anda, and their colleagues, in their study conducted from 1995 to 1997. ACEs refer to traumatic experiences in a per- son's life occurring before the age of 18. These include: * experiencing violence, abuse, or neglect; * witnessing violence in the home or community; * having a family member attempt or die by suicide. In addition, aspects of the child's environment that can challenge their sense of safety (Butler, 2020) are also identified and include children's experiences of * substance misuse; * mental health problems; * instability due to parental separation or incarceration of a parent, sibling, or other members of the house- hold ACEs are linked to chronic health problems, mental illness, and substance use problems in adolescence and adulthood. ACEs also have the potential to negatively impact education, job opportunities, and earning potential . However, having a key person or one good adult in our lives is linked to better outcomes and over- all health (Jigsaw, 2022) 2.4 The one good adult/ The key person Research (Nicholson et al., 2019) suggest that just one positive adult can dramatically improve the outlook of a child impacted by trauma and Adverse Childhood Experiences (ACEs). This relationship acts as buffer against toxic stress and has the potential to change the course of a child's life. Those who spend more time with children have a greater opportunity to provide the tools that can really have a positive impact 'Envisioning Cork as Ireland's first trauma sensitive city fills my heart with joy & so much hope. Understanding the impact of Adversity and Trauma, help us all to find ways to look through the lens of "what happened" instead of "what's wrong with you'. Trauma is common and if you work with people you work with trauma. However, we also know what can help mitigate trauma, a responsive, compassionate, and caring relationship. In fact, all trauma sensitive practices begin with a caring & compassionate relationship. A smile has the potential to change a person's brain & your smile might be the single only smile someone sees in a day. Our daily interactions that we all have with each other are very important and relationships are built in the small moments. We all need to be aware and ready to play our part in healing the impact of trauma and adversity. To me, Cork as a trauma sensitive city means a city rooted in empathy & validation of all people's life experiences & is a city that commits to building consistent and caring relationships. As Bruce Perry highlights, 'Relationships are the agents of change, and the most powerful therapy is human love. People not programmes change people.' Dr Judith Butler , Munster Technological University Quote

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2.4.1 What difference does One Good Adult make? Young people who reported having one good adult tended to have: * Increased self-esteem * More success in school life * Better mental health * More likely to seek help * Less risk-taking behaviours Not having One Good Adult is linked to higher levels of distress, anti-social behaviour, and increased risk for suicidal behaviour. Having One Good Adult is essential.

2.5 Types of Stress Response: Positive, Tolerable and Toxic Stress The Centre for the Developing Child Harvard University (2022) distinguishes between three types of stress responses: positive, tolerable, and toxic. 1. Positive Stress- motivates us to get things done, it is short-lived and once it is over stress levels return to normal levels. 2. Tolerable Stress is more serious but as the name suggests it's tolerable for one reason- we have a key relationship to help us through. 3. Toxic Stress - stress becomes toxic or traumatic when it is prolonged and occurs in the absence of a relationship. (Butler, Clerkin & Cummins, 2022: 130) Toxic stress is trauma. Toxic stress has the potential to profoundly alter the development of a child's brain and can affect the immune system, with research showing a correlation between early adversity and poorer outcomes later in life (Butler et al., 2022; Burke et al ., 2011; ). Young children are especially sensitive to repeated trauma and adversity, largely because their bodies and brains are developing (Butler et al., 2022; Jedd et al., 2015; Bremmer, 2006).

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2.6 A City focused on partnership, prevention and upskilling In 2019, Cork City Council led a call to action for interagency collaboration to provide front-line staff and management across the city to attend Trauma training free of charge. As a city, we wanted to ensure that as many barriers were removed as possible allowing a wide net to be cast to ensure the training reached as many front-line practitioners as possible. The aim was to enable the development of a framework, which would begin the groundwork towards a shared understanding and language in relation to Trauma and its impact right across the lifespan. The training also provided a foundation for the development of practical tools to be used across the services in Cork. To date over 500 front-line practitioners have been trained in 4 full days of Trauma training.

350 individuals attended 2 Days Training on Understanding the impact of relational and developmental trauma and disrupted attachment on children's brains, bodies, emotional, relationships and behaviours, including Adverse Childhood Experiences (ACEs). April 2019 October 2019 Trauma Interagency Steering Group established October 2019

Cork Trauma Sensitive City

November 2019 Attended and presented at Trauma Informed Prevention of Adverse Childhood Experiences - A WHO European Healthy Cities Taskforce Presented to the Trauma Informed Care TIC Conference Dublin - Mick Finn CETB & Sandra Cogan Williamson

Dr Jennifer Hayes and Sandra Cogan Williamson attended Action On Trauma Conference Belfast

January 2020 450 individuals attended 2 days training on Moving towards being and sustaining an adversity, culturally, traumainformed, infused, and responsive organisation- Dr Karen Treisman

September 2020

50 individuals attended 2 screenings of Resilience Documentary to youth workers and family support workers

January 2021 onwards Monthly Steering Group meetings developing strategy and vision for Cork with sessions delivered by UCC, MTU, Public

October 2021 54 participants engaged in 6 Days Pilot Training to 10 Schools and 2 School Completion Programmes on Trauma Responsive Education

Health, Lancashire Police, Plymouth Trauma Network,Novis,Trauma Informed Education.

Development of a bespoke 45 min e-training module - Develop CoP - Grow and develop new partnerships and collaborations - Pledge - Developing Trauma Strategy for Cork City including a road map & Model of best practice -Grow and develop new partnerships and collaborations

2022 & beyond

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2.7 Strategic Goals

Steering Committee

Training & Workforce development

Systems development

Pledge/MOU

Research & Evaluation

Embarking on a population-based Trauma-sensitive approach means developing proactive systems that aspire to prevent trauma from occurring in the first place, promoting protective factors for all children, recognising the behaviours that may be the result of trauma and intervening appropriately, and helping people who are experiencing adverse consequences in a trauma-sensitive way. 2.8 Steering Committee Cork City established a steering committee under the leadership of former Lord Mayor Dr John Sheehan in late 2019, with the overarching aim of making the city Trauma-sensitive . Upon recognising and understanding the connection between trauma and potential poor physical and social outcomes, we have a responsibility to develop a plan to raise awareness about trauma by educating local partners and service providers on what trauma is, the role trauma plays in people's lives and that healing from trauma is through relationships. Becoming a Trauma-sensitive city means we will develop city-wide structures and frameworks that involve recognising, understanding, and responding to trauma that children, young people and communities are exposed to and will develop systems which support those impacted by trauma. This steering group is derived from a coalition of professionals from interdisciplinary services, with professional and personal experience of how trauma can affect people and a working knowledge of the importance of relational repair. Cork City Trauma-Sensitive steering group is made up of more than 30 professionals across public agencies and community groups including; * An Garda Síochána * Cork ETB (CETB) * Universities- MTU & UCC * TUSLA * HSE - Social Inclusion/Public Health/Mental Health/ Drug and Alcohol Services/GP's

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* Department of Social Protection * Cork City Council * TESS - School Completion Programme * Probation * Homeless Services * Traveller Visibility Group * Elected Members * RAPID * Healthy Cities * Addiction Services * Area Based Childhood Committee

All members of the steering group have gained insight into the long-term impact trauma can have on people. They are committed to developing and driving the goals of making Cork City Ireland's first trauma-sensitive city. 2.9 Training & Workforce development Cork City recognised the need to support workforce development in relation to adopting a Trauma-sensitive approach in recent years and in April 2019, and in January 2020, training was provided for key service pro- viders across the city. Dr Karen Treisman delivered training over the course of 4 full days to over 500 individ- uals. 2.9.1 Training - Dr Karen Treisman Training in April 2019 : An Introduction to relational and Developmental Trauma The Objectives of the 2-day training included to: * Develop further knowledge and understanding about the impact of early trauma on children's overall development * Gain further insight into the latest brain science and neurobiology around childhood trauma and neglect * Consider how emotional regulation develops in childhood and how it can be influenced by trauma and ACEs * Learn how to identify children's multi-sensory triggers and emotional hotspots * Gain further understanding as to why therapeutic re-parenting and relationship-based trauma-sensitive practice is so fundamental to children's progress * Increased understanding as to why trauma is a multi-sensory whole-body experience requiring multi- sensory whole-body interventions

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Training in January 2020: Moving towards and sustaining being adversity, culturally, & trauma-informed, infused, and responsive organisation/group

Aims and objectives of the 2-day training included: * Learn about what being adversity, culturally, and trauma-informed, infused, and responsive means and looks like; and establish why it is needed, important, and beneficial. * Identify the key values, principles, and definitions within trauma-informed organisational transformation. * Learn about some of the key aspects to support successful implementation. * Learn about several best practice models for being more trauma-informed and trauma-responsive at an organisational level. * Increase knowledge and understanding around specific components and the nuts and bolts of the practice of being more trauma-informed, such as through induction and recruitment, the language we use, through to the physical environment, through to lived experience involvement, through to team meetings, through to supervision, through to behavioural responses, and much more. * Consider what some of the factors are for improving the effectiveness of trauma-informed practice; as well as what some of the potential obstacles and barriers may be. * Reflect on what is going well already and how can this be magnified, strengthened, and celebrated. * Develop action plans, momentum, and ideas from the group as to ways to become more trauma- informed and trauma-responsive. * Learn more about organisational and secondary trauma, as well as group processes. * Create well-being plans.

Participants received CPD certification from University College Cork (UCC) for full attendance. To date, over 500 individuals from a plethora of services including therapeutic services, homeless services, TUSLA, justice services, education services, youth services, nursing, and midwifery, the HSE (Health Service Executive), Cork City Council, academia, and Cork ETB (Education Training Board) have attended the training. The training programme aimed to develop and embed a common language and understanding across the city of trauma and adversity, and to further enhance service delivery to vulnerable children, families, and communities.

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2.9.2 Trauma Responsive Schools Pilot Programme: Sept 2022 - Jan 2022

A pilot programme for schools was commissioned by Cork Trauma-sensitive Cities in 2022. This programme was developed and delivered in partnership with Trauma Responsive Education, which is a social enterprise. This pilot was delivered to over 60 staff nominated from 10 schools and 2 school completion programmes across the Rapid areas in Cork City. The programme was funded through Rapid and Cork City Council. The focus of the pilot was to build knowledge and understanding within the school of Trauma responsive education, it was delivered across 5 weeks and included pre and post-training follow up, the development of a trauma-responsive plan for each school and quarterly reflective practice sessions annually.

2.9.3 Munster Technological University Trauma Awareness Training: May 2022- December 2022

The Teaching and Learning Unit at Munster Technological University (Cork) funded 3-hour trauma awareness training delivered by Dr Judith Butler and Dr Annie Cummins (Lecturers/ Researchers MTU and steering group members) to Cork ETB principals, Further Education College teachers, Youthreach centres, Active Inclusion, post-primary teachers and primary teachers in 11 colleges and schools in Cork to date. This training introduced Trauma-sensitive approaches in education with a focus on supporting students fleeing war. The awareness training has been evaluated and highlights that 75% of teachers had no relevant training on the needs of children who have experienced trauma. In addition, 96% asserted that the training was 'excellent' (80%) or 'very good' (16%) asserting that it would positively impact their teaching and engagement with learners. The value of this 3-hour sessions can be seen in the responses from the teachers. I must remember to be kind towards learners, if there is a difficulty or a learner has a distressed response then I will think of the regulate, relate, and reason response mentioned. Smile. Give choices. Provide students with a sense of care and community in the classroom as you don't know if they have had this before I'm going to focus on relationships. It's obvious now that I may indeed be the only smile a student sees in a day! Not going to be annoyed & unwelcoming when students are late. I'm going to find what is going on & if I can assist. Meet needs - as you said Maslow & meeting needs come first. I now know I'm a key person in my students' life. People change people. ​

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I hope to try and encourage others to focus on developing relationships, bringing hope, and allow as much autonomy/choice as possible in our communities. ​ The impact that a key person can have on a person's life, that relationships are a buffer for trauma. Students come in our doors, and we have no idea what baggage they may have so we must be aware of that and so be kind. Improving connections and relationships in my class. Changing my views on things e.g. relationship seeking rather than attention seeking Section 3 3.1 Systems development: Upon recognising and understanding the connection between trauma and potential poor physical and social outcomes, we have a responsibility to develop a plan to raise awareness about trauma by educating local partners and service providers on what trauma is, the role trauma plays in people's lives and that healing from trauma is through relationships. Building Cork as a Trauma-sensitive city means we will develop city-wide structures and frameworks that involve recognising, understanding, and responding to trauma that children, young people and communities are exposed to while developing systems which support those impacted by trauma.

TIER 1

TIER 2

TIER 3

Leadership & Corporate Governance - pledge - organizational change - trauma lens on strategic planning, policies, physical environment etc.,

General Awareness - e-training module and pledge

Enhanced Trauma-Sensitive Practice Skills Development - trauma champions/trauma-focused services

3.1.1 Tier 1: General Awareness

Cork Trauma Sensitive City

Becoming Trauma Aware An introduction to psychological trauma

Let's Begin

Module last reviewed: 11/08/2022

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corkcity.ie

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Cork Trauma Sensitive Cities Strategy 2022 - 2025

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Cork Our Vision for a Trauma-Sensitive City City-Wide Trauma Awareness, Sensitivity and Healing through Relationships Trustworthiness Transparency Safety Peer Support Collaboration and Mutuality Empowerment, Voice and Choice Cultural Sensitivity Cork Trauma Sensitive City Cork Trauma Sensitive Cities Strategy 2022 - 2025 City-Wide Trauma Awareness, Sensitivity and Healing Through Relationships Foreword We know that trauma can affect any one of us at any time in our lives.

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UCC / Tusla/ HSE/ Cork City Council - Becoming Trauma Aware : An Introduction to Psychological Trauma 

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UCC / Tusla/ HSE/ Cork City Council - Becoming Trauma Aware : An Introduction to Psychological Trauma 

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Mike Armiger & Karen Treisman : North Somerset - Adversity & Trauma 

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Mike Armiger & Karen Treisman : North Somerset - Adversity & Trauma 

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Dale M. Kushner - 7 Principles for Recovering from Trauma 

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Dale M. Kushner - 7 Principles for Recovering from Trauma 

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The third conversation with Jungian therapist and rabbi Tirzah Firestone.

Today, we speak with Rabbi Dr. Tirzah Firestone for another information-packed discussion. Inherited Wounds: Tirzah Firestone on Ancestral Healing Recognizing and Healing Inherited Trauma " for earlier posts).

Firestone is a Jungian analyst, rabbi, and the daughter of Holocaust survivors, whose research is on recovery from trauma, including the mechanisms of inherited trauma. In the new revised edition of her book, Wounds into Wisdom, Firestone draws on the latest findings in neuroscience and psychology, interweaving them with compelling stories of trauma and healing, to offer readers hope, understanding, and the means to discover how suffering can be transformative.

: There is a lot of new biology that's changing how we think about health, lifespan, trauma, and genetic inheritance. Your book explains this in an accessible way. Please give us an overview.

There is a lot of fascinating research. The last 10 years have given us much more insight into the growing field of epigenetics, which studies the effect of life's stresses on our genes ' activities.

Epigenetics draws on clinical studies with mice and rats, demonstrating stress and struggle can imprint not only on us but on future generations. Early nurturing patterns by the mother, for instance, have been shown to pass to grand-pups and great-grand-pups, even when they had never interacted.

Emory University,a sweet smell, acetophenone, and then received an electric shock to their feet. Associating the two, whenever the mice encountered the smell, they became fearful and froze. Amazingly, their offspring-even the grand-pups who had never met their grandparents or been exposed to the smell or shock-showed 1 mice were exposed to panic in the presence of the smell.

Source: Rasal Hague/CC 4.0

DK: Your own research is on recovery from trauma. Tell us about this study and its findings.

My study was on Jewish people from around the world who had gone through extreme traumas such as war, racial and religious discrimination, the loss of a child to terrorism, and such. My focus was on those who were able to go through the many stages of healing and integration and come out transformed by their traumas.

These are common denominators that I found in my research subjects who thrived again after their tragedies, having transformed their lives.

Source: Pixy/CC0 Public Domain

Holidays can be a particularly challenging time of year, especially for those who are raw from losses and traumatic upheaval. We are often bombarded by family or lack of family, outward cheer that doesn't match our inner felt sense and so many distractions that pull us out of our own inner experience. Take alone time to feel your feelings, journal, take walks, move your energy to let off steam, and avoid excesses like sugar, alcohol, or recreational drugs that do not ground you. The main point: This is the time for doubling down on self-care. Stay in touch with yourself and lead with self-compassion.

References

1. Dias, B. G. and Ressler, K. J. (March, 2014). "Parental olfactory experience influences behavior and neural structure in subsequent generations." Nature Neuroscience 17:89-96

2. Nada Borghol, Moshe Szyf, et al., "Associations with Early-Life Socio-Economic Position in Adult DNA Methylation," International Journal of Epidemiology 41, no. 1 (February 2012): 62-74

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Seven Principles for Recovering from Trauma

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Today, we speak with Rabbi Dr. Tirzah Firestone for another information-packed discussion. Inherited Wounds: Tirzah Firestone on Ancestral Healing Recognizing and Healing Inherited Trauma " for earlier posts). Firestone is a Jungian analyst, rabbi, and the daughter of Holocaust survivors, whose research is on recovery from trauma, including the mechanisms of inherited trauma.

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Dr. Sara Byrne - Colby Pearce : Key Reflections in TIP 

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Dr. Sara Byrne - Colby Pearce : Key Reflections in TIP 

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Relias Learning - Creating a Trauma Informed System of Care

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Relias Learning - Creating a Trauma Informed System of Care

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Hazel Larkin, Woman Up! Trauma Recovery Podcast with Sian Carter 

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Hazel Larkin, Woman Up! Trauma Recovery Podcast with Sian Carter 

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11/26/2022 Woman Up! S1 Ep 9 - Dr Jane Mulcahy

This week, I'm joined on Woman Up!, by Dr Jane Mulcahy. Jane is a Research, Policy, Advocacy and Legal Consultant, working in the area of criminal justice, penal policy, and social justice. In addition, she hasaddressed the UN Committee against Torture on human rights issues in prison, the Justice Sub-Committee on Penal Reform on proposed bail reform, at the Fair Trials' Expert Seminar on Pre-trial Detention in London and the Bail and Jail event at Harvard Law. Jane has also delivered several keynote addresses in Ireland and abroad.A podcast host herself, Jane's award-winning production is called "Law and Justice". There is a spin-off of this podcast, available on YouTube. Called "How to talk policy and influence people" Jane and her interviewees address the subjects of attachment; the harmful impact of childhood adversity; embodied trauma and structural inequity; and the importance of cultivating safety and relational health for individual and societal wellbeing.You can contact Jane on Twitter: @janehmul LinkedIn: https://www.linkedin.com/in/jane-mulcahy-45536a8a/ You Tube: https://www.youtube.com/@JaneMulcahy/featured

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Woman Up! S1 Ep 12 - Sian Carter | Woman Up

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Listen to Woman Up! S1 Ep 12 - Sian Carter from Woman Up. Sian Carter is a qualified and accredited coach with over 20 years' experience in HR, personal development and coaching.Having experienced menopause at an early age, Sian set out to help as many women as possible through menopause coaching and mentoring.

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Dr.Aimie Apigian - 3 Ways to Know if Your Body is Stuck in a Trauma Response 

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Dr.Aimie Apigian - 3 Ways to Know if Your Body is Stuck in a Trauma Response 

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The 3 Ways to Know Your Body is Stuck in a Trauma Response

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Relias Learning Webinar - Implementing Trauma Informed Care Systems 

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Relias Learning Webinar - Implementing Trauma Informed Care Systems 

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A deep dive into information about the principles of a trauma-informed care approach and what a trauma-informed care organization looks like.

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Understanding of adverse childhood experiences has grown in recent years. We now know more about how external circumstances cause psychological trauma in some c

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Sally Hog, CEO of Parent-Infant Foundation- Understanding Early Trauma: The case for supporting parent-infant relationships

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Sally Hog, CEO of Parent-Infant Foundation- Understanding Early Trauma: The case for supporting parent-infant relationships

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Beth Tyson - The Best Trauma Informed Books of 2022

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Beth Tyson - The Best Trauma Informed Books of 2022

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By Beth Tyson, MA Childhood Trauma Expert As my holiday gift to you I am sharing a round-up of my favorite parenting and trauma-informed books of 2022! These books are not necessarily published in 2022, and they are not mentioned in any particular order. I also do NOT receive any compensation for su…

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Beth Tyson - Childhood Trauma Newsletter 2022

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Beth Tyson - Childhood Trauma Newsletter 2022

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The December Childhood Trauma Newsletter - Holiday Trauma Tips, 2022 Book Suggestions, & Free Event

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By Beth Tyson, MA - Childhood Trauma Consultant and Psychotherapist Happy-ish holidays and welcome to the December 2022 issue of the Childhood Trauma Newsletter. The holiday season can be a cocktail of every emotion with more highs and lows than the stock market.

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Jason Wachob, MBG - 3 Tips To Resolve Your Trauma & Prevent Disease, From An MD

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Jason Wachob, MBG - 3 Tips To Resolve Your Trauma & Prevent Disease, From An MD

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In other words: Your past traumas, whether big or small, can impact your well-being in a major way. So if you're serious about preventing disease and enhancing healthspan, you need to focus on healing those psychological wounds. Below, Maté offers three tips to do just that:

1.

"Ninety-five percent of trauma is multigenerational," says Maté. "You unwittingly pass it on." Meaning, your trauma might actually be a byproduct of your parents' (or grandparents') experience that wasn't quite resolved by the time they had you-and that can affect how you interact with the world. Remember, trauma is not about a specific event. "It's the wound that you're carrying," Maté reminds us. That wound usually runs deep.

2.

At the same time, quality relationships are crucial for healing from trauma. "Our biology is dependent on our psychological states, and that depends on our social relationship with others," Maté says. "That's just a scientific fact about human beings."

Most people have trouble saying no, says Maté-which is intriguing, considering "no" is often a baby's very first word. "Nature's agenda is that we should all develop into independent human beings with our own sense of what we want and what we don't want, our own sense of values, our own sense of perspective on the world, our own desires," he shares. "In other words: Nature wants to set a boundary between ourselves and other people's will."

The takeaway.

Your emotional well-being can totally influence your physical health; just take it from Maté: "We can't separate the mind from the body, the individual from the environment," he says. Everyone's road to trauma healing looks a little different, but if you don't mend your deep, psychological wounds, it's nearly impossible to stay well.

So what happens? Well, according to Maté, people receive messages in early childhood that in order to be acceptable, they have to be compliant. "They have to suppress their own will, their own needs, their own perspective, and they have to serve others," he says. As a result, they feel uncomfortable saying no as they grow older.

Now, this is problematic, because if you don't know how to say no, "your yeses don't mean a thing," says Maté. If you begrudgingly say yes to a task, you can also grow resentful, which can have physiological impacts on your body. "Furthermore, you'll be tired afterward because you're already tired to start with," says Maté. "So, not saying no has impacts on you." Consider it your sign to set good, healthy boundaries.

At the risk of sounding like a broken record: Human beings are social creatures; we are averse to loneliness. That's why extreme loneliness is considered a risk factor for mortality 1, says Maté. "When you're lonely, you are likely to get sicker faster and to die quicker of your disease."

Moral of the story? Focus on quality social connections. In fact, you might unconsciously attract people into your life with similar traumas, says Maté. "We always find somebody at the same level of traumatization, which means that in a good relationship, people can grow up together," he notes. You don't want to foster any codependency, but if both of you are open and willing to heal those traumas together, Maté says that's a wonderful opportunity.

Lean on your relationships.

So the question becomes: How do you identify trauma that's not exactly yours? The thing is, it actually starts with looking inward. "The more people understand their own traumas, the more [they] see with clear eyes the traumas of others," says Maté. "The nervous system has a memory in it that is not necessarily conscious, but the wound will still show up in the present moment."

That's why Maté likes to ask folks about the last time they were upset with somebody. "Most of the time people are upset, it's about something else," he says. "It's easy for me to tell about somebody's childhood trauma if they tell me the last time they were really upset with somebody in their lives. Usually, it's about old stuff."

Understand multigenerational trauma.

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This Is How Your Trauma Impacts Your Health & What To Do About It, From An MD

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In other words: Your past traumas, whether big or small, can impact your well-being in a major way. So if you're serious about preventing disease and enhancing healthspan, you need to focus on healing those psychological wounds. Below, Maté offers three tips to do just that: 1.

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Dr.Natalia Rachel - The 6 Pillars of Trauma Informed Awareness 

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Dr.Natalia Rachel - The 6 Pillars of Trauma Informed Awareness 

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To be trauma-informed is to have empathy with more data-points.
It’s also to have a textured undertanding of the experience of a traumatized person or group, AND how our interactions can be a force for healing or harm.
➡️Here are some of the areas we need to be aware of:
📌Perception vs reality
The traumatized self will perceive through the lens of threat and exclusion, and often project past experiences into the present.
📌 The power of relationships
Relationship dynamics are often the cause of trauma. They are also the remedy, if we relate with deeper intelligence.
📌 Triggers and resolution
Triggers are the trauma seeking resolution. Rather than quiet them, we need to create compassioante curious space for their resolution.
📌 Threat vs. Safety
The body is experiencing a sense of threat and finding somatic safety is sometimes the first way to begin healing.
📌 Mind-body Split
The mind and body have often processed very different experiences and may continue to live in ‘alternate realities’. Listening to stories and bringing them back together allows reintegration.
📌 Re-traumtization
The traumatized self may continue to experience retraumatization if the past and the present stay linked.

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Maudesly Hospital-Specialist Trauma Stress Clinic - ACAMH Trauma Guide 

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Maudesly Hospital-Specialist Trauma Stress Clinic - ACAMH Trauma Guide 

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This topic guide has been written by Dr Andrea Danese, Consultant Child & Adolescent Psychiatrist, and Dr Patrick Smith, Consultant Clinical Psychologist. Credit to the National and Specialist Anxiety and Traumatic Stress Clinic, Michael Rutter Centre, Maudsley Hospital.

Prof Andrea Danese is Professor of Child & Adolescent Psychiatry at the Institute of Psychiatry, Psychology and Neuroscience at King's College London. He is also Honorary Consultant Child and Adolescent Psychiatrist at the National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression at the South London & Maudsley NHS Foundation Trust.

The research from his team focuses on childhood trauma, and he has published widely on the consequences of childhood trauma, the biological mechanisms through which childhood trauma affects health, the mechanisms of resilience, the reversibility of biological liability linked to trauma, and treatment of trauma-related psychopathology. Dr Danese is also Consultant Child & Adolescent Psychiatrist of the National & Specialist Child Traumatic Stress & Anxiety Clinic, at the Maudsley Hospital, London, UK. This is a top-tier clinic for children with complex histories of trauma victimisation and treatment resistance. The clinic has also been advising the UK Department of Health on public health strategies and clinical response to emergencies.

Dr Patrick Smith is a Reader in Child Clinical Psychology at the Institute of Psychiatry, Psychology and Neuroscience at King's College London. He is also Honorary Consultant Clinical Psychologist at the National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression at the South London & Maudsley NHS Foundation Trust.

Most children and young people (hereby children) experience at least one traumatic event before age of 18 years. A sizeable minority of children exposed to trauma will develop symptoms including re-living of the trauma, avoidance strategies, and physiological hyper-arousal. When these symptoms persist for more than one month after trauma and are impairing, they indicate a diagnosis of Post-Traumatic Stress Disorder (PTSD). It is important to identify and treat PTSD because many children fail to recover from the symptoms without treatment. Trauma-Focused Cognitive Behavioural Therapy is the treatment with the strongest evidence based in children and is often effective. Eye Movement Desensitisation and Reprocessing (EMDR) can also be helpful. There is no clear evidence to support use of medications for treatment of PTSD in children, but medications may be very helpful to treat other psychiatric problems (e.g., depression, anxiety) that often accompany PTSD.

LIVE STREAM Live Stream

More details

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Trauma: an introduction to symptoms, diagnosis and treatment approaches for trauma in children and young people. From this topic guide, you can find the latest blogs, events, publications, videos and podcasts.

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Dr.Maria Parker - Dealing With The Trauma of Large Scale Payoffs 

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Dr.Maria Parker - Dealing With The Trauma of Large Scale Payoffs 

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In light of the ongoing layoffs within the tech sector, psychotherapist Maria Parker takes a closer look at the trauma workers can face when going through these experiences.

To be human is to be wired for connection and when this connection is abruptly and mercilessly severed, people are deeply impacted on many levels.

Chaos and disruption ignite fear, anxiety and trauma or re-traumatisation, feelings of not being safe or of a separation from future optimism. This is just some of what organisational trauma looks like. Gabor Mate states that: "Trauma is not what happens to you but what happens inside of you as a result of what happened to you."

Being left alone after a traumatic incident with no support or guidance leaves people's nervous systems in disarray with many showing signs of PTSD, anxiety and depression.

Each individual impacted by layoffs is going to create their own story about what happened based on who they are and what their experience of life has been to date. Anyone left behind will have difficult feelings of guilt, shame and shock to deal with.

Each one of us has experienced early life traumas or experiences that shape who we are today and impact how resilient we are, or not. Each person is not an island but a member of a family, a community or relationship, each at varying stages within their lives.

Just as each human is unique, so too are their living stories. Some alone and lonely, others starting out in relationships, others observing the price of the soaring cost of living and others dealing with the desperate grief that comes from the death of a child.

Trauma impacts and infiltrates all aspects of who the person is and this excessive activation of the flight, fight and freeze response within us can lead to long-lasting changes in the body and brain. When we understand the stress response, we can make changes that will support the choices we make going forward and lead to a sense of regaining control where it has been lost.

To do this, you must understand what happens for you when you have been pushed out of your window of tolerance.

Reacting to trauma

This window, when you are in it, means that you can manage what is currently going on in your life. You will experience stress and pressure but it doesn't affect you too much. This is exactly where you want to be in life. Once a hugely stressful or traumatic event occurs in our lives that we aren't prepared for - which they do - we move into one of two places: hyperarousal or hypoarousal.

Hyperarousal is where you feel anxious, overwhelmed or out of control, your body moves into fight or flight and releases adrenaline and cortisol, the two primary stress hormones. This happens automatically within your body in response to the threatening environment around you.

When you are in fight or flight, it is very difficult to gain perspective about what your options are, your true potential is out of reach and it is not possible to be creative about what your next moves are going to be. It is all about survival.

Hypoarousal means you shut down or zone out, your body wants to shut down by blocking out all that is going on around you. You may feel frozen, disassociate and suffer with digestive issues. Being aware of how we react to stress and trauma gives us the ability to make the changes needed to move forward in our lives.

You must first observe what is happening within your body. Once you identify the response you have had to your experience, you can look at ways of healing. You will want to move into what we call the 'parasympathetic nervous system' where you will then be able to navigate the world again with safety and flexibility. You will be able to reconnect with others and have the ability to see your options and possibilities clearly.

If you notice that you have gone into the fight or flight response, you then need to look at ways to become grounded again. Begin with self-compassion, kindness towards you and the situation you are in.

Pause, breathe into that gentle feeling, know you are not alone and this too shall pass. The hormones that have been released during this phase of the stress response will need time to reduce within our bodies.

We can help by becoming conscious of the thoughts we are having and what attention we are paying to them. Are we believing what we are thinking? Is there something more positive I can replace them with? If not, could I just allow the thought to pass and not grasp onto it?

The more energy we give to our negative thoughts, the more activated our systems become. Meditation is an excellent way of focusing the brain and it allows our bodies to begin to relax. If this is too difficult to start with, begin with getting outside in nature for a walk, guiding your mind to just be in the present moment. Remember this will take a little time to work but with conscious focused effort, it will.

If you are in a freeze response, you may feel out of touch with the world, as if everything around you has slowed down. A great breathing technique is four-seven-eight breathing, which will help you to ground yourself within your surroundings again.

In for a count of four, hold for seven and slowly breathe out for the count of eight. This is very supportive for your nervous system. Ensure you are in a place you do feel safe and never be afraid to reach out for support.

By understanding why we react the way we do to traumatic events, it gives us back some of our power to deal with them. Never forget that you will get through this and that with knowledge comes choice.

During the greatest upheavals comes opportunity and some of the greatest learning. If possible, use this time to develop these superpowers within yourself.
Maria Parker is an accredited psychotherapist, mental health nurse and emotional intelligence consultant with 22 years of clinical experience. 10 things you need to know direct to your inbox every weekday. Sign up for the Daily Brief, Silicon Republic's digest of essential sci-tech news.

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Dealing with the trauma of abrupt large-scale layoffs

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In light of the ongoing layoffs within the tech sector, psychotherapist Maria Parker takes a closer look at the trauma workers can face when going through these experiences. To be human is to be wired for connection and when this connection is abruptly and mercilessly severed, people are deeply impacted on many levels.

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NAMI- Lexi Manion : When Trauma is Triggered at Work

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NAMI- Lexi Manion : When Trauma is Triggered at Work

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When Trauma Is Triggered at Work | NAMI: National Alliance on Mental Illness

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We don’t often discuss the experience of managing triggers in the workplace.

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Associate Press, John Leicester - Ukraine Works to Heal Soldiers Mental Scars 

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Associate Press, John Leicester - Ukraine Works to Heal Soldiers Mental Scars 

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KYIV, Ukraine -- Sleep plunges the soldier back into the horrors of Ukraine 's battlefields. He can hear bombs falling again and picture explosions. He imagines himself frantically running, trying to save himself and others. The nightmares are so vivid and frightening that he pleads with his doctor for help. "It will blow my mind," he warns. "So do something."

"Very, very, very stressful," Witalij Miskow, 45, says of the night terrors he's fighting with tranquilizers and therapy at a mental health treatment center for soldiers on the outskirts of Ukraine's capital, Kyiv.

When peace eventually returns to Ukraine, many thousands of other soldiers are likely to come home like Miskow with a condition known as post-traumatic stress disorder, or PTSD. Psychologists, veterans affairs officers and former combatants who have struggled with nightmares, distressing flashbacks and other PTSD symptoms are already working to head off a potential mental health crisis among soldiers and their families from the particularly gruesome, intense and grinding war.

Whether it's increasing awareness and funding for mental health care or training counsellors to help soldiers talk through psychological traumas, the goal is to prevent potentially destructive PTSD-related problems, including suicides, family violence, alcohol and drug abuse, from taking root.

Ex-paratrooper Sgt. Maksym Pasichnyk says civilian life was "very complex" for him after years of fighting pro-Russian forces in eastern Ukraine and once Moscow then launched its full-blown invasion, now in its tenth month. His long exposure to combat, death and destruction left the 28-year-old with an array of PTSD symptoms. He fears many other servicemen and their families could likewise suffer.

"The repercussions come later. You have a din in your ears, you start vomiting, you come home and have constant shifts of blood pressure and you lash out at your family members, your kids, your wife," he says.

"You constantly think that someone is watching you, you overthink, you abuse drugs and drink, you lose yourself," he adds. "If you want to get help, you are interned in a psychiatric hospital, where they turn you into a vegetable. If you show flashes of anger, they give you tranquilizers and you just sit there."

Pasichnyk saw his last combat at the very start of the Feb. 24 invasion. His unit was inserted by helicopter at night to defend an airfield on Kyiv's outskirts. The firefights and ensuing long slog back to the capital butchered his feet. The bleeding, bruising and bone fractures were so severe that he was discharged from further service.

Outwardly, the muscular veteran looks a picture of health. But physical integrity can hide soldiers' inner suffering, Pasichnyk cautions.

"They look fine," he says, "but they're not."

On Nov. 12, Pasichnyk went back to the damaged Hostomel airbase where he fought, a return that again stirred flashbacks of the events he endured there. Setting off from the disemboweled remains of what before the battle had been the world's biggest aircraft, he ran a half-marathon to raise awareness of PTSD and to fund the treatment costs for 10 veterans with symptoms.

Pasichnyk says he worries not only about the risk of traumatized soldiers taking their own lives but also that they could turn guns on others and "might resort to terrorist acts."

Ukraine's Veterans Affairs Ministry spokeswoman Iulia Vorona says statistics on suicides and PTSD among veterans and their families aren't being made public during the war for security reasons.

But speaking five months before the invasion, the veterans affairs minister, Yuliia Laputina, said there had already been "great demand" from military families for psychological support as a result of fighting since 2014 against Moscow-backed separatists in eastern Ukraine.

The minister, who has a Ph.D. in psychology, expressed particular concern that many are going back to "remote villages where there is no psychologist."

"We must build a system where emergency psychological assistance will work in the most remote corners," she said.

In a subsequent interview this month with The Associated Press, one of her deputies, Eugen Kotyk, said the ministry is "actively working" on a suicide and alcohol risk-reduction program.

Based on figures from previous conflicts, around 20% of troops exposed to intense fighting in Ukraine could develop PTSD, estimates British psychiatrist Neil Greenberg, a professor of defense mental health at King's College university in London who previously served as a Royal Navy medical officer for 23 years, including in Iraq and Afghanistan. In the wake of the Russian invasion, he has also done online training for the Ukrainian military on managing traumatic events.

Unlike soldiers who fought in Afghanistan or U.S. troops in the Vietnam war, Ukrainian soldiers are fighting in and for their homeland, with evident public support, a clear enemy and solid goals and justifications. All that could help lessen the mental heath fallout for Ukrainian veterans, says Greenberg, who describes it as "a psychologically good war for Ukraine."

But a victory for Ukraine, returning soldiers being well-treated afterward and reconstruction will also play roles in determining whether psychological illnesses cause "mass, mass casualties" among veterans "or just a large number," Greenberg adds.

Anticipating that many will need help, Ukrainian psychologist Andrii Omelchenko is training volunteers - 300 so far and aiming for a total of 2,000 - to provide counselling to soldiers.

Omelchenko also does hands-on counselling with troops in the field and continues that work online when he is back in Kyiv, talking them through battlefield traumas on video calls from his 17th-floor office. One recent call was with a frontline commander who was suffering from debilitating panic attacks, after he'd seen a missile strike that severely injured three soldiers.

Russia's heavy reliance on artillery bombardments is exacting a psychological toll on Ukrainian solders, Omelchenko says. He says social media are another psychological stress because they show soldiers that while they're in trenches, loved ones and friends may be enjoying comparatively normal lives.

"It's really painful," Omelchenko says. "Civilian life has a lot of good things which are not proper to show."

On the other hand, Omelchenko says he is also fielding calls from families asking how best to deal with soldiers who are coming back changed from battle - taciturn, distant, on edge and in their own worlds. Omelchenko previously experienced that himself with his grandfather, who'd fought as a young teenager in World War II.

"My grandfather never smiled," Omelchenko says.

At the Forest Glade rehabilitation clinic outside Kyiv, Miskow is continuing his recovery. As well as pharmaceuticals, the facility uses yoga, acupuncture, soothing sounds and other therapies on its 220 patients.

"I'm happy, I'm still alive," Miskow says.

Still, he then cries when talking about an artillery strike that killed several of his friends.

"I'm getting used (to) these feelings, but it's still very, very difficult," he says. "If you're not here, you don't understand at all, you won't understand."

---

Follow AP coverage of the war in Ukraine at: https://apnews.com/hub/russia-ukraine

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'Do something:' Ukraine works to heal soldiers' mental scars

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KYIV, Ukraine -- Sleep plunges the soldier back into the horrors of Ukraine 's battlefields. He can hear bombs falling again and picture explosions. He imagines himself frantically running, trying to save himself and others. The nightmares are so vivid and frightening that he pleads with his doctor for help.

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West Midlands Public Health-Certified Online Training Course : ACE’s & Early Years Trauma 

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West Midlands Public Health-Certified Online Training Course : ACE’s & Early Years Trauma 

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An Introduction to ACEs Early Trauma V2.0

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Mental Health Today - “Trauma Card” Project Launched by HealthWise Essex to Support & Empower Trauma Survivors 

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Mental Health Today - “Trauma Card” Project Launched by HealthWise Essex to Support & Empower Trauma Survivors 

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Connection Matters Academy - The Brain, Our Own Personal Body Guard! 

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Connection Matters Academy - The Brain, Our Own Personal Body Guard! 

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Podcasts + InterviewsA Healing Journey Towards Healthy, Empowering Relationships with Dufflyn Lammers