Pulling it all together: Trauma-Informed Care
Posted On April 17, 2019
This month we have spent time exploring the basics of becoming trauma-informed. We’ve examined how mindfulness, neuroplasticity, and resiliency help form the tripod on which we begin to understand and defeat the consequences of surviving trauma.
In this article, we are going to explore together how all the writings we’ve published this month fit into the trauma-informed care model. We also shall look at how finding a therapist who is trauma-informed can enhance your healing.
A Brief Recap of Mindfulness, Neuroplasticity, and Resiliency
Mindfulness is the practice of remaining in the “now” and allowing yourself to feel emotions without judging them. Mindfulness also involves paying attention to your surroundings and enjoying the sensation of being safe and happy.
Although some compare mindfulness to meditation, it isn’t quite the same. While meditation is often used to practice mindfulness, it isn’t necessary to sit in the lotus position to do be mindful. Instead, mindfulness comes when we walk in the woods or on the beach, or by merely retreating into our homes to think about that for which we are grateful.
Neuroplasticity is the ability of the human brain to make new pathways and memories based on new knowledge. Children are born equipped with billions of brains cells (neurons). Neuroplasticity allows them to make new connections (synapses) based on what they need via learning information from caregivers and their environment. At different stages in their brain development prune away any links between the brain cells (synapses) that they are using.
Because of neuroplasticity, even adults who have pruned away billions of synapses are also capable of making new ones through mindfulness and other types of learning activities.
A Brief Recap of the Adverse Childhood Experiences Study
I realize we have covered the ACEs study in depth in other pieces, but a reminder of this groundbreaking study is essential. Knowing the difference changes the way mental health professionals see adverse childhood experiences.
In the years 1995-1997, a new study was conducted by the Kaiser Permanente, an American organization in conjunction with the Centers for Disease Control (CDC).
The study came on the heels of Permanente’s obesity clinic experiencing a 50% drop out rate but was successful at losing weight in their program. Vincente Felitti, the head of Permanente’s Department of Preventative Medicine, conducted interviews with those who had left the program trying to ascertain the cause of the drop-out rate. Felitti conducted face-to-face interviews with 286 people and found a majority he spoke with had experienced childhood sexual abuse.
So, in 1995, Felitti and Robert Anda from the CDC surveyed 17,000 volunteers and their findings both alarmed and changed the treatment of adverse childhood experiences.
Felitti and Anda asked the 17,337 participants, half of which were female, about their experiences with:
- Physical abuse
• Sexual abuse
• Emotional abuse
• Physical neglect
• Emotional neglect
• Exposure to domestic violence
• Household substance abuse issues
• Household mental health issues
• Parental separation or divorce
• An incarcerated household member
The findings of the two-year study were astonishing.
According to the United States Substance Abuse and Mental Health Association (SAMSHA), the ACEs study found the following:
- Adverse childhood experiences are universal. For example, 28% of study participants reported physical abuse and 21% said sexual abuse. Many also reported experiencing a divorce or parental separation or having a parent with a mental and substance use disorder.
- Childhood experiences often occur together. Almost 40% of the original sample reported two or more ACEs and 12.5% experienced four or more. Because ACEs occur in clusters, many subsequent studies have examined the cumulative effects of ACEs rather than the individual effects of each.
- Adverse childhood experiences have a dose-response relationship with many health problems.
- As researchers followed participants over time, they discovered that a person’s cumulative ACEs score has a strong, graded relationship to numerous health, social, and behavioral problems throughout their lifespan, including substance use disorders. Furthermore, many issues related to ACEs tend to be comorbid, or co-occurring.
Further, approximately two-thirds of the subjects of the study experienced at least one adverse childhood experience, 87% reported experiencing additional ACEs.
Compared to an adverse childhood score of zero, having four ACEs created a 700% greater incidence of alcoholism, doubled the risk of having cancer, and increased one’s developing emphysema by 400%. An ACEs score above six created a 3000% increase in attempts to die by suicide.
The people who volunteered for the ACEs study done by Felitti and Anda were followed and are still being monitored to determine how they fared after the original research.
The researchers found that within a decade 1,539 of participants of the original ACEs study had died. They also found that the rest of the subjects with an ACE score of six or higher, when compared to a control group, had a risk of death 1.5 times greater than the control group had had zero ACEs.
On average, the people from the original ACEs study had lost twenty years from their lives, dying at around 61 years, much less than the average age of death for the control group of 79 years.
The Importance of Building Resilience
We investigated together in the last article of this series the importance of building resilience. If you remember, we found that resiliency isn’t something humans are born with but rather something we learn from our experiences with our caregivers in childhood.
Deprived of the teaching of resiliency in childhood, we grow up to be adults who are confused and overwhelmed by the events we encounter in our lives.
Developing resilience would seem to some to be an easy goal to achieve, however, that is not the case. One does not establish a resilient lifestyle by accident. It takes hard work and determination to overcome the trap of feeling such self-pity for oneself that we become stuck in the quagmire of our traumatic history.
In 1889, a French psychologist, philosopher, and psychotherapist who worked in the areas of dissociation and traumatic memory. In the book
The book, The Psychology of Pierre Janet, written by Elton Mayo in 1952, Janet is said to have discovered that complex trauma is not reconcilable in the psychic apparatus of children, and this lack of ability to integrate the traumatic experience is believed to be the basis of psychiatric disorders in adults.
Janet was saying that because children were not capable of understanding or reconciling what was happening to them during traumatic events. This lack of perception meant they could not place the trauma they were surviving into context in their mental picture of themselves.
These children became faced with the decision of accepting that the very people who were supposed to care and nurture them were harming them or pushing it away and not acknowledging what was happening.
The result of this irreconcilable conundrum sets children up for a lifetime of dissociation, mental health problems, and ill physical health.
For children to acknowledge the people they love are dangerous is akin to emotional suicide.
As children, we faced with histories of events that, because of their traumatic and painful nature, we kept secret. This secrecy was to become the basis for the inability to cope later in life.
The Power of Trauma-Informed Care
Have you ever wondered why therapy could be such a powerful force for healing? What in psychotherapy, where we engage with another human being, aids us in healing from traumatic childhoods full of adverse childhood experiences?
There are many answers to that question, but one of the most important and influential aspects of therapy is telling the story we were forbidden to tell. In telling our secrets, we remove the power from those who harmed us and put back where it belongs, to the survivor.
A therapist who is trauma-informed understands the power of breaking the silence and telling secrets. However, they face a hard task in that they must be cautious so that their care isn’t harmful, but helpful.
We touched on the tenants of trauma-informed care briefly in the first article of this series. However, the factors that come into play when working with a trauma-informed therapist are essential to understanding clients with CPTSD.
According to SAMHSA, there are four principles that a trauma-informed therapist should follow that outline the trauma-informed approach:
Realizes the widespread impact of trauma and understands potential paths for recovery;
Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
Seeks to resist re-traumatization actively.
The trauma-informed approach to help aids therapists form the right treatment the individuals who seek their help.
All the principles are to guide the trauma-informed therapist in finding the right treatment plan to help a client who comes to them with complex trauma.
The Six Key Principles of Trauma-Informed Care
Trauma-informed care involves the delivery of help to a traumatized client through an increased understanding of the impact of complex trauma on an individual’s life.
Since therapists cannot tell at first glance who is living with the effects of complex trauma and who isn’t, these six key principals should apply to everyone who comes into their office.
It is only by following the six key principals that a therapist can avoid re-traumatizing their new client.
The six key principles of trauma-informed care are as follows:
Trustworthiness and Transparency
Collaboration and mutuality
Empowerment, voice, and choice
Cultural, Historical, and Gender Issues
SAMHSA offers a beautiful explanation for each principle:
Safety – The Therapist makes sure their client feels physically and psychologically safe.
Trustworthiness and transparency – The therapist ensure all decisions are conducted with transparency and the goal of building and maintaining trust between the client and their family members if any are involved.
Peer support and mutual self-help – These are integral to the healing of the client and is understood as a critical vehicle for building trust, establishing safety, and empowerment. The therapist will attempt to help their traumatized client seek either group therapy inside the clinical setting or outside such 12-step groups.
Collaboration and mutuality – There are true partnering and leveling of power differences between therapist-client. There is recognition that healing happens in relationships and the meaningful sharing of power and decision-making.
The therapist recognizes that everyone has a role to play in a trauma-informed approach.
Empowerment, voice, and choice – Throughout treatment, individuals’ strengths are recognized, built on, and validated and new skills developed as necessary.
The therapist aims to strengthen the clients’, and family members’ experience of choice and recognize that every person’s experience is unique and requires an individualized approach.
This approach includes a belief in resilience and in the ability of individuals and communities to heal and promote recovery from trauma.
This approach builds on what clients have to offer, rather than responding to perceived deficits.
Safety. Major developmental theorists such as Abra- ham Maslow, Erik Erikson, and John Bowlby saw security as a core developmental need of infants. Maslow numbered it among the primary survival needs while Erikson understood that the first “psychosocial” crisis for any infant is the establishment of trust (based on a sense of being safe).
Cultural, historical, and gender issues – The trauma-informed therapist actively moves past cultural stereotypes and biases (e.g., based on race, ethnicity, sexual orientation, age, geography), offers gender-responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma.
Trauma-Informed Care Isn’t Only the Therapists Responsibility
From the moment you walk into your therapist’s office for the first time until you leave them altogether, you accountable for how well you respond to their help.
Healing from complex trauma is NOT your therapist’s responsibility, it is yours.
Granted, if the therapist you are seeing isn’t well-trained, acts in an inappropriate manner isn’t a good match, or is incapable of helping you then find another therapist that CAN help you.
There again, it is up to you to do what is right for you, NOT the therapist.
It is essential to do your part in your healing work by informing yourself of your diagnosis and remaining hopeful in the process of your recovery.
It is vital for you to tell your therapist about trauma symptoms that often accompany complex trauma, such as substance abuse, eating disorders, depression, anxiety, and suicidal thoughts. Your therapist cannot help you heal if you are not honest with them.
There is no sense sugar coating it, healing from complex trauma is a painful process. You will need a therapist who is trauma-informed and willing to stay with you while you grieve the childhood you never had and face the memories and reality that as your life.
However, a trauma-informed therapist needs to let the survivor know they are respected and remain as transparent as possible within the limits of the therapeutic environment.
The trauma-informed therapist needs to believe in your recovery and understand that the expectation for all their clients who are survivors of trauma is healing.
The therapist needs to remain hopeful and believe in their client’s healing even if the client does not see it.