Trauma-Informed Care

How neuroscience influences practice

Amanda Evans, Patricia Coccoma

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317807971
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

This accessible book provides an overview of trauma-informed care and related neuroscience research across populations. The book explains how trauma can alter brain structure, identifies the challenges and commonalities for each population, and provides emergent treatment intervention options to assist those recovering from acute and chronic traumatic events. In addition, readers will find information on the risk factors and self-care suggestions related to compassion fatigue, and a simple rubric is provided as a method to recognize behaviours that may be trauma-related.

Topics covered include:

• children and trauma

• 
  
  

• adult survivors of trauma

• 
  
  

• military veterans and PTSD

• 
  
  

• sexual assault, domestic violence and human trafficking

• 
  
  

• compassion fatigue.

• 
  
  

Trauma-Informed Care draws on the latest findings from the fields of neuroscience and mental health and will prove essential reading for researchers and practitioners. It will also interest clinical social workers and policy makers who work with people recovering from trauma.

Chapter 1

Understanding trauma-informed care

Exposure to trauma may cause long-term distress in men, women, and children. There is little dispute among medical and mental health professionals that trauma and adversity can directly influence physical health and mental well-being. Across the globe, people experience catastrophes, interpersonal violence, war, and human rights violations. However, while social service and mental health professionals openly acknowledge this information, knowledge alone does not necessarily translate well into direct practice. In recent years, there has been global interest in concept of trauma-informed care. This term refers to an attempt to create a paradigm shift that encourages human service providers to approach their clients’ personal, mental, and relational distress with an informed understanding of the impact trauma can have on the entire human experience. Advances in neuroscience research support a trauma-informed approach. While most people who experience traumatic events do not have residual symptoms to the point of qualifying as a disorder, many may experience clusters of symptoms that can interfere with social and occupational functioning. Creating systems with a focus on trauma-informed care calls for factoring “normal” responses to trauma into how providers conduct their daily business (NCTIC, n.d.; Ko, et al., 2008; Harris and Fallot, 2001).

Emerging research on neurobiological changes that can occur within the human brain because of traumatic events has assisted in making the argument for implementing trauma-informed care. According to a wealth of neuroscience research, trauma can cause structural damage within the brain that contribute to adaptive behaviors in the brain’s attempt to maintain safety (Liston, et al., 2009; Juster, et al., 2011). These adaptive processes, over time, become maladaptive and interfere with emotion regulation and attentional behaviors. These are the clients we see in practice. Trauma can contribute to depression (Thienkrua, et al., 2006; Neria, 2010; Rao, et al., 2010), anxiety (Derryberry and Reed, 2002; Goldin, et al., 2009; Graham and Milad, 2011), and personality disturbances (Kobasa, 1979; Linehan, 1993; Haller and Miles, 2004).

In the United States, the National Center for Trauma-Informed Care articulates this paradigm shift as moving from asking, “What is wrong with you?” to one that asks, “What has happened to you?” (NCTIC, n.d.). In order to make this shift, we must:

1 move away from a pathology-based approach toward trauma survivors;

2 begin to recognize physical, relational, and emotional symptoms that may be a result of trauma exposure, but are often overlooked; and

3 implement services that incorporate best-practice methods for working with people who have survived traumatic events.

Understanding advances in neuroscience can assist care providers, mental health professionals, and medical practitioners to understand how trauma affects the human brain and influences behavior. Armed with this knowledge, there is the opportunity to examine past ways of understanding trauma and recovery and move toward new methods of assessment and intervention. New approaches and applications of neuroscience findings should attempt to create a bridge where gaps in recovery have been identified (Vieth, 2009) and should accommodate multicultural and multinational similarities and differences across societies worldwide (Miller, 2007).

The intent of this book is to assist practitioners in the application of knowledge gained from neuroscience related to trauma and to provide strategies and treatment techniques that have demonstrated efficacy for various populations. The authors intentionally designed the format not to be prescriptive regarding intervention methods. We attempted to identify interventions that have evidence of efficacy and appear to be congruent with neuroscience findings. A gap was identified in available research on interventions that may demonstrate portability across cultures. The few that were identified as demonstrating portable cultural application relied heavily on specialist practitioners for implementation (Errebo, et al., 2008; Weiner, et al., 2009). As we will discuss further, research on trauma and trauma interventions comes primarily from developed nations with mental health resources.

While the concept of trauma-informed care is gaining wide appeal in the United States, and other countries in the Western world, application of this approach varies from country to country and is not without its controversies. The reason for this has several dimensions:

1 many countries do not have the resources to assess and treat mental illness;

2 many countries and cultures hold negative stereotypes related to mental disorders; and

3 there is general mistrust regarding diagnostic labels and ascribing pathology to life events (World Health Organization, 2005; Rodin and van Ommeren, 2009).

Stigma and mental health

Globally, people who demonstrate symptoms of any mental dysfunction have experienced social stigma related to mental illness. In an attempt to mitigate this stigma, several countries have implemented national campaigns targeting the public’s attitudes and stereotypes related to mental health with undetermined outcomes. While reliable outcome data on the impact of these campaigns is sparse, according to Vieth (2009) there is evidence that an education initiative introduced in Germany demonstrated some encouraging evidence of a diminished perception by the public that persons with schizophrenia were dangerous.

Stigma may be a contributing factor in the lack of data on mental health in many countries. In determining content for inclusion in this text, a comprehensive review of the literature was performed in order to identify strategies that may be useful not only in countries with extensive resources allocated to mental health, but also in lower-resource countries that may only have the ability to use specialists for the care of the most severely mentally ill. The cultural variances in trauma recovery and related research presented a challenge to the original intent of the authors, which was to create a text that combined knowledge obtained from neuroscience related to trauma across diverse populations and offer appropriate intervention methods obtained from the literature. The challenge of accomplishing this has been significant because the vast majority of the evidence-based literature on trauma recovery and mental health comes from Western countries, particularly the United States, which generally have specialized resources to treat mental disorders. However, research to meet this challenge revealed a larger global story; there is a lack of mental health research from most countries across the world.

Members of the Mental Health Research Mapping Project of the World Health Organization (WHO) and the Global Forum for Health Research conducted a comprehensive review of over 10,000 research articles related to international mental health. Their findings revealed that of the countries considered low-middle-income, 57 percent contributed fewer than five articles to the total mental health literature (Sharan, 2007). This dearth of research does not mean an absence of mental illness. In fact, epidemiology studies conducted by the WHO identified depression/anxiety, substance use disorders, and psychosis as the top three disorders worldwide, specifically as they affect children, adolescents, and women exposed to violence/trauma (Sharan, 2007). Lack of research resources dedicated to mental health may also reflect negative stigma related to mental health found in various resource-poor countries as it related to policy.

In the international arena, there has been considerable debate on the tendency to over-pathologize posttrauma human response (World Health Organization, 2005; Rodin and van Ommeren, 2009). Fear that an overemphasis on trauma may lead to an increased practice of “labeling” people with mental illness has generated some well-deserved debate (Steel, 2009; Rodin and van Ommeren, 2009). The negative stigma related to mental health is prevalent in most countries, but in some to the extent that survivors fear being ostracized from their societies if they seek mental health treatment. Within the context of human rights, literature related to mental health and human rights violations has become more prolific since the establishment of diagnostic criteria for PTSD. While the concern regarding cultural applications of this criterion is valid, many researchers argue that the ability to use these criterion can play an important role in raising awareness regarding the extent and the impact of human rights violations (Steel, 2009).

Negative stigma related to mental illness also translates into policy. Findings from research prepared by the World Health Organization reveal that 37 percent of the countries in the world do not have a mental health policy. Low-and-middle-income countries (LMICs) spend less than 1 percent of their health budgets, which are limited, on mental health (World Health Organization, 2001). The lack of policy focus and funding for mental health results in research findings that are skewed toward interventions embraced by resource-rich countries. Therefore, most evidence-based interventions will largely be validated in countries with the resources to utilize mental health specialist to implement them. Given the global nature of trauma, reliance on mental health specialists alone to assist in trauma recovery is intrinsically flawed. However, the absence of research and methods that offer alternatives to this specialized approach to recovery creates challenges for change.

The call for a trauma-informed approach arises largely from an emerging acceptance that we, as providers of care, may be missing some fundamental issues that hinder a client’s ability to integrate the trauma experience into their life and return to a reasonable sense of “normal.” Many of these issues relate to safety. Additionally, after trauma, people try to cope. Sometimes, their methods of coping become destructive, such as abusing substances. According to Harris (2001), agencies that provide services for the homeless have long been aware of that many of their clients have significant trauma histories. However, these services are not focused on trauma, so past trauma is rarely addressed. A study by Christensen, et al. (2005) examined data collected from homeless individuals with co-occurring disorders over a one-year period. Their findings indicated that 79.5 percent of the clients evaluated had a history of physical or sexual abuse at some point in their lifetime. Within that same sample, all of the homeless women had a trauma history. At face value, it appears absurd to ignore a major life event that nearly 80 percent of a total population served experienced. However, many providers offer services that do not appear to relate to trauma, or perhaps even mental health. While they may know that their clients share this history, they are at a loss as to how to change their approach to services (Harris and Fallot, 2001). Even within the field of mental health, many providers have no training on trauma. Future innovative treatment strategies must assimilate what we know about biochemistry, social contexts, and environmental factors in order for mental health practitioners to move into the twenty-first century and successfully help trauma survivors (Miller, 2007).

The tendency to ascribe pathology to posttrauma responses is well documented and predominantly a Western society phenomenon (Micale, 2001). The Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association (APA) is widely used, even outside of the United States, as a method of standardizing clusters of symptoms that are severe enough to cause interference with social and occupational functioning (American Psychiatric Association, 2000). The term posttraumatic stress disorder (PTSD) was first recognized in the DSM in 1980 and was largely a result of advocacy work done on behalf of Vietnam veterans who were experiencing significant post-war mental distress and not receiving services (Micale, 2001). Since that time, the concept of PTSD has expanded beyond combat veterans and is often applied, perhaps overly, across populations.

However, trauma impacts survivors in more ways than the cluster of symptoms found in PTSD. There is some global concern related to the perception that there is a growing propensity to over-label persons with PTSD. Even within countries, such as the United States, that generally accepts the concept of PTSD, there is concern that the criteria are too narrow and ignore a variety of other issues that are also directly related to traumatic experiences (van der Kolk, 2002; Herman, 1992). Early childhood trauma can adversely impact the ability to develop relational trust that can be lifelong. Substance abuse, depression, anxiety disorders, and somatic illness can also be attributed to traumatic events (van der Kolk, 2002; van der Kolk, et al., 2005). These symptoms cluster under the title of Complex Trauma or Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Herman (1992) has been a proponent for a broader understanding of survivors of chronic trauma for over three decades. In a comprehensive review of 50 years of research, Herman observed that survivors of prolonged trauma report symptoms that require an expanded perspective that goes beyond the diagnostic criteria of PTSD. According to Herman’s research, survivors of prolonged trauma have higher rates of dissociation, anxiety disorders, suicidality, somatic complaints, and personality changes. Further research on the cumulative nature of prolonged exposure to trauma reveals that both adults and children demonstrate more complex symptoms of trauma (Cloitre, et al., 2009). These symptoms are evidenced in addition to the classic symptoms of PTSD, which include: hypervigilance, avoidance behaviors, recurrent and intrusive thoughts or images about the event, recurrent distressing dreams about the event, intense distress when exposed to internal or external cues that symbolize the event (American Psychiatric Association, 2000). While recognizing the severity of disruption symptoms of PTSD inflict on trauma survivors’ lives, these criteria may be too narrow to understand the full implications of the impact of traumatic event (van der Kolk, et al., 2005). Improved understanding of how the brain responds to trauma enhances our ability to recognize the function of both adaptive and maladaptive behaviors, thoughts, and feelings. When the utility of these behaviors, thoughts, and feelings are understood and normalized by the survivor and practitioner, realistic tasks, interventions, and goals can be established. What makes trauma-informed care appealing is that it moves from an individual pathology perspective to a more holistic assessment of the impact of a trauma on all aspects of a trauma survivor’s life (Capezza and Najavits, 2012). An in-depth discussion of this complexity is provided in Chapter 4 of this text.

Trauma-related illness

Over the past two decades, much has been written about the trauma and other co-occurring psychological symptoms. While the relationship of trauma to issues such as homelessness, mental illness, and substance abuse is well recognized, providers of services often treat them as distinct and separate issues. In the United States, the governmental agency, Substance Abuse and Mental Health Services Administration (SAMHSA) established a National Center for Trauma-Informed Care (NCTIC). According to their website, the NCTIC seeks to promote the adoption of trauma-informed care in a variety of settings including mental health, housing, domestic violence shelters, peer support groups, and victim assistance programs. The NCTIC encourage programs to recognize the following:

• a trauma survivor’s need for respect, to be informed and hopeful during their recovery;

• the connection between trauma and symptoms of trauma (e.g., depression, anxiety, and substance-related disorders); and

• the need to work directly with survivors and their friends and family, and other provider organizations in a way that will lead to empowerment of survivors (NCTIC, n.d.).

The physical impact of stress is as detrimental to well-being as the emotional symptoms of stress. A review of the research done on stress over the past two decades reveals the need to approach the concept of stress-related illnesses from a broader interdisciplinary framework (Juster, et al., 2011). Chronic stress, or threat, that activates the fear circuitry within the brain can disturb the immune system’s ability to fight illness bec...