Trauma and resilience
Transcript Of Trauma and resilience
OCTOBER 2014
SNAPSHOT
Trauma and Resilience
How can we promote resilience and recovery for people who have experienced traumatic events?
“The experience of trauma is simply not the rare exception we once considered it. It is part and parcel of our social reality.” – Fallot and Harris, 2009.
Over the last few decades, there has been a growing awareness of how traumatic experiences can significantly affect our health and well-being. This awareness, coupled with research showing that trauma is relatively pervasive, has led to an increased focus on providing children, adults, and families with services and supports that are specifically designed to be comfortable, accessible, and effective for people who have experienced trauma. Within fields such as mental health and child welfare, it has become increasingly common to hear about “trauma-specific” or “trauma-informed” approaches, and much has been written about how to infuse principles of trauma-informed care within settings such as criminal justice, child welfare, and schools.
This snapshot is intended for people who are working with children, adults, and families in other settings, such as churches or other faith communities, child care programs, support groups, shelters, or other community social services. People who have experienced trauma may be served in any of these settings. They may also be people that you see every day in the community – friends, neighbors, colleagues, or family members. This brief provides a basic overview of trauma and its impact, principles of trauma-informed care or support, and effective approaches to promote recovery. It also includes some specific recommendations to consider as initial steps in providing support to people who have experienced trauma.
Wilder Research
Information. Insight. Impact.
In partnership with
What do we mean by trauma and how prevalent is it?
A traumatic experience can be any extremely stressful event that taxes our ability to cope, resulting in fear, horror, or helplessness. People may find a wide variety of experiences to be traumatic, such as natural disasters, accidents, serious illnesses, fires, or war-related violence. Violent crime, bullying, domestic violence, sexual violence, child abuse, or neglect can also be traumatizing. Traumatic events can occur at any point in a person’s life. They may involve a single event, or repeated exposure over many years.
We know that trauma rates are high. National community-based surveys find that 50 to 90 percent of adults have experienced at least one traumatic event, with some studies finding an average of nearly five traumatic events occurring in their lifetimes. However, it is difficult to arrive at a consistent estimate of trauma exposure. Variability in research methods, definitions of trauma, and study populations make it difficult to state exactly how prevalent trauma is. Some studies have explored the prevalence of trauma within specific service settings, finding a high representation of people with a history of trauma. For example, some studies have estimated that at least 90 percent of people receiving mental health services have a trauma history. Prevalence rates have also been found to be high in areas such as juvenile justice, child welfare, homeless shelters, and substance use treatment programs.
How are people impacted by trauma?
Trauma can have significant and widespread impacts. How someone is affected by a traumatic experience can vary tremendously, based on factors such as the person’s age, the type of event experienced, the social support they have available, and their coping strategies. Symptoms or impacts may appear immediately following a traumatic event, or may emerge over time. In some, but certainly not all cases, serious mental health outcomes such as Post-Traumatic Stress Disorder (PTSD) can emerge.
While there is broad variability, research has found that trauma can have a negative impact on:
Sense of safety Emotional self-regulation (i.e., ability to
understand emotional experiences and adjust or manage emotions) Academic problems Self-concept Perception of control Long-term physical health issues
Cognitive skills, such as problem solving, concentration, or abstract reasoning
Emotional distress, such as depression or anxiety
Interpersonal relationships and social skills Aggression, hostility, and risk-taking Agitation or irritability Withdrawal
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While traumatic events can occur at any age, those that occur during childhood can be especially important, with the potential for more significant and longer-lasting impacts. Children’s short-term coping challenges can become more persistent, compromising long-term development. Some children may experience “complex trauma,” which typically refers to repeated traumatic events that occur within the child’s social environment or caregiving relationships, especially child abuse and neglect. The impact of complex trauma can be especially problematic. Some children face challenges in forming relationships, including positive attachments to others. A lack of secure relationships, chronic feelings of not being safe, feelings of helplessness and hopelessness, excessive feelings of stress, and developmental disruptions can combine to create significant challenges for youth that can persist over time.
Repeated exposure to traumatic events can also affect brain development for children. Their brains may be smaller. Development of brain circuits is also impacted, affecting cognitive processing and hormone production. They can also over-develop the parts of their brain that control fear or stress, making these parts of the brain more likely to engage, overwhelming parts of the brain that may promote feelings of calmness or concentration.
Strategies for coping with trauma may contribute to the challenges. Trauma experiences often overwhelm the person’s coping resources. This can lead the person to find coping strategies that may work in the short run, but may cause serious harm in the long run. For example, following a trauma, individuals are at higher risk for behaviors such as substance use, eating disorders, violence, or sexual promiscuity. These strategies may feel adaptive in the short-run, by allowing the person to feel calm or to forget the traumatic event. However, ultimately these strategies do not resolve the underlying reactions to trauma, and can lead to their own negative health and economic outcomes.
Culture can play a powerful role, in exposure and interpretation of traumatic events, traumarelated symptoms, and intervention approaches. Cultural, historical, and intergenerational trauma are all important contributors to health and well-being. Trauma-related symptoms may vary across different cultural communities. Strategies for providing effective services can also vary based on cultural values.
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Study finds adverse childhood experiences relate to risky adult health behaviors
One study that has received a lot of attention is the Adverse Childhood Experiences (ACE) study. The ACE study was conducted as a partnership between the Centers for Disease Control and Prevention (CDC) and a community health clinic in San Diego. Observing some common linkages between negative childhood experiences and health concerns, Drs. Robert Anda and Vincent Felitti conducted a larger study to explore the influence of stressful and traumatic childhood experiences. More than 17,000 adults (primarily white and middle class) were surveyed about their childhood experiences, health-related behaviors, and health-related status. Adverse childhood experiences included emotional, physical, or sexual abuse; emotional or physical neglect; parental separation or divorce; incarceration of a family member; having a mother who was treated violently; and growing up in a household where someone abused substances or had a mental illness.
The study yielded a number of important findings. A high percentage of adults (approximately two-thirds) reported at least one adverse childhood experience. Often, adverse childhood experiences went together. One in five study participants reported three or more. Given one ACE, there was an 80 percent chance of having exposure to another.
The researchers calculated an ACE score for each participant, based on the number of different categories of adverse experiences reported. The frequency and severity of adverse experiences are not accounted for in the ACE score, just the number of different types of experiences. The researchers found that the impact of ACEs is cumulative. As ACE scores increased, so did the likelihood that participants were engaging (or had engaged) in a variety of risky health behaviors. For example, compared to persons with an ACE score of 0, those with a score of 4 or more were twice as likely to be smokers, 12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs.
The findings suggest that high-risk behaviors may be used, in part, to alleviate emotional or social distress that results from ACEs, increasing risk for leading causes of death and contributing to earlier mortality rates. The short- and long-term outcomes of ACE include a multitude of health and behavioral
problems. As the number of ACEs a person experiences goes up, the risk for the following health outcomes also increases:
• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease
• Depression • Fetal death • Illicit drug use • Ischemic heart disease • Liver disease
• Risk for intimate partner violence
• Multiple sexual partners • Sexually transmitted
diseases • Smoking • Suicide attempts • Unintended pregnancies
The true nature of preventative medicine
This graphic illustrates the possible connections between Adverse Childhood Experiences and longer-term health outcomes. Experiencing ACEs can directly lead to a variety of social, emotional, and cognitive outcomes, as described above. These outcomes can contribute to individuals adopting maladaptive coping strategies and high-risk health behaviors, leading to higher rates of disease, disability, and eventually early death.
In 2008, the CDC developed a set of ACE questions to include in the Behavioral Risk Factor Surveillance System (BFRSS), a survey used by states to determine residents’ health status based on behavioral risk factors. In 2011, Minnesota became the 18th state to add the ACE questions to the BRFSS survey. The Minnesota results are similar to those obtained in the initial study and replications conducted in other states. Over half of Minnesotans have experienced at least one ACE. The five most common ACEs reported by Minnesotans were verbal abuse (28%), living with a problem drinker (24%), separation or divorce of a parent (21%), mental illness in the household (17%), and physical abuse (16%). For those Minnesotans with at least one ACE, 60 percent have two or more ACEs and 15 percent have five or more ACEs. Increases in the number of ACEs were associated with increased issues such as alcohol and substance abuse, depression, anxiety, and smoking.
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What helps promote resilience?
While trauma can have a powerful influence, it is important to note that it does not affect all people the same way. Some people who experience trauma develop significant and long-lasting problems, while others (who may have experienced similar traumatic events) may have minimal symptoms or recover more quickly. The term “resilience” is generally used to describe the capacity of people to successfully adapt and recover, even in the face of highly stressful and traumatic experiences.
Resilience can be enhanced by strengthening a variety of protective factors. A number of personal characteristics can promote resilience, such as having a positive temperament, sociability, optimism, and an internal locus of control. Some of these characteristics represent personality characteristics that can be difficult to change. However, much can be done to promote resilience. Research has found that resilience can be optimized by strengthening three levels of protective factors:
Individual (i.e., cognitive ability, self-efficacy, self-regulation, coping strategies, spirituality)
Family (supportive parent-child interaction, social support)
Community characteristics (positive school experiences, community resources)
Protective factors that promote resilience can also vary culturally. Much of the existing research on resilience was conducted with white university students, and the results may not generalize to other populations. Very few studies have been conducted with persons of color, people with disabilities, and other populations. We need to learn more about culturally-based aspects of resilience. For instance, existing models of resilience may place too much emphasis on individualistic aspects of coping, while more collectivist characteristics may be more relevant in other cultural communities.
What helps people recover from trauma?
Despite broad impacts of trauma, people can and do recover. Without intervention, traumarelated symptoms may persist over time. However, numerous studies have found that interventions and support can help people to recover from traumatic experiences. As noted above, in some cases, exposure to traumatic events can affect children’s brain development. With the right kinds of intervention, even this damage may not be permanent. The brain is also capable of repair and recovery, a principle referred to as neuroplasticity.
A number of service models have been designed specifically for people who have experienced trauma. Within a variety of helping professions, efforts are underway to develop, offer, and test interventions specifically designed for people who have experienced trauma. Many of these interventions are offered in mental health settings. Some of the most common and well-established
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trauma-specific services are Eye Movement Desensitization and Reprocessing (EMDR), TraumaFocused Cognitive Behavioral Therapy (TF-CBT), Child Parent Psychotherapy (CPP), AbuseFocused Cognitive Behavioral Therapy (AF-CBT), Parent Child Interaction Therapy (PCIT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), and Child and Family Traumatic Stress Intervention (CFTSI).
While the specific approaches used in these interventions vary, most share goals associated with re-establishing a sense of safety, managing emotions, understanding the traumatic experience, and developing coping strategies. A variety of research studies show that these trauma-specific models have better outcomes than “treatment as usual,” including reduced psychiatric or trauma symptoms, reduced substance use, improved daily functioning, and increased strengths such as self-identity, healthy relationships, and safety.
“A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings.” – Gillece, 2012
Some service settings are increasingly moving towards “trauma-informed” approaches. There are a number of different definitions of what it means to be “trauma-informed,” but at the basic level, this means offering services or supports in a way that addresses the special needs of people who have experienced trauma. To be trauma-informed, all components of an agency incorporate a thorough understanding of the prevalence and impact of trauma and the various ways in which people recover and heal from trauma.
While there is not one standard definition, the following principles are typically emphasized in trauma-informed approaches:
Trauma awareness – services and organizational practices reflect an understanding of trauma, including how various behaviors may represent adaptations to traumatic experiences
Safety – Approaches and service settings are designed to promote both physical and emotional safety of participants and program staff
Opportunities to rebuild control – Services emphasize the importance of choice for consumers and create environments that promote personal control
A focus on strengths – Approaches are designed to support people in identifying and using their own strengths and skills, rather than focusing on deficits
Collaboration – There is true partnership and collaborative decision making between staff and consumers and among organizational staff
Trustworthiness and transparency – Organizational operations and decisions are conducted openly, with a goal of promoting trust among staff and consumers
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Cultural competence – Cultural, historical, sexual orientation, and gender issues are actively identified and addressed, and the organization promotes culturally-driven healing practices
Consumer voice and choice – Consumers experience choice and the ability to individualize services to best meet their own needs, while also participating in the development, implementation, and evaluation of services
While research supports the benefits of trauma-specific mental health services, it is important to note that less data are available to validate the importance of trauma-informed care more broadly. While many of the values of trauma-informed care are positive aspirations in their own right, research is just beginning to emerge to document whether service experiences and outcomes improve when organizations more formally adopt trauma-informed frameworks. Some preliminary results – primarily qualitative in nature – suggest that consumers and staff respond well to trauma-informed care and that program staff report more positive outcomes of services.
What about prevention?
Given the potential negative impact of trauma, it is also important to consider strategies for preventing the occurrence of traumatic events, including adverse childhood experiences. There are some challenges in shaping prevention efforts, however. First, while much is known in general about prevention strategies, it is difficult to prioritize efforts to reduce risk of traumatic events. Trauma can come in many forms, and the cumulative impact of multiple exposures can be more significant than any one single risk factor. On the other hand, we do know that some risks, such as childhood sexual abuse, can have disproportionate impacts. We also do not have a good strategy for identifying individuals at risk, and directing responses based on exposure and effects of exposure.
PREVENTION EFFORT GOALS
• support the quality or quantity of relationships
• increase safety • promote social-emotional competence • promote mastery • increase the capacity of systems to
support these goals
When considering prevention, it can be useful to take a public health approach. Public health models emphasize positive health promotion, along with risk reduction and intervention. Prevention efforts should take place in various settings and using various approaches. Public health models supplement indicated interventions (strategies for promoting well-being and reducing challenges in individuals with high risks and/or symptoms) with selective interventions (interventions to address known risk factors in participants at potential risk of issues) and universal actions (address health promotion and risk mitigation in the entire population regardless of individual/group risk). No single system or community group can be responsible for trauma or ACE prevention. Selective and universal prevention efforts in particular need to be offered in settings where the general population is most likely to be.
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Prevention efforts can focus on a number of different goals, such as supporting the quality and quantity of relationships, increasing safety, promoting social-emotional competence (affect regulation and expression, empathy, self-regulation), promoting mastery, and increasing the capacity of systems (neighborhoods, schools, workplace, and social groups) to support these goals. Cost-benefit analyses have demonstrated a stronger return on investments that result from strengthening families, supporting development, and preventing maltreatment during childhood and adolescence rather than funding treatment programs later in life.
What can we all do to support people who have experienced trauma and promote resilience?
The following recommendations are designed to provide a starting point in offering supports to individuals who have experienced trauma.
Increase your understanding of trauma and its impact. Many resources exist regarding trauma and strategies for providing trauma-informed care across a wide variety of discipline areas. The first step in responding appropriately to trauma is to learn to recognize common reactions to traumatic experiences and to understand the purpose and function of these reactions. It is also important to gain a deeper understanding of cultural variation in trauma exposure and responses, and to learn strategies for responding appropriately.
Screen for trauma exposure and symptoms. A key first step in providing trauma-informed services is to conduct universal screening related to trauma histories, symptoms, and protective factors. Having a complete set of information regarding trauma can be critical in tailoring services to meet the unique needs of the individual or family. Trauma screenings can be standalone, or embedded into other screening or assessment processes.
Screening can be done in a wide variety of service settings. Many standardized tools and surveys already exist.
TRAUMA TRAINING AND EDUCATION
There are many options for educational opportunities – classes, professional conferences, trainings, and books. You might want to talk to counselors or to others with indepth training in trauma-informed care. Many resources are available online, through sites such as:
ACES Connection (http://acesconnection.com/)
National Center for Trauma-Informed Care (http://www.nasmhpd.org/TA/nctic.aspx)
National Child Traumatic Stress Network (http://www.nctsn.org/)
California Center of Excellence for Trauma Informed Care (http://www.traumainformed-california.org/)
Community Connections (http://www.communityconnectionsdc.org/w eb/page/673/interior.html)
Family and Youth Services Bureau’s National Clearinghouse on Families and Youth: (http://ncfy.acf.hhs.gov/topics/traumainformed-care)
National Council for Behavioral Health (http://www.thenationalcouncil.org/)
International Society for Traumatic Stress Studies (http://www.istss.org/)
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Reach out and offer support to people who have experienced trauma. Whether you are formally involved in providing intervention or support services, or whether you are simply concerned about others in your community, it can be a powerful experience to reach out to people who have experienced trauma. The International Society for Traumatic Stress Studies has created a series of recommendations for offering support. Recommendations include listening without judgment, offering consistent emotional support, providing practical help, and providing company for anxietyprovoking events. It is typically more helpful to listen, and to provide a safe place for trauma survivors to talk about their experiences, rather than trying to problem solve for them or offering advice. It is important to validate their feelings and reactions, and to offer concern and support.
It may be helpful to participate in a training program, such as “mental health first aid.” Mental health first aid is a brief training program designed to give people the skills needed to help someone who is developing a mental health problem or experiencing a mental health crisis.
Learn what trauma-specific services may be available in your community and make referrals. Trauma-specific mental health services may be offered in a variety of settings, such as outpatient mental health clinics, homes, hospitals, schools, and other settings. Since these services are specifically designed for individuals who have experienced trauma, it may be helpful to connect people to programs. Doctors, clergy, local mental health associations, state or county government, insurance companies, and other service providers may be able to provide information about services available in your area. In some cases, it may be helpful or appropriate to help connect people to services, such as making initial contact with providers or offering a ride to services.
In addition to trauma-specific services, help connect people with other sources of support. In addition to formal mental health services, you can help connect people to other formal and informal networks. Depending on the person’s needs, a variety of services might be helpful (such as self-help groups, substance abuse treatment, or domestic violence support). Informal support systems are also important. Encourage people to get additional support from friends, family members, religious institutions, support groups, self-help resources, or others.
SUPPORTING FAMILIES— THE RESEARCH
Research overwhelmingly points to the benefits of supporting children and families at an early age to prevent maltreatment and its negative effects on brain development before they occur. In addition, cost-benefit analyses demonstrate the stronger return on investments that result from strengthening families, supporting development, and preventing maltreatment rather than funding treatment programs later in life.
Promote positive parent-child relationships. Families are an important focus for prevention efforts, intervention, and support. Many adverse childhood experiences have their origin in the parent-child relationships (i.e., abuse and neglect). Conversely, a strong relationship with a caregiver is a powerful buffer, protecting children from the impact of traumatic stress. Some of the most powerful protective factors include strong attachment between parents and children, caregiver knowledge of parenting and child development, parental resilience, social connections, and concrete support for parents.
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A variety of strategies can be used to support families. Some services may involve only the caregivers, while others may involve the parent and child together. Effective parent education programs exist, which can help promote positive parenting and reducing risks for child maltreatment. These programs include the Triple P program (Positive Parenting Program), Strengthening Families, Community Partnerships for Protecting Children, and Strong Communities. Other intervention approaches can also be beneficial, such as home visiting programs or parent-child centers. Informal modeling and mentoring are also important. In both formal service settings and informal relationships, you can help parents create safe environments, understand child development, recognize their child’s cues, and meet their child’s emotional and behavioral needs.
Promote positive youth development. Adolescence is a critical period of development, and provides a variety of opportunities to help individuals recover from traumatic events that they have already experienced, and to promote resilience to help them face potential future events. There is a strong convergence between the research on positive youth development and the research on recovery from trauma. In other words, the characteristics that predict positive life outcomes for youth in general are also characteristics that may protect them from the negative effects of traumatic events.
THE FIVE DOMAINS OF POSITIVE YOUTH DEVELOPMENT
1. Competence 2. Confidence 3. Connection 4. Character 5. Caring
Positive youth development is often defined around five domains: Competence, Confidence, Connection, Character, and Caring. Helping youth develop strong relationships with peers and family, access positive role models, and connect to supportive institutions can all play a powerful role. Across a variety of program efforts, focus on opportunities to help youth develop positive relationships with responsible and caring adults, build social and emotional competence, and develop feelings of mastery and confidence. These characteristics can be promoted through a variety of programs, including mentoring, social-emotional learning programs, and after-school programs.
Adopt trauma-informed principles at your agency. Trauma-informed principles can be adopted across a wide variety of organizations. As an initial step, it can be helpful to conduct an organizational assessment, several of which have been developed. An assessment can help you identify your agency’s current strengths in providing trauma-informed care, and to prioritize action steps (i.e., changing internal policies, modifying the physical environment to promote safety, revising internal policies, providing more opportunities for consumer-driven care, etc.).
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SNAPSHOT
Trauma and Resilience
How can we promote resilience and recovery for people who have experienced traumatic events?
“The experience of trauma is simply not the rare exception we once considered it. It is part and parcel of our social reality.” – Fallot and Harris, 2009.
Over the last few decades, there has been a growing awareness of how traumatic experiences can significantly affect our health and well-being. This awareness, coupled with research showing that trauma is relatively pervasive, has led to an increased focus on providing children, adults, and families with services and supports that are specifically designed to be comfortable, accessible, and effective for people who have experienced trauma. Within fields such as mental health and child welfare, it has become increasingly common to hear about “trauma-specific” or “trauma-informed” approaches, and much has been written about how to infuse principles of trauma-informed care within settings such as criminal justice, child welfare, and schools.
This snapshot is intended for people who are working with children, adults, and families in other settings, such as churches or other faith communities, child care programs, support groups, shelters, or other community social services. People who have experienced trauma may be served in any of these settings. They may also be people that you see every day in the community – friends, neighbors, colleagues, or family members. This brief provides a basic overview of trauma and its impact, principles of trauma-informed care or support, and effective approaches to promote recovery. It also includes some specific recommendations to consider as initial steps in providing support to people who have experienced trauma.
Wilder Research
Information. Insight. Impact.
In partnership with
What do we mean by trauma and how prevalent is it?
A traumatic experience can be any extremely stressful event that taxes our ability to cope, resulting in fear, horror, or helplessness. People may find a wide variety of experiences to be traumatic, such as natural disasters, accidents, serious illnesses, fires, or war-related violence. Violent crime, bullying, domestic violence, sexual violence, child abuse, or neglect can also be traumatizing. Traumatic events can occur at any point in a person’s life. They may involve a single event, or repeated exposure over many years.
We know that trauma rates are high. National community-based surveys find that 50 to 90 percent of adults have experienced at least one traumatic event, with some studies finding an average of nearly five traumatic events occurring in their lifetimes. However, it is difficult to arrive at a consistent estimate of trauma exposure. Variability in research methods, definitions of trauma, and study populations make it difficult to state exactly how prevalent trauma is. Some studies have explored the prevalence of trauma within specific service settings, finding a high representation of people with a history of trauma. For example, some studies have estimated that at least 90 percent of people receiving mental health services have a trauma history. Prevalence rates have also been found to be high in areas such as juvenile justice, child welfare, homeless shelters, and substance use treatment programs.
How are people impacted by trauma?
Trauma can have significant and widespread impacts. How someone is affected by a traumatic experience can vary tremendously, based on factors such as the person’s age, the type of event experienced, the social support they have available, and their coping strategies. Symptoms or impacts may appear immediately following a traumatic event, or may emerge over time. In some, but certainly not all cases, serious mental health outcomes such as Post-Traumatic Stress Disorder (PTSD) can emerge.
While there is broad variability, research has found that trauma can have a negative impact on:
Sense of safety Emotional self-regulation (i.e., ability to
understand emotional experiences and adjust or manage emotions) Academic problems Self-concept Perception of control Long-term physical health issues
Cognitive skills, such as problem solving, concentration, or abstract reasoning
Emotional distress, such as depression or anxiety
Interpersonal relationships and social skills Aggression, hostility, and risk-taking Agitation or irritability Withdrawal
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While traumatic events can occur at any age, those that occur during childhood can be especially important, with the potential for more significant and longer-lasting impacts. Children’s short-term coping challenges can become more persistent, compromising long-term development. Some children may experience “complex trauma,” which typically refers to repeated traumatic events that occur within the child’s social environment or caregiving relationships, especially child abuse and neglect. The impact of complex trauma can be especially problematic. Some children face challenges in forming relationships, including positive attachments to others. A lack of secure relationships, chronic feelings of not being safe, feelings of helplessness and hopelessness, excessive feelings of stress, and developmental disruptions can combine to create significant challenges for youth that can persist over time.
Repeated exposure to traumatic events can also affect brain development for children. Their brains may be smaller. Development of brain circuits is also impacted, affecting cognitive processing and hormone production. They can also over-develop the parts of their brain that control fear or stress, making these parts of the brain more likely to engage, overwhelming parts of the brain that may promote feelings of calmness or concentration.
Strategies for coping with trauma may contribute to the challenges. Trauma experiences often overwhelm the person’s coping resources. This can lead the person to find coping strategies that may work in the short run, but may cause serious harm in the long run. For example, following a trauma, individuals are at higher risk for behaviors such as substance use, eating disorders, violence, or sexual promiscuity. These strategies may feel adaptive in the short-run, by allowing the person to feel calm or to forget the traumatic event. However, ultimately these strategies do not resolve the underlying reactions to trauma, and can lead to their own negative health and economic outcomes.
Culture can play a powerful role, in exposure and interpretation of traumatic events, traumarelated symptoms, and intervention approaches. Cultural, historical, and intergenerational trauma are all important contributors to health and well-being. Trauma-related symptoms may vary across different cultural communities. Strategies for providing effective services can also vary based on cultural values.
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Study finds adverse childhood experiences relate to risky adult health behaviors
One study that has received a lot of attention is the Adverse Childhood Experiences (ACE) study. The ACE study was conducted as a partnership between the Centers for Disease Control and Prevention (CDC) and a community health clinic in San Diego. Observing some common linkages between negative childhood experiences and health concerns, Drs. Robert Anda and Vincent Felitti conducted a larger study to explore the influence of stressful and traumatic childhood experiences. More than 17,000 adults (primarily white and middle class) were surveyed about their childhood experiences, health-related behaviors, and health-related status. Adverse childhood experiences included emotional, physical, or sexual abuse; emotional or physical neglect; parental separation or divorce; incarceration of a family member; having a mother who was treated violently; and growing up in a household where someone abused substances or had a mental illness.
The study yielded a number of important findings. A high percentage of adults (approximately two-thirds) reported at least one adverse childhood experience. Often, adverse childhood experiences went together. One in five study participants reported three or more. Given one ACE, there was an 80 percent chance of having exposure to another.
The researchers calculated an ACE score for each participant, based on the number of different categories of adverse experiences reported. The frequency and severity of adverse experiences are not accounted for in the ACE score, just the number of different types of experiences. The researchers found that the impact of ACEs is cumulative. As ACE scores increased, so did the likelihood that participants were engaging (or had engaged) in a variety of risky health behaviors. For example, compared to persons with an ACE score of 0, those with a score of 4 or more were twice as likely to be smokers, 12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs.
The findings suggest that high-risk behaviors may be used, in part, to alleviate emotional or social distress that results from ACEs, increasing risk for leading causes of death and contributing to earlier mortality rates. The short- and long-term outcomes of ACE include a multitude of health and behavioral
problems. As the number of ACEs a person experiences goes up, the risk for the following health outcomes also increases:
• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease
• Depression • Fetal death • Illicit drug use • Ischemic heart disease • Liver disease
• Risk for intimate partner violence
• Multiple sexual partners • Sexually transmitted
diseases • Smoking • Suicide attempts • Unintended pregnancies
The true nature of preventative medicine
This graphic illustrates the possible connections between Adverse Childhood Experiences and longer-term health outcomes. Experiencing ACEs can directly lead to a variety of social, emotional, and cognitive outcomes, as described above. These outcomes can contribute to individuals adopting maladaptive coping strategies and high-risk health behaviors, leading to higher rates of disease, disability, and eventually early death.
In 2008, the CDC developed a set of ACE questions to include in the Behavioral Risk Factor Surveillance System (BFRSS), a survey used by states to determine residents’ health status based on behavioral risk factors. In 2011, Minnesota became the 18th state to add the ACE questions to the BRFSS survey. The Minnesota results are similar to those obtained in the initial study and replications conducted in other states. Over half of Minnesotans have experienced at least one ACE. The five most common ACEs reported by Minnesotans were verbal abuse (28%), living with a problem drinker (24%), separation or divorce of a parent (21%), mental illness in the household (17%), and physical abuse (16%). For those Minnesotans with at least one ACE, 60 percent have two or more ACEs and 15 percent have five or more ACEs. Increases in the number of ACEs were associated with increased issues such as alcohol and substance abuse, depression, anxiety, and smoking.
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What helps promote resilience?
While trauma can have a powerful influence, it is important to note that it does not affect all people the same way. Some people who experience trauma develop significant and long-lasting problems, while others (who may have experienced similar traumatic events) may have minimal symptoms or recover more quickly. The term “resilience” is generally used to describe the capacity of people to successfully adapt and recover, even in the face of highly stressful and traumatic experiences.
Resilience can be enhanced by strengthening a variety of protective factors. A number of personal characteristics can promote resilience, such as having a positive temperament, sociability, optimism, and an internal locus of control. Some of these characteristics represent personality characteristics that can be difficult to change. However, much can be done to promote resilience. Research has found that resilience can be optimized by strengthening three levels of protective factors:
Individual (i.e., cognitive ability, self-efficacy, self-regulation, coping strategies, spirituality)
Family (supportive parent-child interaction, social support)
Community characteristics (positive school experiences, community resources)
Protective factors that promote resilience can also vary culturally. Much of the existing research on resilience was conducted with white university students, and the results may not generalize to other populations. Very few studies have been conducted with persons of color, people with disabilities, and other populations. We need to learn more about culturally-based aspects of resilience. For instance, existing models of resilience may place too much emphasis on individualistic aspects of coping, while more collectivist characteristics may be more relevant in other cultural communities.
What helps people recover from trauma?
Despite broad impacts of trauma, people can and do recover. Without intervention, traumarelated symptoms may persist over time. However, numerous studies have found that interventions and support can help people to recover from traumatic experiences. As noted above, in some cases, exposure to traumatic events can affect children’s brain development. With the right kinds of intervention, even this damage may not be permanent. The brain is also capable of repair and recovery, a principle referred to as neuroplasticity.
A number of service models have been designed specifically for people who have experienced trauma. Within a variety of helping professions, efforts are underway to develop, offer, and test interventions specifically designed for people who have experienced trauma. Many of these interventions are offered in mental health settings. Some of the most common and well-established
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trauma-specific services are Eye Movement Desensitization and Reprocessing (EMDR), TraumaFocused Cognitive Behavioral Therapy (TF-CBT), Child Parent Psychotherapy (CPP), AbuseFocused Cognitive Behavioral Therapy (AF-CBT), Parent Child Interaction Therapy (PCIT), Cognitive Behavioral Intervention for Trauma in Schools (CBITS), and Child and Family Traumatic Stress Intervention (CFTSI).
While the specific approaches used in these interventions vary, most share goals associated with re-establishing a sense of safety, managing emotions, understanding the traumatic experience, and developing coping strategies. A variety of research studies show that these trauma-specific models have better outcomes than “treatment as usual,” including reduced psychiatric or trauma symptoms, reduced substance use, improved daily functioning, and increased strengths such as self-identity, healthy relationships, and safety.
“A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings.” – Gillece, 2012
Some service settings are increasingly moving towards “trauma-informed” approaches. There are a number of different definitions of what it means to be “trauma-informed,” but at the basic level, this means offering services or supports in a way that addresses the special needs of people who have experienced trauma. To be trauma-informed, all components of an agency incorporate a thorough understanding of the prevalence and impact of trauma and the various ways in which people recover and heal from trauma.
While there is not one standard definition, the following principles are typically emphasized in trauma-informed approaches:
Trauma awareness – services and organizational practices reflect an understanding of trauma, including how various behaviors may represent adaptations to traumatic experiences
Safety – Approaches and service settings are designed to promote both physical and emotional safety of participants and program staff
Opportunities to rebuild control – Services emphasize the importance of choice for consumers and create environments that promote personal control
A focus on strengths – Approaches are designed to support people in identifying and using their own strengths and skills, rather than focusing on deficits
Collaboration – There is true partnership and collaborative decision making between staff and consumers and among organizational staff
Trustworthiness and transparency – Organizational operations and decisions are conducted openly, with a goal of promoting trust among staff and consumers
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Cultural competence – Cultural, historical, sexual orientation, and gender issues are actively identified and addressed, and the organization promotes culturally-driven healing practices
Consumer voice and choice – Consumers experience choice and the ability to individualize services to best meet their own needs, while also participating in the development, implementation, and evaluation of services
While research supports the benefits of trauma-specific mental health services, it is important to note that less data are available to validate the importance of trauma-informed care more broadly. While many of the values of trauma-informed care are positive aspirations in their own right, research is just beginning to emerge to document whether service experiences and outcomes improve when organizations more formally adopt trauma-informed frameworks. Some preliminary results – primarily qualitative in nature – suggest that consumers and staff respond well to trauma-informed care and that program staff report more positive outcomes of services.
What about prevention?
Given the potential negative impact of trauma, it is also important to consider strategies for preventing the occurrence of traumatic events, including adverse childhood experiences. There are some challenges in shaping prevention efforts, however. First, while much is known in general about prevention strategies, it is difficult to prioritize efforts to reduce risk of traumatic events. Trauma can come in many forms, and the cumulative impact of multiple exposures can be more significant than any one single risk factor. On the other hand, we do know that some risks, such as childhood sexual abuse, can have disproportionate impacts. We also do not have a good strategy for identifying individuals at risk, and directing responses based on exposure and effects of exposure.
PREVENTION EFFORT GOALS
• support the quality or quantity of relationships
• increase safety • promote social-emotional competence • promote mastery • increase the capacity of systems to
support these goals
When considering prevention, it can be useful to take a public health approach. Public health models emphasize positive health promotion, along with risk reduction and intervention. Prevention efforts should take place in various settings and using various approaches. Public health models supplement indicated interventions (strategies for promoting well-being and reducing challenges in individuals with high risks and/or symptoms) with selective interventions (interventions to address known risk factors in participants at potential risk of issues) and universal actions (address health promotion and risk mitigation in the entire population regardless of individual/group risk). No single system or community group can be responsible for trauma or ACE prevention. Selective and universal prevention efforts in particular need to be offered in settings where the general population is most likely to be.
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Prevention efforts can focus on a number of different goals, such as supporting the quality and quantity of relationships, increasing safety, promoting social-emotional competence (affect regulation and expression, empathy, self-regulation), promoting mastery, and increasing the capacity of systems (neighborhoods, schools, workplace, and social groups) to support these goals. Cost-benefit analyses have demonstrated a stronger return on investments that result from strengthening families, supporting development, and preventing maltreatment during childhood and adolescence rather than funding treatment programs later in life.
What can we all do to support people who have experienced trauma and promote resilience?
The following recommendations are designed to provide a starting point in offering supports to individuals who have experienced trauma.
Increase your understanding of trauma and its impact. Many resources exist regarding trauma and strategies for providing trauma-informed care across a wide variety of discipline areas. The first step in responding appropriately to trauma is to learn to recognize common reactions to traumatic experiences and to understand the purpose and function of these reactions. It is also important to gain a deeper understanding of cultural variation in trauma exposure and responses, and to learn strategies for responding appropriately.
Screen for trauma exposure and symptoms. A key first step in providing trauma-informed services is to conduct universal screening related to trauma histories, symptoms, and protective factors. Having a complete set of information regarding trauma can be critical in tailoring services to meet the unique needs of the individual or family. Trauma screenings can be standalone, or embedded into other screening or assessment processes.
Screening can be done in a wide variety of service settings. Many standardized tools and surveys already exist.
TRAUMA TRAINING AND EDUCATION
There are many options for educational opportunities – classes, professional conferences, trainings, and books. You might want to talk to counselors or to others with indepth training in trauma-informed care. Many resources are available online, through sites such as:
ACES Connection (http://acesconnection.com/)
National Center for Trauma-Informed Care (http://www.nasmhpd.org/TA/nctic.aspx)
National Child Traumatic Stress Network (http://www.nctsn.org/)
California Center of Excellence for Trauma Informed Care (http://www.traumainformed-california.org/)
Community Connections (http://www.communityconnectionsdc.org/w eb/page/673/interior.html)
Family and Youth Services Bureau’s National Clearinghouse on Families and Youth: (http://ncfy.acf.hhs.gov/topics/traumainformed-care)
National Council for Behavioral Health (http://www.thenationalcouncil.org/)
International Society for Traumatic Stress Studies (http://www.istss.org/)
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Reach out and offer support to people who have experienced trauma. Whether you are formally involved in providing intervention or support services, or whether you are simply concerned about others in your community, it can be a powerful experience to reach out to people who have experienced trauma. The International Society for Traumatic Stress Studies has created a series of recommendations for offering support. Recommendations include listening without judgment, offering consistent emotional support, providing practical help, and providing company for anxietyprovoking events. It is typically more helpful to listen, and to provide a safe place for trauma survivors to talk about their experiences, rather than trying to problem solve for them or offering advice. It is important to validate their feelings and reactions, and to offer concern and support.
It may be helpful to participate in a training program, such as “mental health first aid.” Mental health first aid is a brief training program designed to give people the skills needed to help someone who is developing a mental health problem or experiencing a mental health crisis.
Learn what trauma-specific services may be available in your community and make referrals. Trauma-specific mental health services may be offered in a variety of settings, such as outpatient mental health clinics, homes, hospitals, schools, and other settings. Since these services are specifically designed for individuals who have experienced trauma, it may be helpful to connect people to programs. Doctors, clergy, local mental health associations, state or county government, insurance companies, and other service providers may be able to provide information about services available in your area. In some cases, it may be helpful or appropriate to help connect people to services, such as making initial contact with providers or offering a ride to services.
In addition to trauma-specific services, help connect people with other sources of support. In addition to formal mental health services, you can help connect people to other formal and informal networks. Depending on the person’s needs, a variety of services might be helpful (such as self-help groups, substance abuse treatment, or domestic violence support). Informal support systems are also important. Encourage people to get additional support from friends, family members, religious institutions, support groups, self-help resources, or others.
SUPPORTING FAMILIES— THE RESEARCH
Research overwhelmingly points to the benefits of supporting children and families at an early age to prevent maltreatment and its negative effects on brain development before they occur. In addition, cost-benefit analyses demonstrate the stronger return on investments that result from strengthening families, supporting development, and preventing maltreatment rather than funding treatment programs later in life.
Promote positive parent-child relationships. Families are an important focus for prevention efforts, intervention, and support. Many adverse childhood experiences have their origin in the parent-child relationships (i.e., abuse and neglect). Conversely, a strong relationship with a caregiver is a powerful buffer, protecting children from the impact of traumatic stress. Some of the most powerful protective factors include strong attachment between parents and children, caregiver knowledge of parenting and child development, parental resilience, social connections, and concrete support for parents.
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A variety of strategies can be used to support families. Some services may involve only the caregivers, while others may involve the parent and child together. Effective parent education programs exist, which can help promote positive parenting and reducing risks for child maltreatment. These programs include the Triple P program (Positive Parenting Program), Strengthening Families, Community Partnerships for Protecting Children, and Strong Communities. Other intervention approaches can also be beneficial, such as home visiting programs or parent-child centers. Informal modeling and mentoring are also important. In both formal service settings and informal relationships, you can help parents create safe environments, understand child development, recognize their child’s cues, and meet their child’s emotional and behavioral needs.
Promote positive youth development. Adolescence is a critical period of development, and provides a variety of opportunities to help individuals recover from traumatic events that they have already experienced, and to promote resilience to help them face potential future events. There is a strong convergence between the research on positive youth development and the research on recovery from trauma. In other words, the characteristics that predict positive life outcomes for youth in general are also characteristics that may protect them from the negative effects of traumatic events.
THE FIVE DOMAINS OF POSITIVE YOUTH DEVELOPMENT
1. Competence 2. Confidence 3. Connection 4. Character 5. Caring
Positive youth development is often defined around five domains: Competence, Confidence, Connection, Character, and Caring. Helping youth develop strong relationships with peers and family, access positive role models, and connect to supportive institutions can all play a powerful role. Across a variety of program efforts, focus on opportunities to help youth develop positive relationships with responsible and caring adults, build social and emotional competence, and develop feelings of mastery and confidence. These characteristics can be promoted through a variety of programs, including mentoring, social-emotional learning programs, and after-school programs.
Adopt trauma-informed principles at your agency. Trauma-informed principles can be adopted across a wide variety of organizations. As an initial step, it can be helpful to conduct an organizational assessment, several of which have been developed. An assessment can help you identify your agency’s current strengths in providing trauma-informed care, and to prioritize action steps (i.e., changing internal policies, modifying the physical environment to promote safety, revising internal policies, providing more opportunities for consumer-driven care, etc.).
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