1. Trauma Past, Trauma Present: Looking at Addiction through a Trauma Informed Lens
Allison Sampson Jackson, PhD, LCSW, LICSW, CSTOP
Family Preservation Services of VA
Providence Service Corporation
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3. Defining Trauma:
a traumatic event, either witnessed or experienced, representing a fundamental threat to one’s physical integrity or survival
responses involve intense fear, helplessness or horror
the meaning of the event may be as important as the actual physical act/experience
what we want to emphasize is that it is an individual's subjective experience that determines whether an event is or is not traumatic

4. Key Component of Trauma
Is the experience of loss!
Loss of:
boundaries
safety
trust
power and control
innocence
protection
attachment
possessions
consistency/predictability
sense of self/body image

6. Exposure to Violence in Childhood
46 million of 76 million children
are exposed to violence, crime and abuse each year
Finkelhor, D., et al. (2010). Trends in childhood violence and abuse exposure: evidence from 2 national surveys. Archives of Pediatric and Adolescent Medicine, 164(3), 238–242.
Information and slide part of Dr. Allison Sampson's Trauma Presentation

7. Trauma impacts learning and academic outcomes
Decreased IQ and reading ability
(Delaney-Black et al., 2003)
Lower grade-point average (Hurt et al., 2001)
More days of school absence (Hurt et al., 2001)
Decreased rates of high school graduation (Grogger, 1997)
Increased expulsions and suspensions (LAUSD Survey)

8. Impact of being in Child Welfare System for Foster Care Children
25% will be incarcerated within first 2 years of aging out of the system
More than 20% will become homeless
Only 58% will have a High School Diploma
Less than 3% will have a college education by age of 25
Many will re-enter the system as parents
For children under age of 5, increase likelihood of developmental delays 13-62% compared to 4-10%
Conradi, L. (2012) Chadwick Trauma Informed System Project p. 54
Leslie et. al. (2005). Developmental and Behavioral Pediatrics 26(3),

9. 1 year of violence= 124 billion dollars in recovery costs
The breakdown per child is:
•       $32,648 in childhood health care costs
•       $10,530 in adult medical costs
•       $144,360 in productivity losses
•       $7,728 in child welfare costs
•       $6,747 in criminal justice costs
•       $7,999 in special education costs

10. 223,400,000
223,400,000
317,572,282

11. ACE SCREEN

12. Alcoholism and alcohol abuse
Chronic obstructive pulmonary disease (COPD)
Depression
Fetal death
Health-related quality of life
Illicit drug use
Ischemic heart disease (IHD)
Liver disease
Risk for intimate partner violence
Multiple sexual partners
Sexually transmitted diseases (STDs)
Smoking
Suicide attempts
Unintended pregnancies
Early initiation of smoking
Early initiation of sexual activity
Adolescent pregnancy

14. Unlocking the Brain
At least for today…3 brain levels-they each speak a different language
Brainstem-housekeeping of the
Body, sleeping, eating, breathing
Limbic-smoke alarm, implicit memories
Cortex-planning, logic, reason, judgment
Brainstem and Limbic-what fires together wires together

15. A Person’s Response to Perceived Danger
Trauma Event
Danger Response
Fight Flight Freeze
Aggression Run Away Dissociate
Verbal attack Substance Abuse Non-emotionality
Slide from Ellen Williams, LCSW
Center for Child & Family Services

16. Looking Through The Eyes of a Traumatized Child- How it looks to Us….
Slide from Ellen Williams, LCSW
Center for Child & Family ServicesServices

17. How it looks to The Traumatized Child
Slide from Ellen Williams, LCSW
Center for Child & Family ServicesServices

18. The Hand Model of the Brain

19. The Handy Model

20. Trauma and the Brain
Hippocampus-remembers the facts but not the emotions.
It records the time-frame of significant events, the start, the middle, the end of an event and sends the facts to the cortex-the thinking part of the brain (logic, reason, common sense).

22. Self-Destructive Behavior
Chasing Behaviors
Agitation
Hopelessness
Intrusive Memories
Nightmares
Insomnia
Defiance
Poor Impulse Control
Numbing
Traumatic Event
Shame & Self-Hatred
Depression
Panic Attacks
Dissociation
Somatic Symptoms
Withdrawal
Self-Destructive Behavior
Eating Disorders
Substance Abuse T
Slide by Trish Mullen, Chesterfield CSB

23. We must ……
Respond to the need ….
Not react to the behavior

24. Resilience Trumps Aces
From Trish Mullen, Chesterfield Community services Board

25. Trauma and Attachment

26. Attachment
Many argue that these early relationships (experiences) shape neuronal circuits which regulate emotional and social functioning
Information and slide part of Dr. Allison Sampson's Trauma Presentation

27. Attachment’s Purpose Siegel, 1999
Evolutionary Level – biological
Infant Survival (Bowlby)
Mind Level – biological and social
Caregiver’s brain helps child’s brain to organize regulation
Caregiver’s brain teaches child self-soothing
Child experience of safety allows for exploration
Information and slide part of Dr. Allison Sampson's Trauma Presentation

28. Attachment’s Purpose
Experience of safety is encoded in child’s implicit memory and provides secure base from which to grow and access higher levels of information processing
Information and slide part of Dr. Allison Sampson's Trauma Presentation

29. Trauma and the Brain

30. Understanding “why” …
Information and slide part of Dr. Allison Sampson's Trauma Presentation

31. Brain and Stress
When stress is predictable and moderate, stress can facilitate resiliency and enhance memory
When stress is unpredictable and severe, stress can create vulnerability and memory impairment
Severe and chronic stress in childhood via multiple traumas from caregivers can impact affect regulation, interpersonal relationship skills, and states become traits (fight/flight/freeze… disassociation or hyper arousal)
Information and slide part of Dr. Allison Sampson's Trauma Presentation

32. Types of Stress Unaddressed Repeated Prolonged Intense
Positive Stress
Tolerable Stress
Toxic Stress
Normal and essential part of healthy development
Body’s alert systems activated to a greater degree
Occurs with strong, frequent or prolonged adversity
Brief increases in heart rate and blood pressure
Activation is time limited and buffered by caring adult
Disrupts brain architecture and other organ systems
Mild elevations in hormonal levels
Brain and organs recover
Increased risk of stress-related disease and cognitive impairment
Example: Tough test at school or a playoff game
Example: Death of a loved one, divorce, natural disaster
Example: abuse, neglect, caregiver substance dependence or mental illness
Effective Intervention
Early Detection
Parental Resilience
Social –emotional buffering
Unaddressed
Repeated
Prolonged
Intense
Information and slide part of Harris (2013) Buzz on Brain and Babies Presentation

33. Three parts of the brain …
Brain Stem
Limbic Brain
Cerebral Cortex
Information and slide part of Dr. Allison Sampson's Trauma Presentation

34. Stress and the Brain

36. Vulnerability Mountain
Information and slide part of Dr. Allison Sampson's Trauma Presentation

37. What does this mean for children who have experienced trauma
What does this mean for children who have experienced trauma? EXPERIENTIAL EXERCISE

38. Attachment and BRAIN … what we already know
Review of the exercise … what did you notice about caregiver touch between the two sets of pictures …
What do you think the implicit memories are about caregiving relationships ? About authority figures? About their ability to be safe ?
Information and slide part of Dr. Allison Sampson's Trauma Presentation

39. The needs of the adults and caregivers with trauma …. are no different

40. Cross-Generational Trauma Hendricks (2012) Chapter 12 of Creating Trauma Informed Child Welfare Systems Using Trauma Informed Services to Increase Parental Protective Factors
Women who have experienced trauma are more likely to self- medicate with a substance (55-99%) (1) Intergenerational transmission of trauma (Depression, PTSD) (2) Unresolved childhood trauma can lead to reenactments with partners in adult relationships and/or with their children (3) Unresolved childhood trauma can lead to difficulty forming secure attachments with their children (4) Childhood trauma can result in parenting styles that include threats & violence (2) Childhood sexual abuse survivors can miss “red flags” of sexual abuse with their own children due to avoidance of trauma memories themselves (2)
Najavits, Weiss, & Shaw (1997) The American Journal on Addiction, 6 (4),
Hendricks, A. (2012). Using Trauma-Informed Services to Increase Parental Factors (pp )
Walker (2007) Journal of Social Work Practice, 21 (1),
Main & Hess (1990) In M. Greenberg, D. Cicchetti, & E. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp )

41. BIG PICTURE with Caregivers
Often the caregivers … are the kids we as a system “missed”
They come to us with their own trauma histories
Successful outcomes with our clients means successful work with the family
Screening all caregivers and finding them services is critical to the prevention/treatment/reduction of recidivism for children entering the juvenile justice system

42. - Failure to engage in treatment services - An increase in symptoms
Cross-Generational Trauma Hendricks (2012) Chapter 12 of Creating Trauma Informed Child Welfare Systems Using Trauma Informed Services to Increase Parental Protective Factors
Caregiver functioning following a child’s exposure to trauma is a major predictor of child’s functioning (1 & 2)
If we want to improve a child’s outcome, we must address parent’s trauma history … failure to do so can result in (2) …
- Failure to engage in treatment services
- An increase in symptoms
- An increase in management problems
- Retraumatization
- An increase in relapse
- Withdrawal from service relationship
- Poor treatment outcomes
Linares et al (2001) Child Development, 72,
Liberman, Van Horn, & Ozer (2005) Development and Psychopathology, 17,
Hendricks, A. (2012) pp. 91

43. A Person’s Response to Perceived Danger
Trauma Event
Danger Response
Fight Flight Freeze
Aggression Run Away Dissociate
Verbal attack Substance Abuse Non-emotionality
Slide from Ellen Williams, LCSW
Center for Child & Family Services

44. Self-Destructive Behavior
Chasing Behaviors
Agitation
Hopelessness
Intrusive Memories
Nightmares
Insomnia
Defiance
Poor Impulse Control
Numbing
Traumatic Event
Shame & Self-Hatred
Depression
Panic Attacks
Dissociation
Somatic Symptoms
Withdrawal
Self-Destructive Behavior
Eating Disorders
Substance Abuse T
Slide by Trish Mullens, Chesterfield CSB

45. Not react to the behavior
We must ……
Respond to the need ….
Not react to the behavior

46. PARADIGM SHIFT

47. What does TIC look like?

48. Core areas of focus in Complex Trauma Courtois, C. & Ford, J
Core areas of focus in Complex Trauma Courtois, C. & Ford, J. (2009), Introduction (p.2)
Self-Regulation
Affect Regulation
Disassociation (difficulty in being “present”)
Somatic Dysregulation
Self-Identity
Impaired Self-Concept
Impaired Self-Development
Co-regulation
Secure working model of caring relationship
Disorganized Attachment Patterns
Information and slide part of Dr. Allison Sampson's Trauma Presentation

49. Creating a Culture for TIC
Five Core Values (Fallot, 2009)
Safety
Trustworthiness
Choice (and Voice !!)
Collaboration
Empowerment
We can offer CAPPD to those with work with …
Information and slide part of Dr. Allison Sampson's Trauma Presentation

50. Phase Oriented Care

51. Understand what good trauma treatment looks like …
Phase Oriented Treatment “ Gold Standard”
Phase I: Safety and Stabilization
Phase 2: Trauma Reprocessing
Phase 3: Reintegration
Handout on questions to ask Mental Health Providers
Resource
Information and slide part of Dr. Allison Sampson's Trauma Presentation

52. PHASE ONE: Safety and Stabilization
Phase Oriented Treatment for Trauma (Herman 1992, Janet 1889) from Courtois, C. “Treating Complex Traumatic Stress Disorders”)
PHASE ONE: Safety and Stabilization 
Personal and Interpersonal Safety Established: Education/Support/Safety Planning
Enhance Client’s ability to manage extreme arousal (hyper/hypo)
Active engagement in positive/negative experiences (deal with automatic avoidance behaviors, self awareness of avoidance, increase coping skills and use of coping skills)
Education (psychotherapy, trauma, skills to be learned)
Assess and develop relationship capacity (decrease avoidance of relationships or negative thoughts about relationships, build support network, define client’s attachment network)
Information and slide part of Dr. Allison Sampson's Trauma Presentation

53. Phase Oriented Treatment Phase Oriented Treatment for Trauma (Herman 1992, Janet 1889) from Courtois, C. “Treating Complex Traumatic Stress Disorders”
PHASE TWO: Trauma Reprocessing
Disclosure of traumatic memories, development of an autobiographical narrative (identify emotions connected to trauma memories, grieve and mourn losses, resolution of relationships when appropriate, increased awareness, increase interpersonal and self-regulation skills)
Supporting client in maintaining functioning and not getting lost in memories or seeing themselves as “disabled”, need to affirm strengths, promote positive self-esteem, and internal and external resources now available to them
PHASE THREE: Re-Integration
Growth and period and reengagement in life
Can be time of client realizing losses, discover of unresolved developmental deficits, fine tuning of self-regulation skills

54. Replacing Coping Behaviors
Phase One Work

55. Self-Destructive Behavior
Chasing Behaviors
Agitation
Hopelessness
Intrusive Memories
Nightmares
Insomnia
Defiance
Poor Impulse Control
Numbing
Traumatic Event
Shame & Self-Hatred
Depression
Panic Attacks
Dissociation
Somatic Symptoms
Withdrawal
Self-Destructive Behavior
Eating Disorders
Substance Abuse T
Slide by Trish Mullens, Chesterfield CSB

57. Respond to the need
Don’t react to the behavior

58. Post Traumatic Growth
Typically percent of survivors say that they have experienced positive changes of one form or another
Construct meaning from what happened
Survivor and thriver stories
What to do with the “broken vase” ?

59. Post Traumatic Growth http://ptgi.uncc.edu/
Posttraumatic growth tends to occur in five general areas.
Sense that new opportunities have emerged from the struggle, opening up possibilities that were not present before.
Changes in relationships with others (ex: closer relationships with some specific people, increased sense of connection to others who suffer)
Increased sense of one’s own strength – “if I lived through that, I can face anything”
Greater appreciation for life in general
Experience a deepening of their spiritual lives, however, this deepening can also involve a significant change in one’s belief system

60. Resilience http://acestoohigh.com/ Resilience Factors (APA website)
Caring/Supportive Relationships (primary)
Capacity to make realistic plans and take steps to carry them out
A positive view of yourself and confidence in your strengths and abilities
Skills in communication and problem solving
The capacity to manage strong feelings and impulses

61. Examples
Protective Factors
Families who thrive

62. Targeting Change
One tool …

63. When in their upstairs brain
Support folks you work with in developing goals based on their motivation … what do they want for their life today, what do they hope for, “magic wand questions”, what is their goal each day !!!
Collaborative Planning with Consumers…
Interviewing for hopes
Brain storm how to get there
Creating a plan where they have a support system and access to skills that will help them reach their goal
Respecting their boundaries/contracting
LET’ PRACTICE ….

64. Skill Building

65. Replacing Coping Skills

66. Steps to replacing coping behaviors
Identify current self-regulation strategies
Help consumer make meaning out of why they chose these strategies (ex: brain, ACE score, etc)
“Magic Wand” question … focus of change
Teach about the skills needed to build self-regulation
Focus work on building resilience and new coping strategies like a muscle
Track progress with something like the diary card
Frame replacing coping behaviors as a journey, it will take time

67. Dialectical Behavioral Therapy – Informed
DBT was developed in the late 1970s by Dr. Marsha Linehan and colleagues
Main goals: cope with stress, regulate emotions, improve relationships with others
Learning new behaviors -- which can be anything a person thinks, feels or does
Validation – the push for change can feel like it invalidates the pain that a consumer feels, validation is critical to helping consumer move forward
i.e. the unhealthy coping strategy makes sense given your experience, even though it is not the best approach to solve the problem

68. Dialectical Behavioral Therapy – Informed
Dialectics (opposites)
Dialectics makes three basic assumptions:
all things are interconnected
change is constant and inevitable and
opposites can be integrated to form a closer approximation of the truth
In DBT, the work is focused on resolving seeming contradictions between self-acceptance and change in order to bring about positive changes for an individual

69. DBT – Informed Skills Self Regulation Mindfulness
Interpersonal Relationship Skills
Distress Tolerance Skills

70. Accept and Change

71. Vulnerability Mountain

72. Self Regulation Self-Regulation (“sunscreen”)
Relaxation and Grounding Exercises
Bilateral Movement
Attunement Exercises
Guided Imagery
Self-Care Plan (daily practice)

73. Mindfulness – art of being present in the moment
Mindfulness Scale (MAAS)
Mindfulness Exercise (sheet) – breathing, “one thing”
Mindfulness Principles
Mindfulness at UCLA

74. Self Awareness “knowing your skin”
Educate children and adults about their triggers and trauma responses
Wise old owl (Hawn Foundation)
Guard Dog (Hawn Foundation)
Smoke Detector (Van der kolk)
Alarm System ( ARC book pp )
Light Switch (“Please Explain Anxiety to Me”)
Teach and practice with them identification of feelings and needs
Engage them in “Behavioral Experiments” where the try something different
Teach about Thought Distortions (“thought distortion box”) so they can begin to recognize thoughts they tell themselves that take them down to “Distress Valley”
Supporting beliefs that child or adult deserves “good” things
Recognizing “bumps in the road” don’t mean “a crash”

75. Teaching About the Brain
Upstairs/downstairs brain teaching practice
Using of multiplying connection tools (amazing brain pamphlets)
Partnering with Parents
Now you practice ………

76. Interpersonal Effectiveness Skills
Self Help Tools
EX: Cheerleading statements (connected to building positive self-identity)
“Cheerleading statements are statements that people make to themselves in order to give themselves permission to ask for what they need or want, to say no, and to act effectively”
ACTIVITY
Can you build some cheerleading statements with your neighbor ??

77. DISTRESS TOLERANCE

78. Distress tolerance skills (taken from the Accepts skills … DBT informed)
o Activities (physical and mental) – mental vacation, bi-lateral movement (walking), temperature change
o Contributing – helping others gets you out of yourself and your stress (smiling, give compliment, invite someone to coffee, hold a door, do a favor)
o Comparisons – Bringing perspective to current situation, what skills have helped you cope before (have helped your children cope before) … validate yourself
o Emotions – Seek out activities that create feelings that are OPPOSITE from the painful ones you are experiencing (listen to music, favorite movie, work on a project --- favorite hobby)
o Push Away – Put away distressing memories in a “lock box” or in the “parking lot” for a little while … can do this in writing or mentally
o Thoughts – distract your thoughts with “one-thing” exercises, read something inspiring, “just worrying exercise”
o Sensations – Any physically vigorous activity or actively awakening senses (brisk walk, cold bath/hot bath, splash cold water on face, lotions on your wrist, strong taste, bold colors (Mandela), music)
Pederson, L. (2012). The Expanded Dialectical Behavioral Therapy Skills Training Manual . Eau Claire: CMI Education Institute, Inc. pp

79. PRACTICE
Using the ACCEPTS Model … turn to your neighbor and think through activities that will fall under 2 of these categories that you could use with consumers you work with …

80. Skill building resilience starts with you …
Who is taking care of you ??
Information and slide part of Dr. Allison Sampson's Trauma Presentation

81. Mirror Neurons

82. Impact of Working with Victims of Trauma
Trauma experienced while working in the role of helper has been described as:
Compassion fatigue
Countertransference
Secondary traumatic stress (STS)
Vicarious traumatization
Unlike other forms of job “burnout,” STS is precipitated not by work load and institutional stress but by exposure to clients’ trauma.
STS can disrupt child welfare, police and juvenile justice workers’ lives, feelings, personal relationships, and overall view of the world.
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83. Healing the hero
Produced by Trish Mullen, LPC Chesterfield CSB

84. Impact of Chronic Stress http://www.helpguide.org/mental/stress_signs.htm
raise blood pressure
suppress immune system
increase the risk of heart attack and stroke
contribute to infertility
speed up the aging process (life expectancy)
create vulnerability for anxiety and depression
obesity
skin conditions (ex: eczema)
sleep problems
digestive problems
Information and slide part of Dr. Allison Sampson's Trauma Presentation

85. Vicarious Trauma’s Impact Personally (Yassen, 1995)
Emotional
Roller coaster
Overwhelmed
Depleted
Behavioral
Negative coping mechanism
Difficulty sleeping
Absent- mindedness
Cognitive
Spaciness
Apathy
Perfectionism
Minimization
Information and slide part of Dr. Allison Sampson's Trauma Presentation

86. Personal Impact … (Yassen, 1995)
Spiritual
Hopelessness
Anger at a Higher Power
Physical
Aches and pains
Impaired immune system
Breathing difficulties
Interpersonal
Withdrawn
Intolerance
Loneliness
Projection of anger and blame
Information and slide part of Dr. Allison Sampson's Trauma Presentation

87. Professional Impact (Yassen, 1995)
Performance of Job Tasks
Decrease in quality and quantity
Increase in mistakes
Avoidance of job tasks
Morale
Dissatisfaction
Negative attitude
Detachment
Information and slide part of Dr. Allison Sampson's Trauma Presentation

88. Professional Impact (Yassen, 1995)
Interpersonal
Withdrawn from colleagues
Impatience
Poor communication
Staff conflicts
Behavioral
Tardiness
Absenteeism
Faulty Judgement
Information and slide part of Dr. Allison Sampson's Trauma Presentation

89. Managing Stress
Request and expect regular supervision and supportive consultation.
Utilize peer support.
Consider therapy for unresolved trauma, which your work may be activating.
Practice stress management through meditation, prayer, conscious relaxation, deep breathing, and exercise.
Develop a written plan focused on maintaining work–life balance.
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90. Perry and Cost of Caring http://childtraumaacademy
Information and slide part of Dr. Allison Sampson's Trauma Presentation

91. Self-Care “Whether you and I and a few others will renew
the world some day remains to be seen.
But within ourselves we must renew it each day.”
—Hermann Hesse

92. Self-care Strategies http://www. compassionfatigue
The best strategy to address compassion fatigue is to develop excellent self care strategies, as well as an early warning system that lets you know that you are moving into the caution zone of Compassion Fatigue.

93. Self Care: Need Options
Time and Connection:
10 second exercises
2 minute exercises
5-10 minute exercises
20-30 minute GI, Walking Meditation
(Belleruth Naparstek)
Trish Mullen, LPC

94. Brain Gym

95. Practice Figure 8 with whole right arm/left arm
Figure 8 with both arms
Cross crawl (opposite right hand to bent left knee, then left hand to bent right knee)

96. Self Care Apps Provider Resilience GPS for the Soul
Mediation Oasis Apps
Mindfulness Training System
IChill App (Peter Levine)
Narrative Therapy Questions (Narrative Q’s)
Brain Wave
Flipagram (example)
NCTSN Self Care Inventory

97. Pocket TM … by Trish Mullen, LPC
Challenge: Working with children who are in their downstairs brain and getting them back up to their upstairs brain … when we all use primarily upstairs techniques in our work … Self care targeted to the right brain and lower brain … HAPPY PLACE

98. Caring For Yourself

99. Creating Internal Awareness

100. Creating Awaresness

101. Window of Tolerance
Pat Ogden

102. Using Grounding Techniques to Stay in the Window of Tolerance
Mental Grounding
Physical Grounding
Soothing Grounding
Somatic Grounding
Najavitis, L.M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. NY: Guilford.

103. Practice Examples Distress Tolerance “Down Stairs Brain”
Temperature Change
Grounding by looking up
Bi-lateral movement
Butterfly taps
Compassion Hold

104. “Dig where the ground is soft” Chinese proverb
Conclusion: “Dig where the ground is soft” Chinese proverb Instead of picking your trickiest area, pick the issue that you can most easily visualize improving on. (e.g.: “making a commitment to going for a walk every lunch time vs. getting rid of my difficult supervisor”). You may not notice it right away, but making one small change to your daily routine can have tremendous results in the long term. Imagine if you started walking up two flights a stairs per day instead of using the elevator, what might happen after three months?

105. Together we can make a difference
Becoming Trauma Informed is a process …

106. THANK YOU ……
Dr. Allison Sampson-Jackson Family Preservation Services, Inc