Monday, September 22, 2014

Helping Survivors with Traumatic Brain Injury

Working with survivors of domestic violence and sexual assault can sometimes be overwhelming when we realize all of the issues with which a victim may have to deal.  There are the immediate safety issues, the long term custody and financial issues, housing, parenting, trauma issues and the possibility of substance abuse and mental health issues related to trauma, and the ongoing systemic issues of oppression and lack of resources.  Amidst all of this we have learned to recognize when the impact of trauma may be affecting the person’s ability to move forward and we have found ways to empower someone to make changes even in the face of these effects.  However, often, because there is already so much, we forget the possibility that the survivor we are working with may be dealing with the effects of a minor or major traumatic brain injury.
The following information is gleaned from various resources that I will include at the end. 
The head and face are among the most common targets of intimate partner assaults, and victims of domestic violence often suffer head, neck and facial injuries. Common forms of physical assault that can cause a brain injury include:
• Forcefully hitting partner on the head with an object.
• Smashing her head against a wall.
• Pushing her downstairs.

• Shooting or stabbing her in the head.
• Shaking her – which moves her brain in a whip-lash motion, smashing it against her skull.
• Obstructing her airway, causing loss of oxygen to her brain, through:
o Strangling her. (She will likely call it “choking.”)
o Trying to drown her.
o Forcing her to use drugs or eat foods to which she is allergic.
Because batterers seldom assault their partners only once, some victims suffer repeated head injuries.
One study of women in three domestic violence shelters found that:
• 92% had been hit in the head by their partners, most more than once.
• 83% had been both hit in the head and severely shaken.
• 8% of them had been hit in the head over 20 times in the past year.
• The more times individuals had been hit in the head or shaken, the more severe, and the more
frequent, were their symptoms. 


What is Traumatic Brain Injury?
Traumatic brain injury (TBI) is an injury to the brain that is caused by external physical force.
·       Penetrating injuries are caused when a foreign object (such as a bullet, knife, or blunt object) pierces the skull. This type of injury causes focal damage, limited to the specific parts of the brain that lie along the path that the object travels.
·       Closed head injuries occur from blows to the head that do not fracture the skull, or from severe shaking. They can cause both localized damage and diffuse or widespread damage, due to bleeding, and to stretching, tearing and swelling of brain tissue – which can continue to damage the brain for hours or days after they originally occur. A DV victim can suffer a closed head injury when her partner hits her on the head with an object, smashes her head against a wall, pushes her downstairs or violently shakes her.
·       Cutting off oxygen, as happens in strangulation, also injures the brain.
A victim of domestic violence may suffer a TBI without knowing it if she had no severe trauma or obvious symptoms at first, or if she did not lose consciousness, or received no medical care.
NOTE: While a TBI can lead to aggressive behavior, it does not cause or excuse the targeted pattern of coercive control usually seen in DV. If a woman thinks her partner is violent because he has suffered a TBI, she might want to try and get an evaluation for him, but she should also be helped to plan for safety.
Brain injury can make it harder for a victim of domestic violence to:
·       Assess danger and defend herself against assaults.
·       Make and remember safety plans.
·       Go to school or hold a job (increasing her financial dependency on the abuser).
·       Leave her abusive partner and live on her own.
·       Access services.
·       Adapt to living in a shelter. She may become stressed, anxious and confused or disruptive, or have trouble understanding or remembering shelter rules and procedures.
·       Retain custody of her children.
Domestic violence service providers. Screen everyone who seeks DV services for TBI. A brief screening tool that was designed to be used by professionals who are not TBI experts is the HELPS.2
HELPS is an acronym for the most important questions to ask:
H = Were you hit in the head? 
E = Did you seek emergency room treatment? 
L = Did you lose consciousness? (Not everyone who suffers a TBI loses consciousness.) 
P = Are you having problems with concentration and memory? 
S = Did you experience sickness or other physical problems following the injury?

If you suspect a victim has a brain injury, or she answers “yes” to any of these questions, help her get an evaluation by a medical or neuropsychological professional – especially if she has suffered repeated brain injuries, which may decrease her ability to recover and increase her risk of death. If she wishes, reach out to the TBI service provider with information about DV, what support she needs, and what services are available to her. Look for ways to work together.

The National Brain Injury Association has links to the TBI associations in each state:  http://www.biausa.org/
Other resources:


Monday, August 18, 2014

Reflecting on Who We Are and How It Impacts Survivors

When providing trauma- informed services to survivors of domestic and sexual violence it important we ensure that we are doing whatever we can to keep from re-victimizing the survivor or engaging in behaviors that may be reminiscent of past abuse.  Through actively engaging in a reflective practice on our own and during supervision we may be able to recognize those conditions within ourselves that get in the way of being able to provide safe, empathetic, and empowering assistance.
We often talk about the experiences of survivors in a way that takes into account the trauma in their lives.  We ask “how do the effects of trauma get in the way or impact the person’s ability to be able to move forward?”  This practice of reflecting on the experience of the survivor can move an advocate from focusing on what is “wrong” with a person to recognizing the impact of trauma and finding ways to reduce the impact and/or engaging with the person in a way that empowers them to be able to move beyond the trauma.
Terri Pease, Ph.D., of the National Center on Domestic Violence, Trauma and Mental Health talks about reflective practice.  She quotes Jeree Pawl, past board president of Zero to Three, to remind us that “who we are is as important as what we do” in our relationships with survivors.  She stresses the importance of reflecting on the impact that survivors have on our lives and the history that we bring into our relationships with them. 
I am often called to provide insight into the actions of a woman in shelter or a woman who is seeking services from a court advocate.  The advocate wants me to explain what is happening with the woman from a trauma-informed standpoint and help her find something different to do to help.  Another step I like to take, though, is to ask “how is this interaction affecting you?”  In other words, can you take a moment to reflect on what may be coming up for you as you work with this survivor?  Many times the challenges of working with survivors can stir up some emotions that we may find difficult to keep from being reflected in our actions.
If the victim is particularly challenging and expresses herself with anger, an advocate may find that she resists working with the victim.  The victim may be engaging in some survival skills that are often labeled as lying, manipulating or attention seeking.  If an advocate can take a few moments on her own or in supervision to reflect on what this is bringing up for the advocate, then it may help to improve the relationship with the survivor.  For example, I know that due to my own past I have difficulty when I am in the presence of extreme anger that feels like it may be directed toward me.  Over the years I have learned to recognize when my own history is starting to blur my interactions and I, hopefully, am able to breathe my way through and not take the survivor’s anger personally.  Additionally, many advocates, including myself, feel helpless when they are unable to meet all the needs of the survivors.  This may feel like frustration with the survivor and it will be reflected in our interactions with her unless we realize that our helplessness has to do with the greater picture and our own fear of not being able to do enough. 
Advocates, in the face of tapped out services within their communities, often feel overwhelmed by the needs of the survivors and feel if they cannot meet them all then they are not good advocates.  Yes, it is hard when the needed services are not available, but we cannot do it all.  We do all that we can and at the end of the day we need to be able to take care of ourselves so that we don’t burn out and become frustrated with the women who are reaching out to us.  An awareness of who we are and what we bring to our work is critical to being able to sustain our relationships with survivors and to being able to be trauma-responsive.    



Painting by Richard Edward Miller

Monday, August 4, 2014

Take a Breath

I was reading a book about trekking through the Himalayas last week.  As part of my self-care I like to make sure that I read things that don’t pertain to anything I do as part of my work life.  However, there were a few paragraphs that jumped out as me as being very important for advocates and survivors. 
The writer was describing how difficult it is to hike at high altitudes.  The oxygen is thin at those altitudes and the effort of climbing over rocks with a heavy backpack can make one feel that she just won’t be able to make it to the next hospitality stop.  The views can also take one’s breath away.  The writer went on to describe a trick that high altitude trekkers use when the going gets tough.  They breathe.  They take ten steps and stop to take ten very deep breaths and then take ten more steps and repeat.  It may feel like slow going but at the end of the day the goal is reached.
I tried it out.  I was biking in unfamiliar territory one day.  I had mapped the route ahead of time but had not paid attention to the fact that there was a half mile stretch that was uphill on a gravel road.  I decided I would need to walk it.  Normally I would force myself to just trudge up the hill and stop when I was out of breath and probably in pain.  I would be red-faced, sweating, and gasping for air.  However, on that day I decided to try the breathing technique they use in the Himalayas.  It was just a New Hampshire hill and not K2 so I modified the technique a little.  I counted fifty steps and then stopped to take ten deep cleansing breaths whether I felt I needed the or not.  I found that not only did I make it to the top of the hill without gasping for air but that I felt pretty good when it was all done.  At the time I was stopping to breath I thought it was just slowing me down, but then I realized that by taking the time to stop and breath I was less likely to need a longer rest period once I reached the top. 
I talked to two different groups of advocates last week and I asked them why they felt they couldn’t do self-care.  The number one reason was “I don’t have time.”  Many felt that they were too exhausted at the end of the day to do anything and some felt that it would be selfish to take time away from family members in order to take care of themselves. 
Advocates often feel like they are trying to climb mountains.  There are obstacles and demands on energy that can make one feel like she will never reach the goal.  When we are under stress we actually do not breathe as well.  Our breaths can become shallow and we take in less oxygen, causing us to tire more quickly and lose the ability to focus.   If mindful  breathing can be a part of your  day it may help to dispel some of the exhaustion that can go along with doing this work.  Take a breath before you pick up the phone.  Take a few breaths before you open a door, as you shift between tasks, or before you get out of your car.  Find some way to remind yourself to do so.  There are plenty of apps on the market or there is even a bracelet you can buy that vibrates to remind you to take a moment to breath.  This blogger has a number of techniques she uses to remind herself to take a break:  http://healingwhole.blogspot.com/2011/05/take-break-create-mindfulness-reminders.html

Remember, though, self care is as important to being able to do your job as it is to have nice clothes to wear to court or have gas in your car to get there.  Find ways to incorporate it into your day or you may find yourself clinging to the side of the mountain.  


The pictures in this post were taken in Tibet in 2007.  Mount Everest is over my left shoulder in the above picture.  

Monday, July 21, 2014

Posttraumatic Growth

There has been some new research coming about on something called posttraumatic growth.  During a presentation last week I mentioned this and very few people in the audience knew about it.  It is primarily a result of resiliency studies in people who have been able to recover from traumatic incidents or even from long term interpersonal trauma.  In order to educate readers about this I have taken the following directly from the University of North Carolina, Charlotte, website.  http://ptgi.uncc.edu/what-is-ptg/

After you read this,  I am sure that you will know of people with whom you have worked who have experienced posttraumatic growth.   In fact, you may also have experienced posttraumatic growth. 

What is PTG?

What is posttraumatic growth? It is positive change experienced as a result of the struggle with a major life crisis or a traumatic event. Although we coined the term posttraumatic growth, the idea that human beings can be changed by their encounters with life challenges, sometimes in radically positive ways, is not new. The theme is present in ancient spiritual and religious traditions, literature, and philosophy. What is reasonably new is the systematic study of this phenomenon by psychologists, social workers, counselors, and scholars in other traditions of clinical practice and scientific investigation.

What forms does posttraumatic growth take? Posttraumatic growth tends to occur in five general areas. Sometimes people who must face major life crises develop a sense that new opportunities have emerged from the struggle, opening up possibilities that were not present before. A second area is a change in relationships with others. Some people experience closer relationships with some specific people, and they can also experience an increased sense of connection to others who suffer. A third area of possible change is an increased sense of one’s own strength – “if I lived through that, I can face anything”. A fourth aspect of posttraumatic growth experienced by some people is a greater appreciation for life in general. The fifth area involves the spiritual or religious domain. Some individuals experience a deepening of their spiritual lives,however, this deepening can also involve a significant change in one’s belief system.


Some Clarifications

Most of us, when we face very difficult losses or great suffering, will have a variety of highly distressing psychological reactions. Just because individuals experience growth does not mean that they will not suffer. Distress is typical when we face traumatic events.

We most definitely are not implying that traumatic events are good – they are not. But for many of us, life crises are inevitable and we are not given the choice between suffering and growth on the one hand, and no suffering and no change, on the other.
Posttraumatic growth is not universal. It is not uncommon, but neither does everybody who faces a traumatic event experience growth.


Our hope is that you never face a major loss or crisis, but most of us eventually do, and perhaps you may also experience an encounter with posttraumatic growth.

Here are some links to other articles on posttraumatic growth:




Monday, July 14, 2014

Teens, Trauma and Relationships

Adolescence is a scary period but even more so for teens who are trauma survivors.    Trauma can make it difficult to parse out what could be normal adolescent development, with all the angst and struggles to separate and mature, versus what impact the history of trauma may be having on the teen.  However, I am going to try and provide some insight into what may be going on and how it impacts teens’ ability to develop healthy relationships. 
Development
In his recent book, Brainstorm: the power and purpose of the teenage brain, Dr. Daniel Siegel describes the overall movement of the teen’s brain to becoming more integrated.  Integration means that more areas of the brain are becoming specialized and interconnected to one another in more effective ways.  This specialization takes place through a process of pruning.  Pruning is the remodeling of the brain, letting go of connections in the brain that are not needed or haven’t been used.  From a trauma perspective, this means that neural pathways that have been strengthened to manage safety or that have been developed as a response to trauma will remain while other pathways that have been ignored due to trauma will be pruned away. 
Dr. Siegel explains that if there is any vulnerability in the brain’s makeup during childhood, adolescence can reveal those brain differences because of the pruning down of the existing but insufficient number of neurons and their connections.  The impact of adverse childhood experiences such as abuse and neglect may become more noticeable because the pruning is unmasking the vulnerabilities that have been lying being the surface.  This also is why major psychiatric disorders (which may be responses to trauma) may express themselves for the first time in adolescence.
Trauma Responses
When the flight, fight or freeze responses engage in adolescents it can lead to long term difficulties.  The fight response is a teen’s struggle to gain or hold onto power, especially when they feel they are being coerced.  The flight response can be seen when a teen disengages, runs away and/or checks out emotionally. The freeze response occurs when a youth gives into those in positions of power and does not or is unable to speak up (Adolescent Health Working Group, 2013, www.ahwg.net).
Teens living in households with ongoing abuse and neglect have probably not been able to learn effective ways to manage their outward emotions and their internal responses.  They may blame themselves for the abuse and feel ashamed about what they have experienced.  They may engage in behaviors to manage their trauma responses in unhealthful and dangerous ways such as with alcohol and drug abuse, self-harm, unhealthy relationships, isolation, and high-risk actions.
Their school performance may be impacted by either under-performing, conflict with school personnel, or skipping classes.  The ability to complete tasks or understand school work can be greatly affected by learning disabilities or impairments that cannot be explained by anything other than the impact of witnessing or experiencing trauma.  Being unable to relate to peers and not feeling able to perform adequately in a school environment can lead to feels of shame and isolation.
Impact on Relationships
As you can well imagine, the above trauma responses would influence relationships that a teen may have during adolescence. There may be ongoing conflict with family members or detachment and isolation in order to avoid more conflict.   They may isolate from their peers because of the shame and guilt they feel about their circumstances and also affiliate with persons who reinforce the bad feelings they have about themselves and/or who are also engaging alcohol/drug use and other risky behaviors in order to validate their own sense of loss, shame and isolation.  Relationships may be modeled after what they have seen in their lives and lead to further abuse.
Interventions
The good news is that strong sustained attachments to safe and nurturing adults and peers can improve a teen’s life.  Within these relationships an adolescent can learn the skills necessary for identifying, expressing, and modulating feelings that arise when he/she is triggered or trying to manage the developmental tasks common to this age group having to do with identity and roles in society.  In addition, teens need to feel competent and be able to plan for and have feelings of control about the future.  Engaging in positive activities that help them discover and nurture latent talents can help increase resiliency and lead to a healthy adulthood.

For more information go to :  http://www.ahwg.net/

Monday, June 23, 2014

It’s All About Feeling Safe

I am often asked about how to help a survivor manage their mental health issues.  The advocate is usually feeling that the “symptoms” are possibly unrelated to domestic violence or sexual assault and the advocate does not feel qualified to address what is happening. 
Yes, there may be instances, such as when a survivor is suicidal or psychotic when an immediate mental health intervention is necessary.  However, the skills that advocates have can be used to help reduce the reactions a person may be having because she does not feel safe in her environment or her body.
Being trauma-informed includes having the understanding that the behaviors that an advocate sees may be directly or indirectly related to the trauma the person has experienced over their lifetime.  These behaviors can range from anxiety to depression, anger to paranoia.  What is important to remember is that what the person probably wants more than anything is to feel safe even when they are yelling at you, refusing to get out of bed, or having difficulty making a decision.  We don’t even have to know what caused the behavior.  We can just start the conversation with “what would help you to feel safe at this moment?” and work from there.
Here are a couple of examples:
A woman is having difficulty going to social services to fill out paperwork.  She gets angry when she is reminded that she needs to do this and she starts avoiding staff rather than following through with the plan.   When sitting with an advocate she may become agitated when she feels the conversation moving toward talking about taking the trip to social services.
The advocate can either remind her that it is necessary that she do this and if she does not follow through she will be reprimanded or the advocate can ask the following questions:
1.        Is there something about the social services office that is stressful for you?
2.       Do you feel safe going to and from the office?
3.       Is there any additional assistance that you need in order to fill out the paperwork?  (She may not feel safe talking about literacy issues and asking for help.)
4.       Do you feel like you aren’t ready to take this step?  (She may be considering returning to her abuser and is afraid to talk to you about it.)
5.       Would you like to do a safety plan around making the trip or do you need a volunteer or staff to accompany you?
There are a number of reasons why she may not be taking the trip to social services but more than likely she does not feel physically or emotionally safe doing so.  She may also be fearful that failure to follow through may mean not being able to receive further services from your program.
A survivor is placed in a hotel room for a few nights due to lack of shelter beds.  She is taken to a local grocery for some food that can be kept in the hotel room refrigerator.  However, she keeps calling the crisis line and staff asking for someone to take her out for a hot meal or more groceries.  Some staff may feel inconvenienced or that the person is trying to get as much free food as possible.  However, the person may be using the frequent calls to staff as a way to touch base with another person.  Hotel rooms can be lonely and the person may be afraid to ask to have her needs met.  She may also need to talk about how she feels about leaving her partner, may not feel safe with her emotions or be fearful of being seen.  It all comes down to wanting to feel safe but not knowing how to ask for it. In many survivors’ lives, asking to get needs met put them at risk of harm.
Even events of extreme paranoia or delusion can be calmed by helping the person find a way to feel safe.  If someone is feeling  they are being watched or that a tracking device has been put on their clothing, it helps to ask a few more questions including “what can I do to help you feel safe?”  It may mean making a couple of changes to the environment in order to help the person feel heard and safer.  More than likely the paranoia and delusion can be traced to some recent or long ago trauma but it is usually evident that the person is not feeling safe in their body or environment. 

Start with what you know and domestic violence and sexual assault advocates know about talking about safety.

Monday, June 9, 2014

As Long As You Are Mobilized You Can’t Shut Down

I went to the 25th Annual Psychological Trauma conference put on by the Trauma Justice Institute in Boston two weeks ago.  I wish I could report on everything that was presented but that would be impossible.  There were a lot of neuroscientists and chemists showing graphs and reading statistics and by the end of the second day of the three day conference a number of us were shuffling around looking brain dead.  It is a good thing we were still walking, though, because one of the important points I wrote down was “as long as you are mobilized, you can’t shut down.”
Stephen Porges said this when he was talking about the polyvagal response ( you can go here for a fairly clear explanation) and I was really struck by the statement.  He was trying to make clear the imperative for movement in times of stress in order to decrease the risk of dissociation (from zoning out to full blown shut down).  Biologically, our bodies need to move in order to regulate.  According to Dr. Porges, our system is constantly monitoring the environment to determine whether or not it is safe (more so for trauma survivors) and when the system is overwhelmed it shuts down.  Movement helps keep the system regulated.
As someone who has been diagnosed with Fibromyalgia and who has developed an understanding of the effects of trauma on the body, I had developed a theory that the nervous system’s response to trauma was the cause of the fibromyalgia.  This theory was validated at the conference by Dr. Porges and there seems to now be more evidence being published.
According to Richard Boyd at http://www.energeticsinstitute.com.au/page/fibromyalgia.htmlPain studies have shown that incomplete pain signals in the body can cause them to be re-sent and even amplified. Fibromyalgia sufferers appear to have a pain signaling problem that is of this nature. The Vagus nerves have been shown to have “communication problems” when traumatised. This is conjecture but a possible framework under which Fibromyalgia exists without showing causes and origins. It may turn out to be a nervous system “network” problem.
So why am I bringing this to your attention?  As advocates we meet a lot of survivors who complain of pain issues and who also dissociate at various levels.  They are often highly medicated  and/or finding ways to retreat from the psychological and emotional pain that are non-productive and reduce physical movement.  The findings that I mention above bring home the point that any opportunity we can provide as domestic violence shelter advocates or as facilitators of support groups to get people up and moving can only increase survivors ability to manage their own trauma responses.  Yoga, tai chi, walking, bicycling, dancing, and swimming are just a few of the ways to help reduce the effects of stress.  If someone is in a lot of physical pain they may need to do gentle yoga or slow walking, but it is still movement. 
I would also, if you are able, take the opportunity to provide support while on a walk.  Is there someplace safe and quiet where you can meet a survivor where you can walk and talk at the same time?  When trying to help someone do an emotional safety plan for the weekend or after a court hearing, recommend movement even if it is just going home where it is safe and putting on some loud music and dancing around the house.

And finally, as advocates we are under a lot of stress.  We don’t even have to be meeting with survivors in order to be influenced by the trauma that they experience.  After attending sessions on child abuse and neglect and human trafficking at last week’s Attorney General’s conference, I needed to be outdoors and moving in order to rid myself of the after effects.  A walk in the woods or bicycling usually helps.  Movement has to be a part of our self care plan as well.