SADness and the Holidays

 It’s that time of year again and amidst all of the Holiday lights and Santa sightings it is good to remind everyone that this is a difficult season for a lot of trauma survivors. It also is a time of year when depression increases due to lack of sunlight.


Seasonal affective disorder (SAD) is a real physical problem. As the days become shorter and we experience more darkness, our bodies produce more melatonin. Melatonin is involved in regulation of sleep, release of hormones, and body temperatures. According to an article on the Mayo Clinic website, SAD symptoms include: depressed mood, irritability, hopelessness, anxiety, loss of energy, social withdrawal, oversleeping (feeling like you want to hibernate), loss of interest in activities you normally enjoy, appetite changes (especially a craving for foods high in carbohydrates such as pastas, rice, bread and cereal), weight gain, and difficulty concentrating and processing information.

It is important to be aware that this may be an added factor when working with trauma survivors. Many of the effects of trauma are intensified by SAD and by the impending holidays. Trauma survivors are often triggered by holiday memories that were more distressing and a far cry from Hallmark moments. They often feel guilt and possible shame because they are not able to enjoy the holidays as much as the rest of the world. It does not matter how much work has been done to heal from the trauma, the holidays can still be a major source of stress for many people due to finances, family obligations, and the intense commercial attention to the season.

If you are a survivor of trauma or working with others who are survivors, I encourage you to develop a list of strategies that can help you get through the season. Here are a few tips that I posted last year.

1. Have an exit strategy. Some survivors are able to say “no” when expected to attend family gatherings where a perpetrator may be present. A sense of obligation to other family members may make it difficult to stay away. If someone is planning to attend a family gathering where a perpetrator is present, it is good to limit the amount of time spent in the situation. Arriving late, having one’s own form of transportation, having an agreement with another family member to assist in maintaining distance are all possibilities.

2. Good self care. With all the stress of the holiday season, immune systems become compromised. Illness and fatigue can increase susceptibility to triggers and make it more difficult to manage reactions and heightened emotional vulnerability. High intakes of sugar through this time can also reduce the ability to combat infection, increasing vulnerability. Any activities that increase a sense of well being such as support groups, mindfulness activities, exercise, and creative projects can help fight off depression.

3. Support. Isolation is often a strategy for managing this time of year that can end up being very unproductive. Existing support groups or informal support of understanding friends may help alleviate some of the loneliness that occurs during the holidays.

4. Limit alcohol intake. Alcohol is a depressant and can also affect the immune system. It also decreases inhibitions and affect sleep patterns which can then lead to increased vulnerability to the effects of trauma or additional trauma.

Please feel free to post your own strategies below.

Dealing with the Effects of Trauma

A SAMHSA Publication – see below for more information




Introduction

This is a serious issue. This booklet is just an introduction—a starting point that may give you the courage to take action. It is not meant to be a treatment program. The ideas and strategies are not intended to replace treatment you are currently receiving.

You may have had one or many very upsetting, frightening, or traumatic things happen to you in your life, or that threatened or hurt something you love—even your community. When these kinds of things happen, you may not “get over” them quickly. In fact, you may feel the effects of these traumas for many years, even for the rest of your life. Sometimes you don’t even notice effects right after the trauma happens. Years later you may begin having thoughts, nightmares, and other disturbing symptoms. You may develop these symptoms and not even remember the traumatic thing or things that once happened to you.

For many years, the traumatic things that happened to people were overlooked as a possible cause of frightening, distressing, and sometimes disabling emotional symptoms such as depression, anxiety, phobias, delusions, flashbacks, and being out of touch with reality. In recent years, many researchers and health care providers have become convinced of the connection between trauma and these symptoms. They are developing new treatment programs and revising old ones to better meet the needs of people who have had traumatic experiences.

This booklet can help you to know if traumatic experiences in your life may be causing some or all of the difficult symptoms you are experiencing. It may give you some guidance in working to relieve these symptoms and share with you some simple and safe things you can do to help yourself heal from the effects of trauma.

Some examples of traumatic experiences that may be causing your symptoms include:

• physical, emotional, or sexual abuse
• neglect
• war experiences
• outbursts of temper and rage
• alcoholism (your own or in your family)
• physical illnesses, surgeries, and disabilities
• sickness in your family
• loss of close family members and friends
• natural disasters
• Accidents

Some things that may be very traumatic to one person hardly seem to bother another person. If something bothers you a lot and it doesn’t bother someone else, it doesn’t mean there is something wrong with you. People respond to experiences differently.

Do you feel that traumatic things that happened to you may be causing some or all of your distressing and disabling emotional symptoms? Examples of symptoms that may be caused by trauma include:

• anxiety
• insomnia
• agitation
• irritability or rage
• flashbacks or intrusive memories
• feeling disconnected from the world
• unrest in certain situations
• being “shut down”
• being very passive
• feeling depressed
• eating problems
• needing to do certain things over and over
• unusual fears
• impatience
• always having to have things a certain way
• doing strange or risky things
• having a hard time concentrating
• wanting to hurt yourself
• being unable to trust anyone
• feeling unlikable
• feeling unsafe
• using harmful substances
• keeping to yourself
• overworking

Perhaps you have been told that you have a psychiatric or mental illness like depression, bipolar disorder or manic depression, schizophrenia, borderline personality disorder, obsessive—compulsive disorder, dissociative disorder, an eating disorder, or an anxiety disorder. The ways you can help yourself handle these symptoms and the things your health care providers suggest as treatment may be helpful whether your symptoms are caused by trauma or by a psychiatric illness.

Help From Health Care Providers, Counselors and Groups

You may decide to reach out to health care providers for assistance in relieving the effects of trauma. This is a good idea. The effects of trauma, even trauma that happened many years ago, can affect your health. You may have an illness that needs treatment. In addition, your health care provider may suggest that you take medications or certain food supplements to relieve your symptoms. Many people find that getting this kind of health care support gives them the relief and energy they need to work on other aspects of healing. To find health care providers in your community who have expertise in addressing issues related to trauma, contact your local mental health agency, hospital, or crisis service.

If you possibly can, work with a counselor or in a special program designed for people who have been traumatized. A counselor or people leading the program may refer you to a group. These groups can be very helpful. However, keep in mind that you need to decide for yourself what you are going to do, and how and when you are going to do it. You must be in charge of your recovery in every way.

Wherever you go for help, the program or treatment should include the following:

Empowerment–You must be in charge of your healing in every way to counteract the effects of the trauma where all control was taken away from you
.

Validation–You need others to listen to you, to validate the importance of what happened to you, to bear witness, and to understand the role of this trauma in your life.

Connection–Trauma makes you feel very alone. As part of your healing, you need to reconnect with others. This connection may be part of your treatment.

If you feel the cause of your symptoms is related to trauma in your life, you will want to be careful about your treatment and in making decisions about other areas of your life. The following guidelines will help you decide how to help yourself feel better.

Have hope. It is important that you know that you can and will feel better. In the past you may have thought you would never feel better—that the horrible symptoms you experience would go on for the rest of your life. Many people who have experienced the same symptoms that you are experiencing are now feeling much better. They have gone on to make their lives the way they want them to be and to do the things they want to do.

Take personal responsibility. When you have been traumatized, you lose control of your life. You may feel as though you still don’t have any control over your life. You begin to take back that control by being in charge of every aspect of your life. Others, including your spouse, family members, friends, and health care professionals will try to tell you what to do. Before you do what they suggest, think about it carefully. Do you feel that it is the best thing for you to do right now? If not, do not do it. You can follow others advice, but be aware that you are choosing to do so. It is important that you make decisions about your own life. You are responsible for your own behavior. Being traumatized is not an acceptable excuse for behavior that hurts you or hurts others.

Talk to one or more people about what happened to you. Telling others about the trauma is an important part of healing the effects of trauma. Make sure the person or people you decide to tell are safe people, people who would not hurt you, and who understand that what happened to you is serious. They should know, or you could tell them, that describing what happened to you over and over is an important part of the healing process.

Don’t tell a person who responds with statements that invalidate your experience, like “That wasn’t so bad.” “You should just forget about it,” “Forgive and forget,” or “You think that’s bad, let me tell you what happened to me.” They don’t understand. In connecting with others, avoid spending all your time talking about your traumatic experiences. Spend time listening to others and sharing positive life experiences, like going to movies or watching a ball game together. You will know when you have described your trauma enough, because you won’t feel like doing it anymore.

Develop a close relationship with another person. You may not feel close to or trust anyone. This may be a result of your traumatic experiences. Part of healing means trusting people again. Think about the person in your life that you like best. Invite them to do something fun with you. If that feels good, make a plan to do something else together at another time—maybe the following week. Keep doing this until you feel close to this person. Then, without giving up on that person, start developing a close relationship with another person. Keep doing this until you have close relationships with at least five people. Support groups and peer support centers are good places to meet people.

Things You Can Do Every Day to Help Yourself Feel Better

There are many things that happen every day that can cause you to feel ill, uncomfortable, upset, anxious, or irritated. You will want to do things to help yourself feel better as quickly as possible, without doing anything that has negative consequences, for example, drinking, committing crimes, hurting yourself, risking your life, or eating lots of junk food.

Read through the following list. Check off the ideas that appeal to you and give each of them a try when you need to help yourself feel better. Make a list of the ones you find to be most useful, along with those you have successfully used in the past, and hang the list in a prominent place—like on your refrigerator door-as a reminder at times when you need to comfort yourself. Use these techniques whenever you are having a hard time or as a special treat to yourself.

_____ Do something fun or creative, something you really enjoy, like crafts, needlework, painting,drawing, woodworking, making a sculpture, reading fiction, comics, mystery novels, or inspirational writings, doing crossword or jigsaw puzzles, playing a game, taking some photographs, going fishing, going to a movie or other community event, or gardening.

_____Get some exercise. Exercise is a great way to help yourself feel better while improving your overall stamina and health. The right exercise can even be fun.


______Write something. Writing can help you feel better. You can keep lists, record dreams, respond to questions, and explore your feelings. All ways are correct. Don’t worry about how well you write. It’s not important. It is only for you. Writing about the trauma or traumatic events also helps a lot. It allows you to safely process the emotions you are experiencing. It tells your mind that you are taking care of the situation and helps to relieve the difficult symptoms you may be experiencing. Keep your writings in a safe place where others cannot read them. Share them only with people you feel comfortable with. You may even want to write a letter to the person or people who have treated you badly, telling them how it affected you, and not send the letter.

_____Use your spiritual resources. Spiritual resources and making use of these resources varies from person to person. For some people it means praying, going to church, or reaching out to a member of the clergy. For others it is meditating or reading affirmations and other kinds of inspirational materials. It may include rituals and ceremonies—whatever feels right to you. Spiritual work does not necessarily occur within the bounds of an organized religion. Remember, you can be spiritual without being religious.

_____Do something routine. When you don’t feel well, it helps to do something “normal”—the kind of thing you do every day or often, things that are part of your routine like taking a shower, washing your hair, making yourself a sandwich, calling a friend or family member, making your bed, walking the dog, or getting gas in the car.

_____Wear something that makes you feel good. Everybody has certain clothes or jewelry that they enjoy wearing. These are the things to wear when you need to comfort yourself.

_____Get some little things done. It always helps you feel better if you accomplish something, even if it is a very small thing. Think of some easy things to do that don’t take much time. Then do them. Here are some ideas: clean out one drawer, put five pictures in a photo album, dust a book case, read a page in a favorite book, do a load of laundry, cook yourself something healthful, send someone a card.

_____Learn something new. Think about a topic that you are interested in but have never explored. Find some information on it in the library. Check it out on the Internet. Go to a class. Look at something in a new way. Read a favorite saying, poem, or piece of scripture, and see if you can find new meaning in it.

____ Do a reality check. Checking in on what is really going on rather than responding to your initial “gut reaction” can be very helpful. For instance, if you come in the house and loud music is playing, it may trigger the thinking that someone is playing the music just to annoy you. The initial reaction is to get really angry with them. That would make both of you feel awful. A reality check gives the person playing the loud music a chance to look at what is really going on. Perhaps the person playing the music thought you wouldn’t be in until later and took advantage of the opportunity to play loud music. If you would call upstairs and ask him to turn down the music so you could rest, he probably would say, “Sure!” It helps if you can stop yourself from jumping to conclusions before you check the facts.

_____ Be present in the moment. This is often referred to as mindfulness. Many of us spend so much time focusing on the future or thinking about the past that we miss out on fully experiencing what is going on in the present. Making a conscious effort to focus your attention on what you are doing right now and what is happening around you can help you feel better. Look around at nature. Feel the weather. Look at the sky when it is filled with stars.

¬¬¬¬_____Stare at something pretty or something that has special meaning for you. Stop what you are doing and take a long, close look at a flower, a leaf, a plant, the sky, a work of art, a souvenir from an adventure, a picture of a loved one, or a picture of yourself. Notice how much better you feel after doing this.

_____Play with children in your family or with a pet. Romping in the grass with a dog, petting a kitten, reading a story to a child, rocking a baby, and similar activities have a calming effect which translates into feeling better.

_____Do a relaxation exercise. There are many good books available that describe relaxation exercises. Try them to discover which ones you prefer. Practice them daily. Use them whenever you need to help yourself feel better. Relaxation tapes which feature relaxing music or nature sounds are available. Just listening for 10 minutes can help you feel better.

_____Take a warm bath. This may sound simplistic, but it helps. If you are lucky enough to have access to a Jacuzzi or hot tub, it’s even better. Warm water is relaxing and healing.

_____Expose yourself to something that smells good to you. Many people have discovered fragrances that help them feel good. Sometimes a bouquet of fragrant flowers or the smell of fresh baked bread will help you feel better.

_____Listen to music. Pay attention to your sense of hearing by pampering yourself with delightful music you really enjoy. Libraries often have records and tapes available for loan. If you enjoy music, make it an essential part of every day.

_____Make music. Making music is also a good way to help yourself feel better. Drums and other kinds of musical instruments are popular ways of relieving tension and increasing well-being. Perhaps you have an instrument that you enjoy playing, like a harmonica, kazoo, penny whistle, or guitar.

_____Sing. Singing helps. It fills your lungs with fresh air and makes you feel better. Sing to yourself. Sing at the top of your lungs. Sing when you are driving your car. Sing when you are in the shower. Sing for the fun of it. Sing along with favorite records, tapes, compact discs, or the radio. Sing the favorite songs you remember from your childhood.

Perhaps you can think of some other things you could do that would help you feel better.



The Healing Journey

Begin your healing journey by thinking about how it is you would like to feel. Write it down or tell someone else. In order to promote your own healing, you may want to work on one or several of the following issues that you know would help you to feel better.

• Learn to know and appreciate your body. Your body is a miracle. Focus on different parts of your body and how they feel. Think about what that part of your body does for you. Go to your library and review books that teach you about your body and how it works.

• Set boundaries and limits that feel right to you. In all relationships you have the right to define your own limits and boundaries so that you feel comfortable and safe. Say “no” to anything you don’t want. For instance, if someone calls you five times a day, you have the right to ask them to call you less often, or even not to call you at all. If someone comes to your home when you don’t want them to be there, you have the right to ask them to leave. Think about what your boundaries are. They may differ from person to person. You may enjoy it a lot when your sister comes to visit, but you may not want a visit from your brother or a cousin. You may not want anyone to call you on the phone after 10 p.m. Expect and insist that others respect your boundaries.

• Learn to be a good advocate for yourself. Ask for what you want and deserve. Work toward getting what you want and need for yourself. If you want to get more education for yourself so you can do work that you enjoy, find out about available programs, and do what it is you need to doto meet your goal. If you want your physician to help you find the cause of physical problems, insist that he or she do so, or refer you to someone else. When you are making important decisions about your life, like getting or staying married, going back to school, or parenting a child, be sure the decision you make is really in your best interest.

• Build your self-esteem. You are a very special and wonderful person. You deserve all the best things that life has to offer. Remind yourself of this over and over again. Go to the library and review books on building your self-esteem. Do some of the suggested activities.

• Develop a list of activities that help you feel better (refer to the list in the section “Things you can do to help yourself feel better”). Do some of these activities every day. Spend more timedoing these activities when you are feeling badly.

• Every family develops certain patterns or ways of thinking about and doing things. Those things you learn in your family as a child will often influence you as an adult—sometimes making your life more difficult and getting in the way of meeting your personal goals. Think about the ways of thinking and doing things that guide you in your life. Ask yourself if they are patterns, and if you need to change them to make your life the way you want it to be. For example, in your family you may have been taught that you never tell anyone certain family secrets. In fact, it may be very important to share some family secrets with trusted friends or health care providers. Or you may have been taught that you must always do what certain members of your family want you to do. As an adult, it is important that you figure out for yourself what it is you want to do. In effect you can become your own loving parent.

• Work to establish harmony with your family or the people you live with. Plan fun and interesting activities with them. Listen to them without being critical.

• Work on learning to communicate with others so that they can easily understand what you mean. When talking with another person about your feelings, use “I” statements, like “I feel sad” or “I feel upset” rather than accusing the other person. You may want to practice good communication with a friend. Ask your friend to give you feedback on how you can be more easily understood.

• You may have lots of negative thoughts about yourself and your life. Work on changing these negative thoughts to positive ones. The more you think positive thoughts the better you will feel. For instance, you may always think, “Nobody likes me.” When you think that thought, replace it with a thought like, “I have many friends.” If you often think that you will never feel better, replacethat thought with the thought, “Every day I am feeling better and better.”

• Develop an action plan for prevention and recovery. This is a simple plan that helps you stay well and respond to upsetting symptoms and events in ways that will keep you feeling well.

Using the activities in the section “Things you can do to help yourself feel better,” make lists of things that will help you keep yourself well and will help you to feel better when you are not feeling well. Include lists:

• to remind yourself of things you need to do every day - like getting a half hour of exercise and eating three healthy meals - and also those things that you may not need to do every day, but ifyou miss them they will cause stress in your life, for example, buying food, paying bills, or cleaning your home;

• of events or situations that may make you feel worse if they come up, like a fight with a family member, health care provider, or social worker, getting a big bill, or loss of something importantto you. Then list things to do (relax, talk to a friend, play your guitar) if these things happen so you won’t start feeling badly;

• of early warning signs that indicate you are starting to feel worse - like always feeling tired, sleeping too much, overeating, dropping things, and losing things.

• Then list things to do (get more rest, take some time off, arrange an appointment with your counselor, cut back on caffeine) to help yourself feel better;

• of signs that things are getting much worse, like you are feeling very depressed, you can’t get out of bed in the morning, or you feel negative about everything.

• Then list things to do that will help you feel better quickly (get someone to stay with you, spend extra time doing things you enjoy, contact your doctor); and

• of information that can be used by others if you become unable to take care of yourself or keep yourself safe, such as signs that indicate you need their help, who you want to help you (give copies of this list to each of these people), the names of your doctor, counselor and pharmacist, all prescriptions and over-the-counter medications, things that others can do that would help youfeel better or keep you safe, and things you do not want others to do or that might make you feel worse.



Barriers to Healing

Are there any things you are doing that are getting in the way of your healing, such as alcohol or drug abuse, being in abusive or unsupportive relationships, self-destructive behaviors such as blaming and shaming yourself, and not taking good care of yourself? Think about the possible negative consequences of these behaviors. For instance, if you get drunk, you might lose control of yourself and the situation and be taken advantage of. If you overeat, the negative consequences might be weight gain, poor body image, and poor health. You may want to work on changing these behaviors by using self-help books, working with a counselor, joining a support group, or attending a 12-step program.



Moving Forward on Your Healing Journey

If you are now about to begin working on recovering from the effects of trauma, or if you have already begun this work and are planning to continue making some changes based on what you have learned, you will need courage and persistence along the way. You may experience setbacks. From time to time you may get so discouraged that you feel like you want to give up. This happens to everyone. Notice how far you’ve come. Appreciate even a little progress. Do something nice for yourself and continue your efforts. You deserve an enjoyable life. Always keep in mind that there are many people, even famous people, who have had traumatic things happen to them. They have worked to relieve the symptoms of this trauma and have gone on to lead happy and rewarding lives. You can too.





Further Resources

Substance Abuse and Mental Health Services Administration (SAMHSA)
Center for Mental Health Services
Web site: http://www.samhsa.gov/

SAMHSA’s National Mental Health Information Center
P.O. Box 42557
Washington, D.C. 20015
1 (800) 789-2647 (voice)
Web site: http://www.mentalhealth.samhsa.gov/

Consumer Organization and Networking Technical Assistance Center
(CONTAC)
P.O. Box 11000
Charleston, WV 25339
1 (888) 825-TECH (8324)
(304) 346-9992 (fax)
Web site: http://www.contac.org/

Depression and Bipolar Support Alliance (DBSA)
(formerly the National Depressive and Manic-Depressive Association)
730 N. Franklin Street, Suite 501
Chicago, IL 60610-3526
(800) 826-3632
Web site: http://www.dbsalliance.org/



National Alliance for the Mentally Ill (NAMI)
(Special Support Center)
Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22201-3042
(703) 524-7600
Web site: http://www.nami.org/



National Empowerment Center
599 Canal Street, 5 East
Lawrence, MA 01840
1-800-power2u
(800)TDD-POWER (TDD)
(978)681-6426 (fax)
Web site: http://www.power2u.org/


National Mental Health Consumers’
Self-Help Clearinghouse
1211 Chestnut Street, Suite 1207
Philadelphia, PA 19107
1 (800) 553-4539 (voice)
(215) 636-6312 (fax)
e-mail: info@mhselfhelp.org
Web site: http://www.mhselfhelp.org/



National Technical Assistance Center (NATC)
National Association of State Mental Health Program Directors
66 Canal Center Plaza, Suite 302
Alexandria, VA 22314
703-739-9333 (voice)
703-548-9517 (fax)
Web site: www.nasmhpd.org/ntac

Resources listed in this document do not constitute an endorsement by CMHS/SAMHSA/HHS, nor are these resources exhaustive. Nothing is implied by an organization not being referenced.

You could also contact your state consumer advocacy network/agency. Find it by looking under Mental Health in the Yellow Pages of your phone book.



Acknowledgements

This publication was funded by the U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS), and prepared by Mary Ellen Copeland, M.S., M.A., under contract number 99M005957. Acknowledgment is given to the many mental health consumers who worked on this project offering advice and suggestions.



Disclaimer

The opinions expressed in this document reflect the personal opinions of the author and are not intended to represent the views, positions or policies of CMHS, SAMHSA, DHHS, or other agencies or offices of the Federal Government.



Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, DHHS.

For additional copies of this document, please call SAMHSA’s National Mental Health Information Center at 1-800-789-2647.

Introduction to Excellent Website on Providing Trauma Informed Services to Women and Girls

Coalescing on Women and Substance Abuse – Linking Research, Practice and Policy


http://www.coalescing-vc.org/index.htm

This site captures material from historical and ongoing projects related to women’s substance use in Canada. The projects described here have been sponsored by the British Columbia Centre of Excellence for Women’s Health with the involvement of many partners. The site was first mounted to share the findings of the Coalescing on Women and Substance Use: Linking Research Practice and Policy project (2003-2008) a project that sparked short-term virtual communities of practice (vCoP) on six key topics related to women's substance use in Canada. Now material continues to be added from both virtual and F2F projects, for example on projects related to girls and heavy alcohol use, and on applying a gender lens to work on the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.

The aim of this site to share and promote action on promising approaches to responding to substance use by girls and women, on the part of service providers, researchers, health system planners and decision makers.

The following discussion questions found on the site can be used by direct services providers to reflect on their current practices and policies in providing trauma-informed services.

1. What have you noticed about the links among trauma, mental illness and substance use problems from your experience of supporting women with these and related challenges?

2. Does your service assume that violence has played some role in the woman’s/girl’s life, even if she has not identified abuse as a source of difficulty?

3. How does your service currently address the needs of girls and women experiencing trauma, substance use and mental health concerns?

4. Does your service provide training to women accessing services in skills useful to healing from trauma as well as substance use and mental health concerns - such as self-soothing, self-esteem, self-trust and assertiveness?

5. Has education (basic information about trauma and its impact) been offered to all staff at your service? Have clinical staff received training on specific modifications of existing services for trauma survivors?

6. What opportunities are there for building awareness/taking action to improve the response for girls and women with substance use problems and related trauma and mental health concerns?

7. Notice the language used within your context. What would happen if ‘symptoms’ were reframed as ‘adaptations’? How would things change at a practice and policy level if ‘disorders’ were considered ‘responses’?

8. Improving the system of care for girls and women requires a paradigm shift from “what is wrong with her?” to “what happened to her?” Consider what this shift might mean for your services or system.

9. How does your organization support efforts to minimize the possibility of re-traumatization?

10. In what ways are girls and women involved in the development of service policies and protocols?

11. How is diversity, such as one’s cultural background, considered in the trauma-specific services you offer?

Harm Reduction in the Context of Domestic Violence Services

This post was taken from Reducing Barriers to Support Women Fleeing Violence, A Toolkit for Supporting Women with Varying Levels of Mental Wellness and Substance Use, a publicaton of the British Columbia Society of Transition Houses.  This particular section of provided by Rhea Redivo of the South Okanagan Women in Need Society.

Harm reduction is a valuable philosophy in approaching women who have substance abuse and mental health issues.


Traditionally, addictions services have focused on abstinence as the primary treatment goal. Harm reduction, however, acknowledges that abstinence, like substance use itself, exists on a continuum. Instead of being a discrete event, it is seen as a progressive, non-linear journey that is unique to each individual and entails both success and failure. For many, immediate and complete abstinence is not only unlikely, but an unrealistic expectation. Relapse and/or some degree of continued use in an inherent part of the recovery journey and therefore expected. The purpose of harm reduction strategies is to reduce the medical, personal and social risks and harms associated with substance use, particularly for the individual, but also for society. Not unlike the purpose of safety planning for women remaining in abusive situation, harm reduction strives to enhance client’s safety while still using and to reduce negative repercussions. In essence, harm reduction strategies ensure clients survive the various stages of their journey with minimal negative effects until such time as they achieve their ultimate goal: abstinence.

As with anti-violence services, the primary focus is safety. Other aspects are raising awareness, respecting choice, and empowering in order to enhance motivation to change. Change is a choice that requires time and commitment to one’s best interests. It must therefore be internally motivated, not externally exposed (Bland &Edmund, 2008). To that end, service is guided by individual need, readiness and choice. Emotional safety is essential. It entails acceptance, respect and gentle honesty while providing information and education that promote women’s understanding of the impact of use on them and their lives, especially health and safety. Recognizing individual strengths and small successes provide encouragement, while acknowledging underlying positive intentions and normalizing substance use as a response to abuse reduces guilt and shame. Empowerment and respecting choice help promote and self-confidence; giving information and raising awareness help increase desire to change. Together, they enhance internal motivation and the likelihood of change.

The basic tenets of ‘harm reduction’ have long formed the basis for anti-violence practice, where the primary goal is to help women reduce, avoid or escape violence and to minimize its effects. Like abstinence, freedom from domestic violence may be the ultimate goal. However, rather than being a discrete event, it is a progressive, non-linear, process that is unique to the individual and occurs over time. Setbacks are also considered an inherent part of the journey and safety planning is standard practice.

Individual choice, education, and empowerment are likewise key practice values, as is the underlying service goal to reduce potential harm pending more substantial change. Women’s needs, readiness and choices guide service provision. Women are not told what to do; they are given information, education and resources so they can decide for themselves what to do. Applying harm reduction requires them same practice values and principles be extended to women who have substance us or mental health issues. Imposing expectations that women immediately leave their abuser or ‘do what we think only revictimizes and disempowers, which undermines, rather than promotes, internal motivation.

Degree of risk
Although domestic violence, substance use, and mental illness often appear together, causal relationships remain unclear. Individually, each can be chronic, progressive, and potentially lethal. When combined, their severity and lethality increase. Since substance use and mental health issues may increase women’s risk for violence as well as the severity of violence, women accessing anti-violence shelters who also have co-occurring substance use or mental health issues are therefore are great risk that those who do not. Mental health issues pose the additional risk of self-harm (Parkes, 2007d). Yet, service is often denied these women due to the very issues that place them at greater risk, which further compromises their safety.

The immediate danger posed by domestic violence is generally great than that posed by substance use or mental health issues, yet either can be equally as lethal as any abuser (Bland, 2008). Policies must therefore strive to balance supporting abstinence with creating safety so that women unable to remain abstinent can ask for help.

Risk reduction involves providing appropriate, effective services for women experiencing both domestic violence and substance use or mental health issues so they can increase their own and their children’s safety and well-being. A harm reduction approach ensures they receive the service they need regardless of these issues or their choices regarding treatment. Inviting women to examine their situation honestly through open, non-critical discussions that also offer information and choices is a key strategy. In addition, substance use and mental health issues must be considered in women’s overall safety plan, which may include identifying triggers for substance use or mental health behaviors, alternate responses, or skill development.

Potential Benefits

Temporary respite from violence provides a window of opportunity for women to reflect not only on violence, but also on substance use or mental health issues, and their impact on health, well-being and safety. Within the safe context of the shelter, women receive safety, support and information that allow them to consider their options. In addition to learning about resources and treatment options available to them, they may also learn alternative coping strategies. These tools allow women to make decision about what will help them on their recovery journey (Bland & Edmund, 2008).

In this way, shelters serve not only as a form of harm reduction, but also as a catalyst for change, and for women with co-occurring substance use, their stay in a shelter appears to be a first step to recovery. Whether brief or more substantive, substance use interventions within shelters appear to help women alter their substance use (Bland & Edmund, 2008). Indeed, after their stay, motivation to use and levels of stress likewise decreased, while perceived ability to face challenges increased. While decline in use is greatest among those with the highest initial level of use and the most significant intervention in the shelter, reductions occurred regardless of the degree of intervention provided (Jategaonkar & Poole, 2004).

More substantive interventions result in more substantive personal change. Incorporating harm reduction and increasing levels of intervention would reduce clients’ risks and provide the necessary support for them to achieve their goals of heal and safety for themselves and their children.

Harm Reduction in the Shelter Context

Research has shown that the most effective intervention offers integrated support nd treatment grounded in policies that recognize the overlap of violence, substance use and mental health issues as well as the context of social and structural determinants (SAMHSA as cited in Poole & the Coalescing on Women and Substance Use Virtual Community, 2007). To be effective service must be grounded in an understanding of how these various issues interact to affect women’s lives and safety.

Harm reduction values and principles must inform all aspects of policy, procedure and service provision. Approach to, and expectations of, clients must likewise reflect these values. Temporary abstinence or other limitations on behavior may be reasonable for some clients; however, for others they are unrealistic and pose a significant barrier, especially for those who still live with violence and have substance use or mental health issues. Imposing such expectations in these cases is contrary to the goals and values of anti-violence services. Encouraging reduction or safer choices may be both more reasonable and more successful.

Service provision must also recognize the potentially differing needs of women with co-occurring substance use or mental health issues. Accompanying memory distortions or cognitive deficits can affect their ability to judge safety, recall incidents, report violence, and enact safety plans. They can also affect their ability to advocate for themselves (Bland & Edmund, 2008), which in turn compromises their capacity to get the help they need or interact effectively with service providers. To accommodate their needs, it may be necessary to repeat information, provide structure, simplify goals, or advocate on their behalf with other service providers so they can access necessary resources. Reducing social stressors like housing, relationships or finances, which likewise interact reciprocally with both substance use and mental health issues, continues to be a key service goal.

Employee Expectations

Harm reduction requires that the issue be addressed. As Bland (2008) states, the “intervention is in the asking.” While shelter employees are not expected to become addictions or mental health counselors, they are expected to be aware of how substance use and mental health issue affect women’s lives and interact with violence. They must be willing and able to create emotional safety for women, to discuss substance use or mental health issues non-critically and without labeling women or judging their treatment choices, and to make links between these issues and the violence they experience or other aspects of their lives. This requires a context of emotional safety. Equally necessary is a thorough knowledge of relevant services and resources, including the degree to which they provide gender-specific services and physical or psychological safety, as well as the potential risks and benefits they present. Providing women with information and choices allows them to decide what they need and how to get it (Poole & the Coalescing on Women & Substance Use Virtual Community, 2007).

In order to admit a problem and ask for help, women need to feel emotionally safe. Emotional safety entails acceptance, sensitivity, gentle honesty and respect. Given the stigma and institutional oppression often associated with substance use or mental health issues, women may initially deny problems. Honesty requires trust, and for women who trust in others and themselves has been repeatedly violated, emotional safety may take time. Blame and moral retribution not only compromise safety, but confirm the stigma they have experience, aggravate the shame and guilt they already feel, and further alienate and disempower them while empowering their abusers.

Screening and Assessment

Given the high co-occurrence of domestic violence with substance use or mental health issues, routine screening and assessment for these issues must be universal. As with screening for violence, the primary purpose of screening for these issues is not to deny service, but to obtain information, in particular information that can help identify those women in need of specific types of support and are then given appropriate choices that help ensure their survival (Bland & Edmund, 2008). In essence, the purpose of screening and assessment to improve the service women receive and thereby enhance their chances of survival despite the challenges they face until they are ready to make larger changes. Their underlying intent is inclusion, not exclusion.

Women are unlikely to identify themselves as addicted (Bland & Edmund, 2008) or mentally ill (Parkes, 2007a) unless their safety is assured. In –depth exploration of these issues is unlikely to occur until trust and safety are established. Initial screening is therefore to be specific and brief and conducted within a context of openness and acceptance. Assessment, which is broader and more comprehensive, begins only after the immediate crisis is over and a trusting relationship has been initiated. In any case, in order to promote safety, and thus disclosure, women are to be offered choices and informed of the reasons behind any questions they are asked.

Safety and Safety Planning

Safety is always paramount, not just for the individual, but also for the group. Effective safety planning must consider individual patterns and consequences of behavior, both in terms of how they affect women personally and their potential effect on other residents. Safety planning is to follow established guidelines within a context of collaboration, sensitivity and respect for all individuals concerned.

Resident Expectations

Creating a safe environment requires consistency, yet flexibility. Rules should be unambiguous, straightforward and specific. Above all, they must be few in number with both expectations and consequences clear and consistently applied. In contrast, guidelines should be wide-ranging and flexible so that enforcement can be responsive to individual needs and circumstances. ‘Fairness,’ like equity, is governed by relativity, and the underlying principle when enforcing rules and guidelines is always a consideration of each woman’s best interests in any given situation.

For more information or to find out how to obtain the above-mentioned toolkit, please contact Linda Douglas at linda@nhcadsv.org

Healing Neen and Being a Drop in the Bucket

A few weeks ago I attended a conference held by the National Association for Infant Mental Health. One of the keynote speakers was Tonier Cain. Her story was inspiring and hopeful. It was also a testimony to the need for trauma responsive services for women.


Tonier spent nineteen years on the streets of Baltimore, using drugs, prostituting, being rape and abused, and going in and out of the correctional system. She had a total of 83 arrests and 66 convictions. She lost five children to the system because of her inability to stay clean and sober and out of jail. It wasn’t until she was able to enter a trauma-responsive treatment program for female offenders that she was able to change her life. She was pregnant and determined not to lose custody of another child and begged a judge to keep her in jail for a few more months so that she would qualify for the program. Once she entered the program she was asked “Tony, what happened to you?” and when she told her life story someone let her know that she was not responsible for all of the bad things that happened to her as a child and she believed them.

Tonier was the oldest child of a drug addict and alcoholic. When she was nine years old her mother had parties and once her mother passed out, her mother’s “guests” would go to the children’s room. Tonier would block the doorway in order to protect her brothers and sisters, sacrificing her safety for theirs. When she was a teenager, her mother signed papers for her to be married to a man who was nine years older than Tonia and who beat her if the house was not as clean as he wanted it to be. She learned that if she used cocaine she was able to find the energy to clean, but was not able to stop the beatings.

Tonier Cain is now a nationally recognized speaker with seven years clean and sober. She is a dynamic advocate for trauma-informed services and is heart wrenchingly honest when speaking about her life.

Tonier’s story is available at http://www.healingneen.org/. The 54 minute DVD is free of charge to anyone desiring a copy. I highly recommend this video as a means of learning how valuable understanding the impact of childhood trauma on a woman’s future can be and knowing that many of the women we work with are responding to the trauma. Also included in the video is a short discussion with Dr. Vincent Filletti M.D., chief researcher of the Adverse Childhood Experiences Study.

As I viewed this video today, I was reminded of a statement made by Patti Bland of the Alaska Network on Domestic Violence and Substance Abuse at a meeting I attended in late September. She stated that “each time we look for reasons not to provide shelter to a battered woman we are colluding with the abuser.” Tonier Cain does not mention it in her video or in her speech, but I can imagine a similar woman seeking services at a domestic violence program and being refused shelter because of her drug use or mental health issues. How often has an abuser used his partner’s drug use or mental illness as a means of control by saying “No one will help you. You’re just a druggie.” “No one is going to take you in. You’re crazy.” And how often is he right? Through the Open Doors to Safety program, this is certainly happening less and less here in New Hampshire. However, there are often other reasons that a woman may not be accepted into shelter that validate the messages that she has been receiving from her current or past abuser. “You’re not worth anything.” “No one will want you.” “You will never get away from me.”

If you work at a shelter program, I invite you to think about Patti Bland’s statement and consider how you can provide services that respond to the trauma that she has experienced through her life and that do not traumatize her further. If you do watch Tonia Cain’s movie, Healing Neen, take time to discuss how you could possible assist a woman who comes to you with a similar story while she is still in active addiction. What community contacts/collaborations do you have in place to assist your program in providing services?

Stephanie Covington, http://www.stephaniecovington.com/ who spoke at the Healing the Wounds of Abuse conference in Manchester and Plymouth NH last month, talked about how we are all drops in the bucket of a woman’s life. She may come and go from our services and we may feel we have failed her. However, we don’t know which drop in the bucket we are, one of the first or one of the many that follow, but eventually, hopefully, there will be enough safety, support, and information provided so that she can make changes in her life. I hope we don’t pass up chances to be a drop in a survivor’s bucket.

Poverty and Trauma - A Paper by Jennifer Frechette, Skidmore College

Dr. Ruby Payne states that the definition of poverty is “the extent to which an individual does without resources.” Payne (2005) states that the resources needed include financial, emotional, spiritual, physical, social support systems, and relationship resources, as well as the knowledge of unspoken social norms (p. 7). Without these, Payne states, people are at higher risk of becoming impoverished and homeless. If these resources and supports are in place the individual is more likely to find stability in others and therefore have support in times of need.


According to the National Child Traumatic Stress Network (NCTSN), homelessness results from severe poverty, the inability to find housing that is affordable, single parenthood, and lack of social supports (2005, p. 1). Those who experience homelessness have an increased susceptibility to trauma, loss of community, family, and security. Families who live in shelters are confronted by many problems such as “the need to reestablish a home, interpersonal difficulties, mental and physical problems” (NCTSN, 2005, p. 1). Homelessness makes families more likely to experience various traumas including physical and sexual assault as well as increased anxiety due to feelings of being overwhelmed and hyper vigilance pertaining to maintaining personal safety (NCTSN, 2005, p. 1). Payne (1996) outlines important things to know about poverty. Firstly, poverty is relative; meaning that it depends on your surroundings and community. Second, poverty occurs everywhere in the world. Third, economic class is ever changing. Fourth, there are different types of poverty, those being generational and situational. Generational, as defined by Payne, is “being in poverty for two generations or longer” whereas situational poverty is caused by circumstances and generally lasts a shorter amount of time. Fifth, society as a whole operates under middle class norms and finally, Payne states that in order to move from “poverty to middle class or middle class to wealth, an individual must give up relationships for achievement.”

The NCTSN ( 2005) states that children bear the most trauma from homelessness stating that homeless children get sick “ twice the rate of other children” and that they “suffer twice as many ear infections, have four times the rate of asthma, and have five times more diarrhea and stomach problems” ( p. 2) . Among these statistics homeless children go hungry twice as often as non-homeless children and are twice as more likely to have difficulty completing each grade of school, as well as are more likely to have difficulties emotionally and behaviorally in school (NCTSN, 2005, p. 2). The NCTSN (2005) states that, “half of school-age homeless children experience anxiety, depression, or withdrawal” (p. 2).

It is important for children in poverty to receive assistance from those around them, including shelter staff. But what is essential is that those that choose to support homeless families provide a safe environment which includes positive role models, positive social interaction, and equality. The NCTSN (2005) states that

By making families co-participants in establishing rules and regulations, and by housing caregivers and children together, programs can help prevent re-traumatization. Programs can also empower families by maximizing their choice and control, thereby ensuring that they constructively use services to attain personal stability and heal emotional hurt (p. 2).

Shelters are the primary safe zone for homeless families in the United States. Many shelters work closely with community health agencies as trauma specific care givers to homeless families (NCTSN, 2005, p. 2). It is important to restore stability, assess trauma within the family, and create a safe net to understand and address the trauma between family members in order to best address and assist each individual family members needs. NCTSN (2005) states that it is important to train shelter staff to understand the link of homelessness and traumatic experience by “promoting wider awareness of the role of trauma in precipitating and extending family homelessness” (p. 2). Collins et al (2010) cite Figley (1988) state that,

"Trauma can impact the family system through several distinct pathways: simultaneous exposure when all members of the family are exposed to the same event; vicarious traumatization or contagion of trauma from an exposed family member to others in the family; intrafamilial trauma when one family member is the perpetrator of the trauma; and secondary stress when traumatic distress symptoms disrupt family functioning (30).Balancing these various pathways for and of trauma can many times distance supports from the

purpose of working with family members who have been exposed to traumatic experiences. Validating each individual in the family’s experience with trauma while balancing the family’s impact or possible perpetration of that event can be difficult. However, what is important to keep in mind is that each family member has a right to be heard and each one is likely to have experienced victimization at some time or another. Balancing the various traumatizations and homelessness of families can be cumbersome; however, there are multiple other factors that play a key role in family functioning. "

Families living in poverty are at risk of facing a number of stressors including conflict within family, violence, various abuses, and neglect from society and are vulnerable to homelessness, financial disparity, and substance abuse (Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayward, A., Kiser, L., Strieder, F.& Thompson, E. , 2010, p. 30). Putnam and Tricett (1993), as cited in Collins (2010) state that there is a concern, among impoverished, about physical safety which is found among multiple generations (p. 30).

Psychological trauma is likely among the homeless for three reasons, (1) The sudden or gradual loss of one's home, (2) the conditions in a shelter and (3) the occurrence of past sexual or physical abuse history previous to homelessness (Goodman, Saxe, and Harvey,1991, p. 1219). Goodman et al( 1991) state that learned helplessness is a potential effect of homelessness that can be prevented by creating an empowering environment around post trauma living and a rebuilding of expectations and norms within the individuals social constructs (p. 1219).

The event of losing one’s home is traumatic enough. What accompanies loss of home is loss of neighbors, community, and places the family that is in this transition in a state of perpetual stress. Goodman et al (1991) cite Shinn, Knickman, & Weitzman (1989, 1991) and Sosin, Pihavin, & Westerfelt (1991), as stating that the transition from being housed to being homeless lasts days, weeks, months, or even longer. Most people living on the street or in shelters have already spent time living with friends or relatives and may have experienced previous episodes of homelessness (p. 1219).

Collins et al ( 2010) cite Wethington et al (2008) as stating that “Although exposure to the social ecology of urban poverty carries significant risk, most children continue to function well and do not develop PTSD” (p. 13). Through supportive relationships with family and friends, these children learn and use coping and problem-solving skills that encourage positive adaptation. Problem solving, coping skills, trauma history, intelligence, supports, poor attachments, and gender of the child are some of the risks and protective factors that children living in poverty can either benefit from or limit children’s ability to adapt and grow (Collins et al, 2010, p. 13) .

Children are the most susceptible to traumatic experience and this susceptibility only increases when they are faced with displacement of home. Goodman et al (1991) state that those that are homeless experience trauma from the process of being homeless but also are traumatized by lack of safety and loss of control in the shelter system (p. 1219) . For many children, stability means going to school each day where their friends are and going home at the end of the day to their family to their bedroom and their space.

One of the most traumatizing experiences that the homeless have is that of leaving the societal norm of what is considered normal for housing and entering into something that is viewed as less than desirable by society. (Goodman et al, 1991, p. 1220). Bowlby ( 1969, 1973) as cited in Goodman et al (1991) states that humans need intimate and long lasting attachments and for homeless children the loss of safety and autonomy makes creating secure emotional attachments difficult (p. 1220). Van der Kolk( 1987) as cited in Goodman et al ( 1991) proposes that “psychological trauma is the perceived severance of secure affiliative bonds, which damages the psychological sense of trust, safety, and security” (p. 1220). Trauma victims that are placed in an unknown and perceivably unsafe living situation often exacerbate their trauma and this often causes distrust and isolation from the social supports of the traumatized, homeless victim ( Goodman et al, 1991, p. 1220). Goodman et al (1991) state that homeless individuals who are able to enter into shelters in their own communities are better off because they can maintain already established connections; otherwise, those made to move out of their neighborhoods many times experience difficulty maintaining ties to that community. Goodman et al (1991) states that, “Physical distance may engender a sense of psychological distance that increases the sense of isolation. Shelter providers should encourage and help homeless residents maintain social networks, thereby building on strengths rather than focusing on deficits” (p. 1222).

By becoming homeless, the individual can often no longer continue their normal routine or functioning extending to work, friends, and otherwise. They lose control over their personal space and their needs which they are forced to rely on others for. Goodman, Saxe, and Harvey (1991) state that the homeless, “may depend on help from others to fulfill their most basic needs, such as eating, sleeping, keeping clean, guarding personal belongings, and caring for children” (1221) . Many shelters separate families, women and children go into one shelter and men in another making what is a stressful situation even worse by further fragmenting families and taking away natural supports put in place within the family as well as removing a potential “safe person” for each individual in the family.

The victimization experienced by homeless women in New York City ranged from 43% being raped by a member of their family, 74% reporting physical abuse, and 25% were robbed (D'Ercole & Struening, 1990 as cited in Goodman et al, 1991, p. 1222). Bassuk and Rosenberg (1988) compared homeless and housed mothers in Boston and found 41% of homeless compared to 5% of housed experienced physical abuse during childhood, and 41% of homeless and 20% of housed had experienced intimate partner violence in their adult lives (Goodman et al, 1991, p. 1222). Collins et al (2010) found in a national study that “50% to 90% of adults in the United States have experienced one or more traumatic events; and 10% to 20% of those exposed will develop all of the symptoms necessary to establish a diagnosis of PTSD” ( p. 21) . Wilson( 2005) cited Newmann and Sallman’s ( 2004) finding that women who experience child abuse are at much higher risk to develop disorders such as anxiety, and substance abuse than women who did not experience child abuse. It was also found that women who experienced sexual abuse as a child ran a higher risk of developing mental health problems such as depression, anxiety, posttraumatic stress disorder among others.

Many of us, when thinking about the poor, automatically turn to third world countries; however, the statistics regarding American children are astounding. According to Collins et al (2010), “49% of American children in urban areas live in low-income families” and that “Families constitute two-fifths of the U.S. homeless population.” (p. 4). 83% of inner city teens have experienced at least one traumatic even and that in that same population, 59%- 92% who are involved in the mental health system report traumatic experiences and urban females are four times more likely to develop severe traumatic stress (Collins et al, 2010, p. 4).

In order to assist those traumatized by and in the homeless and poor communities it is important to keep in mind the family system and structure as a whole. What is important, is treating the family as a whole while recognizing past, present, and future traumas as a whole as well as the various trauma modes experienced by each individual and how that impacted each individual in the collective. Evans & English (2002) and Esposito ( 1999) as cited in Collins et al (2010) state that “There are few well-developed, standardized and empirically supported family therapies for treating family systems impacted by trauma” ( p. 2), meaning those treating family systems in impoverished communities face even a more difficult time finding a successful treatment regime. It is important to understand the effects of trauma and poverty on different family members and among familial relationships, as well as understanding the full range of family members’ responses to trauma and poverty, is critical to improving outcomes.

Collins et al (2010) states that the traumatic context of urban poverty has pervasive effects that slowly erode parent and family function and affect outcomes. Contextual risks of urban poverty (meager resources, crowded conditions, trauma, etc.) affect everyone exposed, but effects on children are exaggerated by reduced parental well-being and family functioning (p. 6).

Understanding the risks of poverty and supporting families, children and parents alike, is essential for actions by parents on children’s problem behaviors (Collins et al, 2010, p. 6).

Goodman et al (1991) states that by viewing homelessness as a psychologically traumatic experience has a number of implications for psychologists and other mental health practitioners. Given that the presence and severity of psychological trauma depends in large part on community response to victims and the overall environment in which they function (see, e.g., Green et al., 1985), improving the psychosocial conditions of shelter life could mitigate or even prevent the development or exacerbation of psychological trauma (p. 1222).

Homelessness in of itself is traumatic. The relief that supports in shelters and social services can provide victims of homelessness is insurmountable.

Homeless children and families experience trauma by virtue of losing their home, community, and stability. Homeless and impoverished people are more likely to experience other forms of trauma as well, such as physical and sexual abuse. What the homeless and impoverished need is support in finding stable employment and housing as well as assistance in addressing their past traumatic experiences. What can assist with decreasing trauma caused by homelessness is support from the surrounding communities and a willingness from society to accept poverty as a reality while breaking down barriers caused by economic status. These actions need to be taken to fully address the trauma the homeless and impoverished experience daily in the United States.


Works Cited:
Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayward,

A., Kiser, L., Strieder, F. Thompson, E. (2010). Understanding the impact of trauma and urban poverty on family systems: Risks, resilience, and interventions. Baltimore, MD: Family Informed Trauma Treatment Center.

http://nctsn.org/nccts/nav.do?pid=ctr_rsch_prod_ar or

http://fittcenter.umaryland.edu/WhitePaper.aspx

Goodman, L., Saxe, L., & Harvey, M. ( 1991). Homelessness as psychological trauma: Broadening perspectives. American Psychologist, 46( 11), 1219- 1225.

National Child Traumatic Stress Network: Homelessness and Extreme Poverty Working Group

( 2005) . Facts on trauma and homeless children . www. NCTSNET. org.

Payne, R.K. (1996). Understanding and working with students and adults from poverty. Instructional Leader 4(2).

Payne, R.K. (2005). A framework for understanding poverty.Highlands, Tx : AHA! Process inc.

Wilson, D. ( 2005). Poverty and child welfare: Understanding the connection. Northwest Institute for Children and Familes.

Sexual assault, domestic violence can damage long-term mental health

(Health.com) -- Women are drastically more likely to develop a mental disorder at some point in their lives if they have been the victim of rape, sexual assault, stalking, or intimate-partner violence, according to a new study in the Journal of the American Medical Association.


While the connection between these harrowing experiences and poor mental health is hardly surprising, experts say the new findings highlight just how strongly the two problems are intertwined -- and how important it is for doctors and other health-care workers to ask women about past episodes of violence, even if they happened years ago.

"When professionals are treating women with depression or mental health issues, it's best to be clued in to the fact that violence might be behind [it]," says Andrea Gielen, Sc.D., director for the Center for Injury Research and Policy at Johns Hopkins University, in Baltimore, who was not involved in the study.

Researchers in Australia analyzed health data from a nationally representative sample of Australian women between the ages of 16 and 85. Episodes of sexual assault, stalking, and other "gender-based violence" were all too common, with 27% of the group reporting at least one episode of abuse.

Fifty-seven percent of the women with a history of abuse also had a history of depression, bipolar disorder, post-traumatic stress, substance abuse, or anxiety (including panic disorder and obsessive-compulsive disorder), versus 28% of the women who had not experienced gender-based violence.

Among women who had been exposed to at least three different types of violence, the rate of mental disorders or substance abuse rose to 89%.

"The extent and strength of the association we found was surprising and very concerning," says lead author Susan Rees, Ph.D., a senior research fellow in psychiatry at the University of New South Wales, in Sydney.

Rees and her colleagues can't say for sure whether the mental health problems in the study were triggered by the violence, or whether women with preexisting mental health issues were more likely to experience violence. (They did, however, control for a range of potential mitigating factors, including socioeconomic status and a family history of psychiatric problems.)

But there is "ample evidence" that traumatic events -- especially interpersonal traumatic events, such as domestic abuse -- can trigger mental problems, Rees says.

Moreover, she adds, episodes of gender-based violence often occur very early in life, whereas mental disorders often don't surface until years later.

Rates of gender-based violence in the U.S. and Australia are comparable, so a study of this kind conducted in the U.S. would likely yield similar results, Rees says. Roughly one-fifth of women in the U.S. say they have experienced intimate-partner violence (which includes domestic abuse), stalking, or both, and 17% say they have been victims of rape or attempted rape, according to the study.

The findings drive home that violence against women is a major public health concern.

"It underscores the impact on society as more than just the immediate consequences, more than just treating women in an emergency department for a violent injury," Gielen says.

Mental health specialists and providers of women's health services should collaborate and develop a unified approach to more effectively screen and treat mental health problems in women who have experienced violence, Rees and her colleagues say.

The U.S. has already taken a promising step in this direction, Gielen says. On Monday, the U.S. Department of Health and Human Services issued new guidelines for preventive care for women that, among other things, require all new health plans to offer no-cost domestic-violence screenings to women beginning in August 2012.

"Almost every public health organization in the country recommends screening for violence, so we're in a really good situation to really move forward," Gielen says. "The big challenge, though, is to work toward what happens after screening: How do we make [screenings] maximally effective, to make sure they really help women?"

Those questions may soon be addressed in the federal Violence Against Women Act, which is up for reauthorization this year. The renewal of the law may provide opportunities for grants, community interventions, and training programs for mental health professionals, Gielen says.

"I think this study really sets up a very hopeful future for providing help to these women who really need it," she says.

Copyright Health Magazine 2010

Generational Poverty and Trauma

  NOTE: Please be aware that for the sake of creating an understanding of some of the issues that pertain to trauma survivors who have grown up in poverty, I will be making some generalized statements. It is very important to know the survivor as an individual with specific issues that may be due to growing up in a specific culture and may not necessarily meet all the characteristics of that culture.


Many of the survivors who seek shelter from domestic violence programs have grown up in generational poverty. Ruby Payne, author of “A Framework for Understanding Poverty” defines generational poverty as families who have lived in poverty for at least two generations, meaning children of parents in poverty grow up to live in poverty themselves. By contrast, families in situational poverty have fallen into poverty because of a traumatic event such as illness or divorce. She writes that families in generational poverty form their own culture with different values, habits and lifestyles from families in the middle class.

Persons who grow up in generational poverty have different values regarding money, different communication styles, and perceive the world based on their own experience. Someone who has grown up in pervasive poverty may not have had resources available with which to develop skills with which they could move out of poverty. These resources include financial means and support systems that can assist the person in moving out of poverty. Trauma also impacts the ability of a person to move out of poverty. Those skills which are necessary in order to maintain safety and survive in a culture of poverty and trauma are primary, while other developmental milestones or skills may not be nurtured and enhanced.

In the following chart I present information based on Ruby Payne’s work but also add in the component of growing up with trauma. It shows the values involved in decision making, conflict resolution, financial decision, and meeting new people and describes the world view of people who have grown up in generation poverty, middle class, wealth, and/or a culture of trauma.

Generational Poverty
Decision Making - Decisions made based on needs of entertainment and relationships


Conflict Resolution - Ability to fight or have someone who is willing to fight for you.

Money - Money is for entertainment and relationships.

World View - The world is what is locally around you.

Meeting New People - Comments are usually made about you before you are introduced to others.


Middle Class

Decision Making - Decisions are made related to work and achievement.


Conflict Resolution - Able to use words as tools to negotiate conflict.

Money - Money is for security and is saved. .

World View - The world is your own nation.

Meeting New People - You introduce yourself to others.

Wealth

Decision Making - Ramifications of the financial, social, and political connections are important to decision making.


Money - Money is for security and is usually invested.

World View - The world is international.

Meeting New People - Someone in the group formally introduces you.

Trauma

Decision Making - Decisions are based on safety


Conflict Resolution - Fight, flight or freeze

Money - The future is improbable. Much has been lost in the past and it is anticipated that loss will occur again. Spending decisions are based on anticipated loss.

World View - The world is unpredictable and limited.

Meeting New People - If I don’t trust you, I won’t talk to you unless I need something from you.



When working with someone who has experienced trauma and poverty it is important not to judge them or have the expectation that they will make decisions the same way that you would if you have not grown up in poverty or with trauma. For example, given that a person has grown up in poverty and trauma she may make a decision to spend an income tax return on entertainment or items needed at this moment rather than saving for the future. For a trauma survivor, given that so much has been lost in the past and that the victim has often felt she is living on borrowed time, saving for a future that may not occur is not considered. By imposing our values on the person we are at risk of alienating her.  It is best to recognize the difference in values and understand that as a domestic violence advocate you need to work within the values of the person for whom you are advocating.

I invite you to have discussions at your workplace that take into consideration the impact of generational poverty and trauma and work toward a greater understanding of the dynamics that occur in the decision making process and communication styles for persons who have not had the resources to be able to move beyond poverty and trauma.

"Working the System"

A couple of months ago I was at a conference where a speaker was discussing children and trauma. He told a story to illustrate the resourcefulness and resiliency of a 15 year old girl whose mother was a prostitute and a drug addict. This young girl also had four brothers and sisters and they were all left to their own devises, basically raising themselves. The gentleman had asked the young girl what she was doing for food. She responded that she was having a hot meal every night of the week. He was surprised. “How do you do that?” he asked. “Well, I know if I go to my friend’s house on Tuesday nights and am hanging around there between 5 and 5:30 that her mom will ask me to stay for dinner. I like that because Tuesday is spaghetti night at her house. On Friday night the Congregational Church as a free dinner and there are other places that serve meal on other nights. I’ve got it covered most nights” she told him. The speaker went on to talk about how resourceful this young girl was. I raised my hand and asked him, “What happens between the age of 15 and 25? Why is it that we can call her resourceful at 15 and at 25 we accuse her of working the system?”

That is the question I want to ask of people. If someone grows up in poverty and is living under the rules of a welfare system, this is the system in which their skill base is built. In fact, there may have been few if any opportunities to learn other skills with which to build a life. Many of us judge people in poverty from our middle class viewpoint, expecting people to have had the same level of support and education that we have had. Unfortunately, this is not true. People who grew up in poverty and trauma have many skills that have served to help them survive. These include knowing where to get a hot meal, how to manage on food stamps, how to keep the landlord at bay, where to sleep in order to stay warm, and what to say or do in order to get needs met. This may mean “lying,”, “manipulating,” and “working the system” in order to have these needs met, because they have learned in the past that telling the truth did not always get needs met and the system is set up in a way that it requires someone to “work it.”

As advocates, we can provide opportunities to learn new survival skills once the person feels safe and stable. Safety and stability means being treated with non-judgment and with recognition of the resiliency and resourcefulness that has gotten her to your door. If she continues to use old skills even after learning new skills, then remember how long it has taken you to learn something new and apply it, or to break an old habit, or just remember that she may not feel safe enough to change yet.

Building relationships based on trust is a key to recovering from trauma. Knowing that you are emotionally safe from judgment is a key component in building that trust.

Book Review – The Boy Who Was Raised as a Dog and other stories from a child psychiatrist’s notebook by Bruce D. Perry, M.D., PhD., and Maia Szalavitz

I have had a number of survivors ask me questions about what trauma has done to their children and how they can help them recover from the impact of witnessing domestic violence or suffering from sexual abuse. Amidst the stories of children who experienced extreme abuse and neglect, Dr. Perry and Ms. Szalavitz, in their book, The Boy Who Was Raised as a Dog, provide hope and encouragement for parents and those who work with traumatized children.

First of all, let me warn you, this book is not for bedtime reading or for reading in large doses. It is hard to put down, but the reader should take breaks, practice self-care, and not focus solely on the horrific stories, but also on the successes that have occurred by providing nurturing, healing environments for children.

Included are the stories of the children of the Branch Davidian cult in Waco, Texas, the effects of living in extreme neglect (a child from a eastern European orphanage, a baby left alone for 8 hours a day by a babysitter who only returned to the house to change his diaper), and children who had suffered from sexual abuse. There is also the story of the children in Gilmer, TX who were the focus in an investigation which led to hysteria and accusations of ritual Satanic abuse.

In addition to describing how trauma affects the brain of a developing child, Dr. Perry also describes how treating the child as if they were still at the age during which the abuse occurred results in the brain being able to get back on track developmentally. The writer’s tell the story of Mama P. who taught a young mother how to nurture her child after the doctors had learned from Mama P the importance of cuddles and hugs. This is not the story of doctors in labs studying rats, but the story of a doctor willing to learn from children and parents about what is best for the child. Dr. Perry spent many hours on the floor with the child, paper and a box of crayons, letting the child lead the way rather than forcing therapy on a child who did not feel safe.

According to the authors, “The human brain develops sequentially in roughly the same order in which its regions evolved. The most primitive, central areas, starting with the brainstem, develop first. As a child grows, each successive brain region, in turn, undergoes important changes and growth. But in order to develop properly each area requires appropriately timed, patterned, repetitive experiences. The neurosequential approach to helping traumatized and maltreated children first examines which regions and functions are underdeveloped or poorly functioning and then works to provide the missing stimulation to help the grain resume a more normal development.” Basically, if a child missed out on a lot of play, nurturing, etc, the then need to have those experiences to be able to develop into full functional adult.

In the last chapter, the authors reiterate what we have also learned from Judith Herman’s book, Trauma & Recovery; healing from trauma occurs best in communities of healthy and nurturing adults. The implications of living in a transient society with less and less money available for safe and stimulating child care, and schools that focus more on cognitive development than on a child’s emotional and physical needs are also discussed, leaving the reader wondering how the recent cuts in many needed programs will affect the next generation.

I highly recommend this book for anyone who is working with traumatized and abused children.

Overview of Supporting Children Living with Grief and Trauma

Last week I attend a training hosted by the Office for Victims of Crime on Supporting Children Living with Grief and Trauma: A Multidisciplinary Approach. The following is a brief review of the information along with some references for further reading.

Children are exposed to violence in every country and every society and across all social and economic groups. There are many ways to categorize these acts. Three of the most common are interpersonal violence, institutional violence, and structural violence.

According to the FBI, 27% of all violence occurs in a family setting. (National Indicent-Based Reporting System, 1996.)

Every year, 3 to 10 million children witness domestic violence. (Carter, Weithorn, Behrman, 1999.)

Children who witness violence at home display emotional and behavioral disturbances as diverse as withdrawal, low self-esteem, and nightmares; and aggression against peers, family members, and property. (Peled, Jaffe, Edleson, 1995.)

About 3.3% of all reported crimes reported take place on school property. Crimes were highest in October.

More than half of the arrestees associated with school crime were arrested for simple assault or drug/narcotic violations.

Children who watch a lot of TV news tend to overestimate the prevalence of crime and may perceive the world to be a more dangerous place than it actually is. (Smith, Wilson, 2002.)



Risk factors that determine if a child will be susceptible to experiencing trauma:
Pre-Event
Age, genetics, intelligence, medical factors
Family stability/instability/lack of bonding
Developmental level
Psychological problems of the child
Previous trauma experiences/early losses
Self-esteem issues of the child
Gender (girls are more likely than boys to suffer trauma)

During the Event

Chaos, lack of control, suddenness of the event
Duration of the event
Age and gender
Inability to help
Time needed to process the event
Physical closeness to the event
Amount of gore, blood exposure, and/or level of atrocity
Perception/mean of the event
Number of incidents
Relationship to victim and/or perpetrator (intentional/accidental)

Post-Event
Media coverage
Cultural influences
Threat of reoccurrence
Shame
Resulting changes and losses
Existence of grief and survivor guilt
Problems with confidentiality
Changes in family and health
Stigma put on child by others, e.g., shunning
Criminal investigation/court involvement
Responses of organization (church, school, community resources)



Impact of Trauma on the Fetus

New studies are showing that there are many complex, long lasting connections between genetics and external factors that influence a child’s brain development. Studies have shown that trauma impacts children while they are still in the womb. When mothers are under heavy stress or have PTSD, the fetus is impacted in a number of ways. Studies of pregnant women who witness the 9/11 World Trade Center collapse showed that the mothers passed on markers of PTSD to their unborn babies. Higher cortisol levels (stress hormones) in mid-pregnancy result in smaller fetuses.

Please see my previous post on how trauma impacts the brains of children,  Effects of Maltreatment on Children

One interesting antidote of the training was the story of the children who were being held in the Branch Davidian compound in Waco, Texas. These children were being interview by the local child protective service agency and were assessed as not having been impacted by the abuse that they had endured at the hands of David Koresh. However, Dr. Bruce Perry came in and engaged in activities with the children that led to his eventually being able to connect them to EEG and EKG machines. When he asked them about what happened to them in the compound the trauma reactions were recorded on the EEG and EKGs, proving that the children were experience trauma responses internally. They had, however, learned in the compound not to express distress outwardly due to the danger of further abuse.



According to Dr. Perry www.childtrauma.org/ there are six core strengths that are an essential part of healthy emotional development of children. They are:

Attachment – the capacity to form and maintain healthy relationships and healthy emotional bonds.

Self-regulation – the capacity to notice and control primary urges such as hunger and sleep, as well as emotions such as fear, anger, and frustration. A child who self regulates learns how to put a moment between an impulse and an action.

Affiliation – the capacity to join others and contribute to a group. The child needs a predictable, safe environment with their peers.

Attunement – recognizing the needs, interests, strengths, and values of others.

Tolerance – the capacity to understand and accept how others are different from the self. Tolerance builds on adult modeling of appreciation of differences.

Respect – appreciating the worth in self and in others.

Core strengths are developmental characteristics that help a child grow into a mature and responsible adult. Resiliencies are the characteristics that allow a child to recover after a traumatic event. Resiliencies include: insight, independence, relationships, initiative, humor, creativity, and morality. Please see www.resiliency.com/  for more information.

Therapeutic models for working with children and grief include cognitive behavioral therapy http://tfcbt.musc.edu/, Eye Movement Desensitization Reprocessing (EMDR) www.emdr.com/, art therapy trauma-informed-art-therapy, writing therapy, play therapy, equine assisted therapy animal-assisted-therapy-heals-childhood-trauma, and group therapy. 

I encourage you to explore the above links to learn more about what can be done to help children who have experienced trauma and grief.