Please take the time to read another blog - Women. Healing. Violence.

This blog post came to my attention today and I am hoping that you will find it as valuable and compelling as I have.

Please note that this full piece is very powerful and can be triggering for some.  Please read slowly and take breaks if necessary.  

Here are a few excerpts from Is it possible to recover from rape and sexual abuse? Yes and No by Laura S. Kerr PhD on her blog "Women, Healing and Violence."  I hope you will take the time to read the full post at http://womenhealingviolence.wordpress.com/2014/11/23/is-it-possible-to-recover-from-rape-and-sexual-abuse-yes-and-no/

"...the process of healing from sexual violence is slow, painful, and expensive. And because I have worked hard for a peaceful mind and body, I am protective of them. I have a low tolerance of toxic attitudes and behaviors that might upend my recovery. But I am also quick to stand up to injustices that impact others, and I have witnessed this trait in people like myself who are committed to healing their wounds of violence and abuse. Unintentionally, we become warriors of the heart — the would-be Bodhisattvas and protectors of those less fortunate and vulnerable — those we imagine are like we were before we reclaimed our right to dignity and self-preservation, and those we imagine could become victims like we once were."

"After sexual violence, most women want to forget what happened, and return to the lives they led prior to the assault. The survivor desires to be the person she was before, and avoid perceiving herself as irrevocably damaged by the rape or sexual abuse. Confusion, humiliation, and hurt are common, and contribute to self-doubt and silence.

Consequently, women often choose a course of action that will protect them from the imagined judgment of others, including avoiding seeking help. And who can blame us? Throughout history, women have been held responsible for the sexual violence perpetrated against them. Remaining silent just may be an archetypal defense response to the anticipated judgment and shaming that across the millennia have been the common response to sexually violated women (along with forced prostitution, stoning to death, and abandonment)."

Book Review – The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel Van der Kolk, MD, Penguin Group, New York, 2014

I am very excited about this recently published book by Dr. Bessel Van der Kolk.  Initially, I did not think that another book could be placed alongside Judith Herman’s Trauma and Recovery as a “go to” text on the intricacies trauma and its effects.  However, I am now going to refer to The Body Keeps the Score as the new, much needed, reference book for anyone interested in the effects of trauma and the varied ways to address its impact on people’s lives.

Not only is this book full of information but it is also written in a format that makes for interesting and engaging reading.  It is not written like a research paper, although the research is well documented.  I was able to read it for hours at a time, not something I can usually do with research articles.

In The Body Keeps the Score, Dr. Van der Kolk relates the history behind today’s current focus on trauma in veterans and survivors of interpersonal trauma.  He tells stories from his own years working for the Veteran’s Administration and finding that the psychotic episodes that veterans were being diagnosed as having (and for which they were heavily medicated) were actually flashbacks of experiences that had occurred in the jungles of Viet Nam.  This eventually led to post traumatic stress disorder being included in the Diagnostic and Statistical Manual when it first arrived in the 1980s.  Dr. Van der Kolk, however, does not tread lightly around the issues surrounding the DSM and its later iterations.  Instead, he is very critical of the process of creating the DSM and its subsequent use by insurance companies, something for which it was never designed. 

Dr. Van der Kolk also describes how after extensive research came out about childhood trauma and its long term impacts he and his colleagues came to the conclusion that a new diagnosis of Development Trauma Disorder needed to included.  This was a request that was denied by the American Psychiatric Association in 2011 even after the results of the Adverse Childhood Experience study were made an integral part of current trauma research.  This has resulted in a loss of research and funding that would assist in addressing the needs of children who have suffered from chronic trauma and continue to be misdiagnosed and heavily medicated in lieu of much needed trauma treatment.

In addition to extensively covering the effects of trauma on children, Dr. Van der Kolk also addresses the controversy surrounding repressed memories and the misguided notions still prevalent in the psychiatric world that repressed memories are not factual.  He provides anecdotal and research based evidence that validates the experiences of people who have regained memories of childhood abuse. 

The most helpful part of this book, and it is really hard to narrow down the best part, is Dr. Van der Kolk’s review of the most helpful trauma therapies.  His devotion to body based modalities is evident and he strong advises against talk therapy as it generates activation/arousal responses that are not helpful until the person is able to trust their body’s responses.  He states that it is through body based modalities that a trauma survivor will eventually gain “self-ownership of their body.”  I am sure that many survivors with whom we work would appreciate knowing that this is a possibility.

I highly encourage anyone who is interested in the field of trauma studies and/or works with survivors of trauma to add this book to their library

Barriers to Leaving – Looking in the Mirror at Domestic Violence Programs

I have spent a large portion of my career working with domestic violence programs both from within and as a part of the community.  There have been a lot of changes over the years that have increased access to domestic violence programs that have made big differences in the lives of survivors who seek a safe environment in which to focus on the next steps in they want to take in order to be free of abuse.

In the past, many domestic violence programs were guilty of restricting access to survivors who were using drugs or alcohol or who had a mental illness.  I remember talking to one program many years ago that had a policy that a person who had used alcohol or drugs in the past thirty days would not be allowed into shelter until she had thirty days clean and sober.  I informed them that I knew that half their staff would not be able to get into shelter if needed.  Eventually, programs realized that expecting a survivor to get clean and sober who was self- medicating the effects of trauma or living with an abuser who used drugs or alcohol as a means of control was unrealistic and was, as Patti Bland of the National Center on DV, Trauma and Mental Health puts it “actually placing the program in the position of colluding with the abuser.”

Another positive step we have taken is the realization that even though domestic violence programs are not (and should never be) clinical programs, we can provide support services to survivors who are experiencing effects of trauma that have often been seen as mental health issues.  Programs no longer ask about medications as a means of determining if a person has a mental health issue and then using that as an excuse to screen someone out of shelter.  It can’t be done and, fortunately, is not being done. 

However, I feel that some programs, after all of these positive changes, forget that we still need to be diligent in looking at the things that may still be happening that set up barriers and decrease the probability that a survivor will seek services from a domestic violence program.  Programs are often so overwhelmed by the ongoing failures and barriers within their community and society that they become complacent and forget to focus on the barriers that may be generated by the domestic violence program.  Here are a few areas that need to be considered in order to truly reduce barriers and provide victim-center services:

Comprehensive Safety Planning vs. Refusing to House Survivors Who Live in the Same Town/City as the Shelter:  Whenever a program says that they cannot house a survivor and her children because she and her abuser live in the same town as the shelter they are setting up a barrier.  The program is forcing a victim to choose between her job/home and her and her children’s local support and safety.  We are saying that in order to receive services she needs to give up even more than she already has to at the hands of the abuser.  Solutions to this issue would be to investigate the “open shelter” concept in which the community is well aware of the location of the shelter, thus encouraging neighbors to report suspicious activity, and making safety planning a high priority in order to be able to assist the survivor in being able to access local resources and maintain employment while still living in the same community as her abuser.  This will reduce transportation issues for court and visitation also.  Yes, there are times when a victim needs to leave the area for her safety, but this should be her choice.

Case Management vs. Support Services:  I am concerned about the concept of “case management.”  As the executive director of a community mental health program I once worked for said “people are not ‘cases’ to be managed.  They are to be supported.”  If we start looking at victims as cases we are in danger of limiting the services we provide to a menu rather than taking a victim-centered approach to supporting the person in the decisions she makes for her future.  We are also in danger of moving to a more clinical approach that looks at symptoms and issues rather than coping skills, victim needs, and systems of oppression and barriers in the community.

Modeling DV Programs’ Services After Homeless Programs:  When we start to provide services in the manner of homeless services we are in danger of forgetting about the issues of domestic violence and trauma.  I have seen program staff become too eager to move the survivor to housing while not addressing the issues of domestic violence and trauma.  Programs need to go back to their mission statement and review the primary purpose of the organization.

The best way to look at services in a program and determine whether or not the services are a barrier to survivors seeking safety is for staff to put themselves in the shoes of the victim.  We often do an exercise called “In Her Shoes” to point out the barriers and difficulties in the community, but we also need to do the same for our programs.  Ask yourself, “If I was a woman in danger, would this program meet my needs for safety, connection, and stability?”

Book Review and Recommendation– Domestic Violence Advocacy: Complex Lives/Difficult Choices 2nd Edition by Jill M. Davies and Eleanor Lyon

I would like to start this post off by saying that this book should be a part of every domestic violence advocacy agency’s library.  Written by Attorney Jill Davies, deputy director of Greater Hartford Legal Aid, Inc.  with over thirty years of working on behalf of family violence victims, and Eleanor Lyon, PhD., former director of the Institute for Violence Prevention and Reduction and consultant with the National Resource Center on DV, Trauma and Mental Health and Futures Without Violence, this book is a comprehensive study and manual for working with survivors of intimate partner violence. 

The basis of the book is to define and encourage the use of victim-defined advocacy.  Victim-defined advocacy broadens advocacy to partnering with the survivor in order to use the victim’s knowledge and perspective in order to make the victim safer.  It includes “learning about her risk analysis and life circumstances, along with her priorities, past and current safety plans and relationship decisions” and building a partnership to review the risks and identify options relevant to her priorities and the dangers she faces.  It is a dynamic and interactive process. 

In addition to the discussion of victim-defined advocacy (which includes stories of survivors and how advocates work with them) the book also provides material on children exposed to domestic violence and working with women with trauma, mental health and substance abuse issues to understand their perspectives and developing safety plans that encompass those issues.  The last section of the book is focused on systems advocacy.

One of the most valuable components of the book for me was a discussion of life generated risks and the batterer’s manipulation of those risks to coerce the partner into staying in the relationship.  It helps move the question from “why doesn’t she just leave?” to “what keeps her from leaving?”  For example, poverty and financial limitations (i.e. limited transportation, limited job opportunities, and limited housing options) are often reinforced by the batterer as a means of control and manipulation.  I am currently using this material in trainings and find it to be valuable in generating discussion.

This book is available through Sage Publications at http://www.sagepub.com/books/Book238008?siteId=sage-us&prodTypes=any&q=domestic+violence+advocacy&fs=1

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:

http://www.opdv.ny.gov/professionals/tbi/dvandtbiprint.pdf

http://www.biausa.org/tbims-abstracts/domestic-violence-related-mild-traumatic-brain-injuries-in-women

http://www.opdv.state.ny.us/professionals/tbi/dvandtbi_infoguide.html

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

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.  

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:

http://www.pickthebrain.com/blog/post-traumatic-growth-what-research-says-about-why-some-grow-while-others-break-in-the-face-of-adversity/

http://trauma-recovery.ca/resiliency/post-traumatic-growth/

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/

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.

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

I went to the 25^th 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.html “ Pain 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.

Coping with Grief and Loss after Trauma

When someone loses a loved one to death it is recognized that the person will go through a grieving process that is considered acceptable by family and society.  Not only is it accepted but there are rituals to assist the person in mourning the loss and family and friends provide support and companionship at various levels after the death of the loved one. 

Unfortunately the grief that one feels after trauma or the end of an abusive relationship is often not recognized and validated for the one who has experienced the trauma.  In fact, the person who has experienced the loss may not even recognize the grief and loss involved until she has begun the healing process.

Significant traumatic events, particularly interpersonal trauma, extreme physical trauma, and the trauma of war, change the life of person who has experienced it.  The change can actually create a new life in which the person feels the loss of who he or she might have been.  In the loss of a relationship, even one in which the person was abused, she may be mourning the loss of the relationship she was hoping to have rather than the actual one she no longer has.   This grief is rarely recognized or addressed, even though many of the feelings occurring post-trauma can be traced back to grief.

Validation of this loss can provide an opportunity for the person to begin to recognize what she may be feeling.  I have heard people rebel against being called a “victim” or a “survivor” because they did not like the new identity and instead wanted to go back to who they were.  This anger is a part of the grieving process. 

In order to assist a person through this process it may be helpful to ask about personal and culturally appropriate rituals that are used to help and spend some time talking about the loss.  After this loss has been recognized the person may then be willing to look at who they have become since the trauma and the strength and resilience that they carry that has helped them get through both the trauma and the loss.

Moving Beyond Being Trauma-Informed

I have never really felt comfortable with the term “trauma-informed.”  It seems passive and too open to interpretation.  Anyone can pick up a book, read an article, or even a blog post and become informed about trauma.  At its most basic, it implies some knowledge of what trauma is and what it does.  It can also be expanded to be a philosophical underpinning of the work that we do to assist victim/survivors of domestic and sexual violence, an understanding that the effects of trauma are because of what was done to a person rather than there being something wrong with her/him.  However, what we really want to be is “trauma-responsive.”  This moves our programs from the basic understanding of trauma to not only having knowledge of the effects of trauma, but also incorporating activities, policies, and interactions that value the experience of the survivor, assist in finding ways to mitigate the impact of trauma, and reduce the possibility of triggering or re-victimizing.

In order to have a definition of trauma-informed services that addresses the needs of domestic violence survivors, the National Center on Domestic Violence, Trauma and Mental Health created the following working definition of “trauma-informed” that moves beyond passive knowledge to a genuine active response. 

”A trauma-informed program, organization, system, or community is one that has undergone a transformation in awareness about the traumatic effects of abuse and violence and incorporates that understanding into every aspect of its practice or program. In such settings, understanding about trauma is reflected in the knowledge, attitudes, and skills of individuals as well as in organizational structures such as policies, procedures, language, and supports for staff.  This includes attending to culturally specific experiences of trauma and providing culturally relevant and linguistically appropriate services. Any person, system, or setting can be trauma-informed. A DV program that is trauma-informed recognizes that survivors, staff, and others they interact with may be affected by trauma they have experienced at some point in their lives. Central to this perspective is viewing trauma-related responses from the vantage point of “what happened to you” rather than “what’s wrong with you,” recognizing these responses as survival strategies, and focusing on survivors’ individual and collective strengths. Trauma-informed programs are welcoming and inclusive and based on principles of respect, dignity, inclusiveness, trustworthiness, empowerment, choice, connection, and hope. They are designed to attend to both physical and emotional safety, to avoid retraumatizing those who seek assistance, to support healing and recovery, and to facilitate meaningful participation of survivors in the design, implementation, and evaluation of services. Supervision and support for staff to safely reflect on and attend to their own responses and to learn and grow from their experiences is another critical aspect of trauma-informed work.” (Training the Trainers Curriculum, NCDVTMH, 2011)

If your program meets this definition, then it is meeting the needs of survivors in a more active, responsive way.

Practicing Non-Violence Toward Self - an excerpt from a piece by Phillip Moffitt

I read this  over the weekend and thought I would share portions of it with you as part of my short series on self-care.  The full piece can be found at http://dharmawisdom.org/teachings/articles/practicing-nonviolence-toward-self

Understanding Violence

Whenever I introduce the topic of violence against self in a Dharma talk, almost everyone squirms. No one wants to hear it. I will directly ask the question: Are you, in an obvious manner or in a series of subtle, covert actions, being violent with yourself? Usually people want to assure me that while they may work too hard at times, stay in an unhealthy relationship, eat too much, or sleep too little, they would not characterize their behavior as violent toward themselves. Yet, person after person, once they've closely examined their lives, experiences a moment of self-recognition that at first can be painful and embarrassing. This initial discomfort is often followed by a sense of liberation as new possibilities arise in their imaginations for how to live more peacefully.

Most people perpetrate this violence against self through mistakenly identifying with various thoughts that arise due to impersonal conditions coming together. The body and mind's well-being are the innocent victims. Each individual has a unique pattern, but the common ground is that you relate to yourself in a manner that results in your life being more emotionally or physically violent than it need be.

You may have limited your understanding of self-violence to physical abuse or other blatant self-destructive behavior that calls for a 12-step program. The word "violence" may sound too harsh to you, but its dictionary meaning is "an exertion of extreme force to cause injury or abuse in the form of distortion or infringement." The extreme force can be a mental act that then shows up in the body or an act that is done repeatedly to an extreme.

You can think of violence as any highly energetic form of relating to a person, including yourself, that is jarring, turbulent, and distorting. Can you identify any times in the last few days in which you treated yourself in a discordant, abrupt, or distorting manner?

The Trappist monk and spiritual author Thomas Merton once said, "To allow oneself to be carried away by a multitude of conflicting concerns, to surrender to too many demands, to commit to too many projects, to want to help everyone in everything is itself to succumb to the violence of our times." Obviously Merton wasn't speaking about pathologically self-destructive behavior. Instead he was drawing our attention to the shadow side of normative, even seemingly positive, culturally approved behavior. He was referring to how we do great violence to ourselves simply in the manner in which we go about arranging our lives.

Gradually I've come to realize that violence against oneself is one of the great denials of our time. People are very willing to talk about the violence that the world does to them, but they're much less willing to own the violence that they do to themselves. Violence against self can most easily be recognized in your experience of the body in daily life. You already know the general health problems that come about because of stress, sleep deprivation, and constant strain. You may not identify them as examples of violence to self, but anytime you make yourself sick or dysfunctional, it is an act of violence for which you need to take responsibility. We all know people who are overworked or have too much stress, which causes problems with the digestive system, heart, or other parts of the body, but who never label their behavior as violence to the self. But is there any description that is more apt?

One of the yamas, or moral restraints, in Patanjali's Yoga Sutra is ahimsa, the practice of nonviolence, and this includes nonviolence toward yourself. Of course, you may well want something in your life so much that you are willing to take a chance of hurting your body by driving it too hard. But usually a conscious, short-term exertion to reach a goal is not what causes violence to self. More often it is a matter of long-term disregard of the signals of imbalance. This disregard comes from repeatedly getting so caught in wanting or fearful mind-states that you're unable to reflect on your own behavior. You may have a surface-level awareness of the distress you are feeling in your body, but you don't sincerely respond to the discomfort. In such instances you are in a driven state, controlled by your mind's imaginary creations rather than your inner values.

Inner development and maturity come from acknowledging to yourself that you are being violent with a human being; the fact that you happen to be the human being who is being hurt does not change the truth of the violence. From a spiritual perspective, it is never right to hurt any human being; including yourself; for selfish reasons or because of sloppy attention to the consequences of your actions. Understanding this is your first step in practicing ahimsa toward yourself.

Taking Time Out

As the Thomas Merton quote points out, if you abuse your time, you are participating in violence against self. This may be in the form of overscheduling to the point that you rob yourself of the experience of being alive. Or it may be in the form of allocating your time in a manner that doesn't reflect your inner priorities. Both create a distortion or infringement of self through strain and turbulence. When you treat your time as though you are a machine; a doing machine; you are committing violence against the sacredness of life itself. Whenever I do Life Balance work with organizational leaders, I have them make a list of their values and prioritize them, then compare their priorities with how they actually spend their time. The disparity is usually shocking.

Another abuse of time that disturbs your well-being occurs if you succumb to the modern-day compulsion to avoid boredom at all costs. In our stimulation-based culture, there is near hysteria around constantly seeking fulfillment through activity, which leaves no time for the quietness of simply being present with yourself. Do you allow yourself time each day, or even weekly, to exist without an external purpose and without even background music or television? Empty time is vital to your well-being, and to deny yourself this nourishment is an act of violence.

You may ask why you continue to abuse your time and your body when you have the option to live more peacefully. Or you may say that you feel as though you have no choice but to be harsh toward yourself because your life situation is such a struggle. Under either circumstance you push the body and strain the mind violently because you are filled with the tension that comes with the feeling that there's not enough of something in your life, whether it's money, love, adventure, or confidence.

Feelings of inadequacy, vulnerability, longing, or not having enough are an inevitable part of the human experience. If you, like most people, have not found spiritual freedom, you cannot stop them from arising. But you can stop such feelings from controlling your life by changing how you perceive them. If you refuse to identify with these feelings, disown them as being neither you nor yours, thus seeing them simply as emotional states of mind that come and go, you will discover there is the possibility for some inner harmony even under difficult circumstances.

For instance, let's assume you cannot change your work schedule, and it seems so overwhelming to you that you regularly get very tense and anxious about it. You can experience the schedule as much less violent by not thinking about it in its entirety except when you are in planning mode. The rest of the time you just do what the plan calls for, concentrating on the task in front of you without adding the thought, "Here I am with all this work and so much more to do this week."

Said another way, don't make a panoramic movie out of your difficult schedule such that you are constantly seeing yourself doing all that has to be done, as if it were going to be done all at once. Instead just do what has to be done right now, for that's all you can do. It may sound like a simple thing to do, but it is very subtle and difficult, yet so liberating!

Another method you can use to cope with overscheduling is to notice each time you experience fear or wanting while thinking about all you have to do. Consciously label these feelings as fear and wanting in your mind and then see for yourself that they originate as impersonal mind-states, the way a storm forms due to weather conditions. The land that receives the storm does not own it, and the storm is not the land; it's just a storm, which due to its own characteristics can cause damage. So it is with the stormy situations in your life where there is a tendency to both deny and take ownership of fear or wanting. This misperception leads you to believe you should be able to control them, which in turn causes the physical contractions and the mental anguish that constitute violence to self.

Stopping the Violence

In seeking freedom from violence to self, practice noticing over and over again that you are constantly, and usually unconsciously, wanting things to be different than the way they are. You become a little dictator to yourself, sitting on a throne, arms crossed, pouting and demanding that things you like should stay the way they are forever and what you do not like should disappear immediately. This craving to hold on to what you like and to get rid of what you find difficult is considered the source of suffering in life and the origin of violence against self. By practicing living with things as they are, you will discover that while life may not be less painful, your experience of it is immeasurably better. Also, fully accepting what is true in the moment is the only firm place to begin to make changes in your life. Living in the moment is not a one-time commitment but something that has to be done again and again.

Nonviolence to self is a lifetime practice of which there are ever more subtle levels to discover. The more you are able to be with yourself in a nonviolent way, the less harm you will do to another. Be gentle with the body and mind; refuse to get caught in believing that things have to be a certain way in order for you to be happy.

Why Is Self-Care So Hard?

I was talking to another advocate the other day about the importance of self-care and came to a few realizations.    Those of us working in domestic violence and sexual assault field are impacted every day by the stories that we hear and we need to have downtime in order to recover from the effects of vicarious trauma.  But many of us seldom take the time.  When asked “why not?” many will just shrug their shoulders and say “I don’t have the time.”  I think that for many people it really goes deeper than that.  I think that if a person asks herself why she can’t find the time, the answer reflects more about the person’s regard for herself than it does time constraints. 

1.        “I am not important enough.”  This reflects an attitude that the advocate feels that the problems of others are more important than her own and that she just needs to buck up and not impose on others in order to take care of herself.  She doesn’t see herself as having any value.  The important thing to remember is that if you don’t take care of yourself, you can’t take care of anyone else. 

2.       Imposter syndrome – This has been written about in different places.  It basically is the innate belief a person has that she is hiding her basic unworthiness from the world and that it is only time before every one finds out what a fraud she is.  Staying busy and refraining from self-care is a way of proving one’s value to the world and/or keeping people from finding out the secret.

3.       The depression that comes from vicarious trauma makes it difficult to do any more than what is asked for and taking the extra steps for self-care seem overwhelming.  Depression also makes a person lose touch with the things she used to love to do.  It always amazes me when an advocate can list the contents of a whole tool box of self-care items for a survivor but fails to open that box for herself. 

4.       Trying to stay ahead of the effects of trauma – Many advocates have their own trauma history and are regularly triggered by the stories they hear.  Staying busy is a way to keep from facing one’s own past, but it can often lead to complete burn out and collapse.  It also contributes to being ineffective as an advocate. 

It may take a few tries to find  activities to alleviate the effects of vicarious trauma.  It may be helpful to think about what you used to do that lifted your spirits and find new ways to enjoy them.  Did you enjoy singing – how about joining an acapella group?  Have you always wanted to play music?  Then take lessons or join a drumming group.  Sports?  I know advocates who have joined roller derby teams and love it.  Outdoors?  Check out www.meetup.com to find out what activities are going on in your area or just grab a friend for a hike in the woods.

If you find you are hesitating or it is difficult to engage in activities that you enjoy or you refrain from spending time with family and friends, then the effects of the vicarious trauma may be deeper.  Seriously consider looking for a good therapist in your area to talk to about what you are experiencing.  It could be the best thing you could do for yourself and for the people with whom you come in contact.

PTSD, Chris Brown and Violence Against Women

According to an article in Rolling Stone, the rehab facility where Chris Brown is receiving treatment for substance abuse reports his actions (including assaults against Rihanna) may be attributable to PTSD and bipolar disorder.  "Mr. Brown will… require close supervision by his treating physician in order to ensure his bipolar mental health condition remains stable," the letter says. "It is not uncommon for patients with Post Traumatic Stress Disorder and Bipolar II to use substances to self-medicate their biochemical mood swings and trauma triggers. . . . Mr. Brown became aggressive and acted out physically due to his untreated mental health disorder, severe sleep deprivation, inappropriate self-medicating and untreated PTSD."

First of all, I find it very interesting that the facility appears to engage with Mr. Brown’s publicist in trying to do damage control by releasing information to the public that excuses his behavior.  Secondly, let’s not fall into the trap of believing that every abuser’s actions are due to PTSD or some other mental health disorder.  I don’t know what in Chris Brown’s personal history may have led to the diagnoses of PTSD.  However, I do know that Chris Brown has lived in a culture that endorses violence against women and by blaming it on PTSD this culture ends up minimizing the impact of other causes of violence.

Violence against women is not caused by mental illness, substance abuse, anger, loss of control, anxiety, problems in the relationship, or the actions of the victim.  It is caused by a need for power and control and a disregard for women as individuals with their own rights.  There is usually a pattern of coercive control that accompanies or leads to the violence.  If the violence was due to any of the above, then the violence would be directed beyond just women. 

It is my hope that any treatment for PTSD and bipolar disorder for someone with Chris Brown’s history would also include a focused long-term batterer’s intervention program that addresses the culture of violence of against women, stops the violence and prevents the reoccurrence of future violence while ensuring victim’s  safety by:  identifying abusive behaviors, teaching alternatives to violence, exploring the impact of violence and abusive behavior on intimate partners, children and others, and assisting the individual in examining the beliefs they hold about the violence