Open Doors to Safety NHCADSV

Human Trafficking in New Hampshire - Guest Post by Jennifer Durant

2012-01-23T13:13:00.000-08:00

Jennifer Durant is the public policy specialist at the New Hampshire Coalition Against Domestic and Sexual Violence. She has been responsible for bringing awareness of the issue of human trafficking to New Hampshire and working very hard for the passage of NH's human trafficking law (see below). The following was written for Human Trafficking Awareness Day in 2011.

January is nationally recognized as human trafficking awareness month. Human trafficking is modern day slavery that involves the sexual and labor exploitation of millions of men, women, and children worldwide. Human trafficking has no borders. Victims can be abused within their own communities or moved throughout the world to avoid detection, forced to live a life of servitude.

It is estimated that about 800,000 to 900,000 individuals are trafficked across international borders worldwide. In the United States alone between 18,000 to 20,000 victims are trafficked into or within this country every year. Sadly, approximately 80% of these victims are children.

New Hampshire is certainly not immune to human trafficking. While human trafficking is very difficult to quantify or count, there is evidence that New Hampshire has experienced both labor and sex trafficking. In fact, ALL 50 states have reported seeing some form of human trafficking. New Hampshire was the location of the second labor trafficking case in the nation brought under federal law in 2003. Timothy Bradley and Kathleen O’Dell both of Litchfield, New Hampshire were convicted of human trafficking for withholding promised wages and refusing to release passport and legal travel documents of four Jamaican men.

There has also been evidence of sex trafficking in New Hampshire. Over the past few years NH’s domestic and sexual crisis centers have worked with several victims of sexual exploitation, who have been forced into street prostitution or forced to work in brothels.

Almost all of New Hampshire’s border states have experienced human trafficking, indicating that this crime clearly exists in the Northeastern region of this country. In Vermont police invaded a brothel where Asian women were forced to work as sex slaves. Experts say the Vermont case fits the pattern of a problem that is reaching into the smallest corners of the country.

In Kittery, Maine, Russell Pallas, a former lawyer and one-time chairman of the Kittery Town Council, was convicted in 2005 of operating a brothel that was disguised as a health club where women and children, as young as 13 years old, were forced to work as prostitutes.

In East Boston, Brighton, and Allston, Massachusetts police made nearly 100 arrests in 2006, posing as johns and then arresting suspects allegedly operating brothels in apartments and houses tucked away on quiet residential streets.

If this problem is prevalent in our border states, then New Hampshire is certainly vulnerable to such activities. These highly publicized cases serve as examples of trafficking taking place in our area but it is important to remember that many cases of trafficking go unnoticed. Most are invisible victims because of their uncertain position of either being undocumented immigrants or seen as social degenerates who voluntarily enter the sex industry.

What can you do?

*Become familiar with our laws…

-In August 2009, Governor Lynch signed HB 474 into law, the first comprehensive human trafficking law in New Hampshire. Human trafficking is now defined in NH’s Criminal Code, making it a class A felony with enhanced penalties for trafficking someone under the age of 18.

*Talk about human trafficking in your community and ask others to educate themselves

-Invite a speaker from a local organization to talk to your group

-Read a book, hold a documentary screening, or write a blog

-Continue to educate yourself and others on the growing crime of human trafficking

Ratified in 1865, the 13th Amendment abolished slavery and outlawed involuntary servitude. And here we are today nearly 150 years later and there is a need for me to be writing this in 2010, for National Human Trafficking Awareness Day. While the term human trafficking is fairly new, the act itself is clearly not. Until we effectively identify victims and provide them with the services they need; until we hold traffickers accountable in a meaningful way for their unspeakable crimes; and until we adequately prevent human trafficking from happening in the first place, the fight will continue – throughout the world, throughout the nation, and throughout the state of New Hampshire.

New Hampshire’s Human Trafficking Efforts

During the 2007-2008 Legislative Session, NHCADSV’s Public Policy Department helped drafted legislation that formed the Interagency Commission to Study the Trafficking of Persons Across Boarders for Sexual and Labor Exploitation to research the issue of human trafficking in the state. Public Policy Specialist, Jennifer Durant, organized the Commission, served as the group’s clerk, and authored a 50-page report setting forth recommendations for the legislature during the 2009-2010 Session. Jennifer has worked in collaboration with several state and social service agencies, law enforcement, and community members to garner support for this legislative effort.

As the result of her work on the Statewide Interagency Commission (SB 194, Chapter 122:1, Laws of 2007), Jennifer then became the primary author of an 8-page bill and lobbied for the passage of the first-ever attempt to criminalize human trafficking in New Hampshire. Signed by Governor Lynch in August 2009 and just in effect since January 1, 2010, it is now a class A felony to traffic a human being for labor and sexual exploitation. The law also allows the state to convict a trafficker with enhanced penalties if they exploit someone under the age of 18.
After two years of legislative successes on human trafficking NHCADSV continued to work with the state’s top leaders to train first-responders and create a statewide protocol to address human trafficking in New Hampshire. Jennifer became the State Coordinator for the newly formed New Hampshire Coalition Against Trafficking (NHCAT), a statewide Coalition that is part of a 2-year project operating with 4 other New England states. This Coalition was made up of key members and organizations in the work against human trafficking. Through NHCAT Jennifer worked to (1) increase awareness of the issue of human trafficking, (2) train providers to work with trafficking victims, (3) identify victims of human trafficking within the New England region, and (4) link trafficking survivors to needed services.

From 2009 to 2010 Jennifer organized and implemented one of the largest trainings on human trafficking for NH’s law enforcement, held on January 20, 2010. The January 20th NH statewide law enforcement training on human trafficking was a successful event in which attendance ranged from NH Prosecutors to State, County, Local, and Federal Law Enforcement officials. A total of 95 Law Enforcement officials attended the training. A little over 70% of attendees came from local police departments (65 officers).

The 8-hour training curriculum included detecting and investigating cases that involve human trafficking. The training was designed to help police officers understand, identify, and investigate human trafficking cases in New Hampshire

Informational pocket cards were created for the January 20th law enforcement training that were designed to be useful in other disciplines. The cards contain information on red flag indicators, as well as who to contact locally if it is believed that someone is being trafficked in the state.

Just to name a few, NHCADSV has worked closely with and has received support from the NH State Liquor Commission, NH State Police, NH Chief’s Association, Manchester PD, Nashua PD, NH Police Standards & Training, NH Sheriffs Association, NH Attorney General’s Office, U.S. Attorney General’s Office, Immigration and Customs Enforcement (ICE), and Department of Children, Youth and Families (DCYF).

After 2 years of work, the NH Coalition Against Trafficking (NHCAT) officially cae to a close in Spring 2011. .

Thanks to the work of NHCAT, a little over 4,300 materials on human trafficking were distributed throughout the state, either at trainings, awareness events, or fundraisers.

Thanks to the work of NHCAT, a little over 400 individuals were trained on human trafficking issues throughout the state of New Hampshire. These trainings covered a wide-range of disciplines including law enforcement, victim advocates, medical professionals, or professionals working in the child protection field.

NHCADSV continues to raise awareness on human trafficking throughout the state. On August 15, 2011 NHCADSV collaborated with a non-profit called Sex + Money - A National Search For Human Worth. The NH screening of this important film on child sex slavery here in the United States brought out 170 NH residents to the event.

Ellen Pence - Why Gender and Context Matter

2012-01-18T13:49:00.000-08:00

The following is Ellen Pence's Keynote from the Batterers' Interventions Services Conference in November 2010. Ellen was one of the early leaders in the violence against women movement and she will be sorely missed. She passed away after a long fight with cancer earlier this month. This video shows her wit, wisdom, and passion for the movement.

The Traumatic Effects of Stalking

2012-01-09T13:31:00.000-08:00

January is Stalking Awareness Month. This is a good time to take a look at the long term impact that stalking can have on the person being stalked. There have been a number of studies done on this issue and I will review some of the conclusions here.

In "Stalking – An Overview of the Problem" [Can J Psychiatry 1998;43:473–476], authors Karen M Abrams and Gail Erlick Robinson write:

"Initially, there is often much denial by the victim. Over time, however, the stress begins to erode the victim's life and psychological brutalisation results. Sometimes the victim develops an almost fatal resolve that, inevitably, one day she will be murdered. Victims, unable to live a normal life, describe feeling stripped of self-worth and dignity. Personal control and resources, psychosocial development, social support, premorbid personality traits, and the severity of the stress may all influence how the victim experiences and responds to it… Victims stalked by ex-lovers may experience additional guilt and lowered self-esteem for perceived poor judgement in their relationship choices. Many victims become isolated and deprived of support when employers or friends withdraw after also being subjected to harassment or are cut off by the victim in order to protect them. Other tangible consequences include financial losses from quitting jobs, moving, and buying expensive security equipment in an attempt to gain privacy. Changing homes and jobs results in both material losses and loss of self-respect."

Surprisingly, verbal, psychological, and emotional abuse have the same effects as the physical variety [Psychology Today, September/October 2000 issue, p.24]. Abuse of all kinds also interferes with the victim's ability to work. Abrams and Robinson wrote this [in "Occupational Effects of Stalking", Can J Psychiatry 2002;47:468–472]:

"… (B)eing stalked by a former partner may affect a victim's ability to work in 3 ways. First, the stalking behaviours often interfere directly with the ability to get to work (for example, flattening tires or other methods of preventing leaving the home). Second, the workplace may become an unsafe location if the offender decides to appear. Third, the mental health effects of such trauma may result in forgetfulness, fatigue, lowered concentration, and disorganisation. These factors may lead to the loss of employment, with accompanying loss of income, security, and status."

Mullen and colleagues have done extensive research on stalking impact in Australia. (Mullen, P.E., M. Pathe, and R. Purcell. Stalkers and Their Victims. (Cambridge University Press, 2000).Their 1997 survey of 100 stalking victims found that stalking resulted in significant activity changes for its victims, including the following:

• Major lifestyle changes or modification of daily activity for 94 percent of victims
• Curtailment of social activities for 70 percent of victims
• Decrease or cessation of work or school attendance for 50 percent of victims (due either to absenteeism or stalker invasion of work or school site)
• Relocation of residence for 40 percent of victims
• Change of workplace or school for 34 percent of victims.

The researchers also found important psychological problems resulting from the stalking, including these:

• Increased anxiety and arousal for 80 percent of victims
• Chronic sleep disturbance for 75 percent of victims
• Recurring thoughts or flashbacks to the stalking, resulting in distress for 55 percent of victims (often triggered by ordinary events such as a ringing telephone or doorbell)
• Appetite disturbance for 50 percent of victims
• Excessive tiredness, weakness, or headaches for 50 percent of victims
• Numbing of responses to others, including feeling of detachment for 38 percent of victims
• Nausea before going to places associated with the stalking for 33 percent of victims
• Increased alcohol or cigarette use for 25 percent of victims
• Contemplation of suicide for 25 percent of victims.

The researchers' analysis of these findings suggested that most of the stalking victims experienced at least one major symptom associated with Post-Traumatic Stress Disorder (PTSD). The authors explain that this is not surprising because "stalking possesses many of the features that may produce chronic stress reactions and related psychological sequelae."Those features include persistent, repetitive trauma; loss of control; state of persistent threat with associated symptoms that may far outlive the actual duration of the harassment; and loss of social supports normally available for crime victims because of mistrust and fear generated by the stalking itself. While many factors affected the specifics of the stalking impact on the victims, there was not one victim who did notexperience some level of harm "that in some cases amounted to profound deterioration in functioning."

It is also important to note that the impact of cyber stalking has the same affect, if not greater, than physical stalking.

According to the Iowa Rape Victim Advocacy Center (www.rvap.org), cyber-stalking can consist of a variety of activities, but it is generally defined as the continued and deliberate harassment, threatening behavior, or unwanted advances towards a person through the internet or other forms of on-line and computer communications. Cyber-stalking does not include occasional junk mail, but it does include any methodical or deliberate attempt to harass the victim.

Cyber-stalkers can find their victims through chat rooms, online communities, discussion forums, e-mails, or through a random search. Even people without access to the internet can be victims of cyber-stalking. All the stalker needs to do is find out personal information about the victim and they can then use that to impersonate the victim and solicit meetings with strangers without the victim ever getting on to a computer.

Cyber-stalking can take many forms, some of which are below.

• threatening or obscene e-mails
• spamming or e-mail bombing- sending large amounts of email to shut down the victims e-mail from working
• live chat harassment
• "flaming"- online verbal abuse
• leaving obscene or threatening messages in guest books or on message boards
• sending electronic viruses
• sending unsolicited e-mail
• tracing computer and internet activity
• impersonation of the victim to solicit sex acts
• identity theft

Cyber-stalking can escalate to physical danger for the victim. If a stalker obtains personal information, such as an address or phone number or even the social security number of the victim, this information can be used to stalk and harass the victim even after the cyber-stalking has ceased.

SADness and the Holidays

2011-12-05T07:38:00.000-08:00

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

2011-11-28T12:40:00.000-08:00

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

2011-11-08T07:24:00.000-08:00

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

2011-10-25T08:04:00.000-07:00

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

2011-10-17T13:39:00.000-07:00

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

2011-09-12T06:12:00.000-07:00

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

2011-08-18T11:47:00.000-07:00

(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

2011-08-12T12:10:00.000-07:00

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"

2011-07-29T07:24:00.000-07:00

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

2011-07-08T13:39:00.000-07:00

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

2011-06-20T08:17:00.000-07:00

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.

Trauma and Recovery: The Aftermath of violence-from domestic abuse to political terror by Judith Herman

2011-05-17T05:52:00.000-07:00

- a book review by Jennifer Frechette, graduate student from Skidmore College.

Jennifer is a case manager at Monadnock Family Services in Keene, NH and is currently undertaking an independent study course on Trauma and Intimate Partner Violence. I am her independent study instructor for this course. She wrote this review as an assignment and it was so well done I asked for her permission to reprint it here.

Trauma and Recovery: The Aftermath of violence-from domestic abuse to political terror, written in 1992 by Judith Herman, published by Basic Book New York, NY reviews the history of psychological trauma including hysteria, shell shock and sexual and domestic violence. Judith Herman also wrote Father-Daughter Incest and other various journal articles. Judith Lewis Herman is a psychiatrist, researcher, teacher, and author whose primary focus has been on the treatment and knowledge of those that have had traumatic experiences as well as those that are victims of incest. Dr. Herman is a Professor of clinical psychiatry at Harvard University Medical School and Director of Training at the Victims of Violence Program in the Department of Psychiatry at the Cambridge Health Alliance in Cambridge, Massachusetts. She is also a founding member of the Women’s Mental Health Collective (Retrieved from http://en.wikipedia.org/wiki/Judith_Lewis_Herman). She received multiple awards ranging Lifetime Awards for Traumatic Stress Studies, Science Awards, and Psychiatric Association awards. Herman created the term “complex post-traumatic stress disorder,” which has now been included as an extension of PTSD (Post Traumatic Stress Disorder). Lenore Walker states that, “Herman's brilliant insights into the nature of trauma and the process of healing shine through in every page of this rich and compassionate book. Must reading for all who are concerned with this most crucial issue of our time" (Hopper, 1996-2010). Laura Davis, Coauthor of The Courage to Heal praised Herman’s work as a, "A triumph. Trauma and Recovery is astute, accessible and beautifully documented. Bridging the worlds of war veterans, prisoners of war, battered women and incest victims, Herman presents a compelling analysis of trauma and the process of healing. She presents a convincing case for the empowerment and care of all trauma victims” (Hopper, 1996-2010).

One of Herman’s biggest contributions to the field of psychology is the concept of complex post-traumatic stress disorder (CPTSD) which is an extension post-traumatic stress disorder (PTSD) to include repeated trauma and its impact on the psyche. (Wikipedia citation) Herman’s purpose for writing this book is to inform the reader of the effects of trauma on the victim, such as hyper arousal, inability to trust and disconnection. Herman cites the women’s liberation movement as the driving force behind her courage and reasoning for writing the book as well as the work that she did during her fellowship which is the backbone to Trauma and Recovery. Herman’s main concentration in Trauma and Recovery is to outline the fundamental stages of recovery which she designates as, “establishing safety, reconstructing the trauma story, and restoring the connection between survivors and their community“(Herman, 1992, p. 3). Herman (1992) cites that her reason for writing Trauma and Recovery was to give a voice to the numerous people who have participated in witnessing other people’s traumatic experience and expanding it to include a united front by which counselors can go forth to assist victims of trauma (p. 237).

The first section of Herman’s book, titled A Forgotten History, outlines the history of hysteria as it pertains to its relation to sexual trauma and the lack of acknowledgement of it in the psychiatric society. Herman states that the women’s movement was the breakthrough for the acknowledgement of women’s sexual and domestic violence and trauma histories and eliminated the silence that permeated psychology society. Herman (1992) states that “To study psychological trauma is to come face to face both with human vulnerability in the natural world and with the capacity for evil in human nature” (p. 7). One of the points that stood out to me in this first section was the importance that victims report their perpetrators and for others who know of violent and sexual crimes to report as well, as Herman (1992) states, “ All the perpetrators asks is that the bystander do nothing” ( p. 7).

Herman introduces the concept of hysteria and neurosis as a field dominated by Janet, Freud, and Breuer who reported that the physical manifestations of hysteria represented past traumatic experiences which had been suppressed in the subconscious. This concept, however, which eventually manifested in the discovery of the high percentage of child sexual abuse, was not well accepted by the public. Dora, a patient of Freud’s who had been sexually abused by her father, received the brunt of the negative public view of Freud’s finding which resulted in Freud dismissing Dora’s trauma history and invalidating her feelings. Herman (1992) also reviews the combat neurosis of what she calls the “sex war” and the prevalent public humiliation and degradation that women who have been raped experience which results in a societal decrease in reporting rape. Herman (1992) discusses the power of psychological trauma, the effects that it has on the somatic nervous system, as well as the significant changes in memory, emotions, adaptive abilities, and arousal (p. 34). She cites memory triggers as a debilitating force that can rear its ugly head at the most unexpected times. Herman outlines that memory for those that have been traumatized is not “ normal memory” and therefore encodes in a different way and triggers constant recitation of the traumatic memories causing constant intrusion into everyday experiences. Herman (1992) goes on to describe constriction or “numbing” which Herman cites as the “third cardinal symptom of post-traumatic stress disorder” (p.42). In this stage people literally become numb to the abuse and begin dissociating in order to cope with the trauma. She states that the most obvious feature of post-traumatic stress disorder is what she calls the “dialectic of opposing psychological states” (Herman, 1992, p. 47).

Herman’s third chapter is titled Disconnection. In this chapter she outlines the way in which traumatic experiences impact the community surrounding those that are traumatized. Herman (1992) cites Janoff- Banc as stating that, “traumatic events destroy the victim’s fundamental assumptions about the safety of the world, the positive value of the self, and the meaningful order of creation” (p. 51). This impacts the traumatized person’s ability to start new relationships, trust others, and maintain current long standing relationships and decreases the person’s ability to believe in themselves. This distrust also manifests into distrust of faith and can result in loss of faith completely. Herman (1992) describes a phenomenon of the traumatized person either clinging to or isolating themselves from those around them and the frequency of changing between the two. This is a phenomenon that I am very familiar with due to working with clients that have PTSD (p. 56).

Herman discusses the impact that trauma has on those it touches and the vulnerability that those face that have been traumatized. Herman (1992) states that the “experience of terror and disempowerment during adolescence effectively compromises the three normal adaptive tasks of this stage of life: the formation of identity, the gradual separation from the family of origin, and the exploration of a wider social world” (p. 61). Herman goes on to encourage reconnection and the vast improvements that it has on the traumatized person’s acuity of life prior to the trauma. She addresses the difficulty of rebuilding a sexual relationship due to distrust, triggers, and previous sexual experiences. Herman encourages open communication between sexual partners and the acknowledgement of the previous trauma by the other member of the sexual relationship. Commonly, women who have been raped experience blame for their actions in being raped as well as a shroud of secrecy regarding their rape by those around them not acknowledging it by its name (Herman, 1992, p. 67).

Captivity, the title of Herman’s fourth chapter, addresses the prolonged repeated trauma that those in captivity experience. She highlights the concepts of psychological domination citing the definition of “seasoning” which is “the systematic use of coercive techniques to break women into prostitution” as an example of psychological domination (Herman, 1992, 76). Alongside “seasoning” comes “breaking” whereby the women being isolated, beaten, and conditioned eventually break and become compliant to their abuser. Herman (1992) states that there are two stages to being “ broken,” stating the first one as when the person “ relinquishes her inner autonomy, world view, moral principles, or connection with others for the sake of survival”( p. 85), and the second is when the person loses the want to live. Herman also describes the phenomena of the victim bonding to the perpetrator due to the victim being emotionally bonded to the perpetrator through the traumatic experience.

Herman thoroughly describes throughout the fourth chapter what victims fear, how they are traumatized continually, and the features that epitomize post-traumatic stress disorder, such as hypervigiliance, anxiety, distrust and at times dissociation. She also addresses the somatic symptoms that can manifest such as headaches, abdominal, back, and pelvic pain, and stomach complications (Herman, 1992, p. 86). Herman describes the ways in which victims stay alive in captive situations not by concentrating on how to escape from their captures but making their situation better; many times this involves dissociation. Herman (1992) completes the chapter by discussing the concept of “survivor syndrome” where survivors often identify themselves alternatively to who they were before the trauma and identify as less than human and often this results in suicide (p. 94). Herman (1992) cites a study where out of 100 battered women, 42 had attempted suicide, stating that “the survivor may direct her rage and hatred against herself. Suicidality, which sometimes served as a form of resistance during imprisonment, may persist long after release” (p. 95).

Herman’s fifth chapter focuses on child abuse and ties together Freud’s diagnosis of hysteria with the modern day diagnosis of multiple personality disorder which incorporates sexual dysfunction, depression, suicidality, amnesia, somatic symptoms, and other symptoms (Herman, 1992, p. 97). Herman (1992) makes it clear that children who are victims of sexual abuse often are “silenced by violence” (p. 98), which often results in distrust and paranoia about telling their story for fear of inadvertently causing harm to their families. Herman goes into detail of what child victims endure during their abuse ranging from forced feeding, sleep deprivation, and the increase in bodily alert systems that they learn i.e. knowing the sounds of the footsteps of their abuser.. Children utilize avoidance techniques and what Herman calls doublethink to cope with the abuse, which many times they carry on into their adult lives which carries into their interpersonal skills and ability to form meaningful, trusting relationships with others. Many survivors of abuse begin to self harm as a way to relieve pain. Herman (1992) states that, “the adult survivor is at great risk of repeated victimization in adult life. The risk of rape…is approximately doubled for survivors of childhood sexual abuse” (p. 111).

In chapter six A New Diagnosis, Herman addresses the need for change in the mental health field for diagnosis mislabeling as well as the need for a new way to look at long term trauma. Here Herman introduces her concept of “complex post-traumatic stress disorder” (CPTSD) which includes “prolonged, repeated trauma” (Herman, 1992, p. 119). Herman (1992) outlines the diagnostic underpinnings of CPTSD including;

1. A history of subjection to totalitarian control over a prolonged period ( months to years)

2. Alterations in affect regulation

3. Alternations in consciousness

4. Alterations in self-perception

5. Alterations in perception of perpetrator

6. Alterations in relations with others

7. Alterations in systems of meaning (p. 121).

Herman (1992) states that she is troubled by the diagnoses that victims of trauma receive citing somatization disorder, borderline personality disorder, and multiple personality disorder as three of them (p. 123). Herman reports that she believes that these are negative diagnoses and can result in complications with standard of care with mental health workers and cooperation from family members. Herman (1992) goes on to elaborate about the diagnosis of borderline personality disorder and the qualifying diagnostic traits that they frequently exhibit such as clinging and withdrawing, unstable relationships, and fear of abandonment (p. 124).

In the second section her book, Stages of Recovery, Herman provides an overview of her stage therapy process which includes establishing safety, remembrance and mourning, and reconnection. In Herman’s overview she discusses the importance of each of these in the process of healing from trauma and provides the reader with working examples of how the stages are worked through as well as other stage theories that have come before hers. Herman outlines that the first task of a therapist is to identify the diagnostic markers and to collect as much information about the patient as they can.

Herman (1992) states that “The first principle of recovery is the empowerment of the survivor” (p. 133), which includes establishing safety within the therapeutic relationship and trust among the support systems that the survivor surrounds herself with. Herman recognizes the difficulty that therapists face with working with victims and the stress that it can place on the therapists stating that “the therapist is called upon to bear witness” (Herman, 1992, p. 135) and by being called upon must align him or herself with the victim and the victim’s experience. Herman discusses the challenges that the therapeutic relationship can face such as counter transference and mistrust as well as the challenges that the survivor faces when attempting to establish safety, especially when she continues to be in an unsafe environment at home. Herman(1992) states that in order to combat the feeling of safety which is taken away from victims when they are traumatized, “ the guiding principle of recovery is to restore power and control to the survivor” ( p. 159). In this section of her book, Herman gives many graphic descriptions of what survivors have been through and uses stories from her own patients to illustrate her therapeutic techniques as it relates to real life traumatic experience.

The second stage of recovery, according to Herman, is Remembrance and Mourning. By completing this stage women reconstruct the memory and are able to “transform the traumatic memory, so that it can be integrated into the survivor’s life” (Herman, 1992, p.173). The therapist’s position is that of witness and an advocate for the survivor. Herman states that it is important to incorporate the feelings of safety and empowerment throughout this stage from the first stage of creating a safe therapeutic relationship. Reconstructing the survivor’s story involves reviewing their life story before and after the abuse. The survivor has to discover what the abuse meant to them. Two common techniques for this are “direct exposure” and “flooding” which are both used to overcome the traumatic experience (Herman, 1992, 181). Finally, after this stage is complete the survivor has to decide what they would like to do about the abuse and have to come to “terms with the impossibility of getting even” (Herman, 1992, p. 189).

The next and final step in Herman’s step theory is Reconnection. In taking this step, survivors make new connections, renew old connections, and incorporate their trauma into their everyday lives. Herman (1992) states that there is a need for the survivor to “taste fear” (p. 198) in this stage and learn how to stick up for themselves. By doing so, they are able to begin to self advocate and might even be able to confront their perpetrator. Herman reflects on the deepening of the therapeutic relationship through the reconnection process and states that the patient (or survivor) becomes able to self evaluate and reflect on the improvements she can make on herself. Herman goes on to discuss the importance of group therapy in mourning the traumatic experience and creating greater connections through common experience. In this ending portion she presents the reader with examples of positive group interactions and the benefits it can have towards survivor’s recovery.

I found Judith Herman’s book a refreshing and vivid look into the world of traumatic experience and therapy interactions. Herman was clear on her stage presentation and provided examples of survivors working through the stage as well as complications that she herself experienced while working through the stages with the survivor in the therapy relationship. Herman didn’t allow for lax conversation in her book and presented the reader with vivid, graphic, and sometimes sickening trauma that victims have gone through and the ways in which she was able to help as well as ways that she was not. I was able to connect the body of work that I have read previously to Herman’s stage theory and found hers to be clearer and more precise than many of the other theorists I have read about. Her ability to adapt to the survivor’s individual experience while maintaining the integrity of her stage theory provided me with a clear opinion that she was versatile and wanting to truly assist survivors in the recovery process.

Works Cited

Herman, J. (1992). Trauma and Recovery: The aftermath of violence-from domestic abuse to political terror. New York, NY: Basic Books.

Hopper, J. (1996-2010). Praise, Table of Contents, & Excerpts [Review of the book Trauma and Recovery]. Retrieved from http://www.jimhopper.com/trauma_and_recovery/

Retrieved from: http://en.wikipedia.org/wiki/Judith_Lewis_Herman.

Things I Have Learned From Trauma Survivors

2011-05-12T11:43:00.000-07:00

I spend a lot of time talking to trauma survivors and have learned so much from them that I have decided to share.

1. It takes a lot of courage to get needs met. Victims of domestic and sexual violence often feel that they are weak or that they do not deserve to have their needs met. Often, in relationships with caregivers or partners, asking for what they need meant being refused, punished, ignored, invalidated, or abandoned. At times, it may even be difficult to pinpoint exactly what is needed because there is no experience of having a need met.

When a trauma survivor learns to ask for what she needs and is met with a positive response, it can be a life changing for her. A survivor recently told me that she had a medical procedure that due to her childhood abuse could have been extremely traumatic for her. However, she was able to explain to the medical personnel what her needs were in the situation and told them how they could help her through the procedure. The medical staff responded positively and the woman was able to get through the procedure without experiencing flashbacks or nightmares. She felt empowered.

Not all survivors are ready to ask to have their needs met when they first start working with advocates or counselors. It may take small steps and advocates need to be aware that. . . . . .

2. Sometimes survivors use different skills than we would use in order to get their needs met. I often hear service providers use the terms “manipulative,” “resistant,” “defensive,” “adversarial,” or “borderline” to describe trauma survivors. They are often accused of “using the system.” Because of their experiences and the responses that they have received from persons in their past, trauma survivors develop a certain set of skills in order to protect themselves, get what they need, and feel safe. These skills may seem counter-productive or negative in the greater world; however, in the world of ongoing invalidation, abuse, and abandonment that they have lived in, these skills are what have worked for them. And – they have not had the safety or the time to learn the skills that many people would prefer they use. It is similar to asking someone from a country where they do not speak English to start speaking English the moment they arrive. It takes time and safety, trusting relationships, and support to be able to learn the skills that are necessary to get needs met in the larger world. As long as they are expecting to be harmed, they will use the skills they have always used.

3. Telling the story can be scary. We often wonder why a person will call a support line or attend a support group once and then never come back. Sometimes it is because she is afraid that if she tells the story (or now that she has) something bad is going to happen. Many childhood sexual abuse victims were told by her perpetrator that bad things were going to happen to her or her family if she told anyone what was happening. As an adult, this message is still held deep in her being and once she tells the story to a therapist, a support group, or family member she may become frightened that something horrible is now going to happen. Unfortunately, this feeling may be validated by negative responses by family members or re-victimization in the systems that are meant to help. She may feel that all of these bad things that are happening are her fault for telling about the abuse. It may take time for her to be able to open up again or to feel safe walking back into an office or support group.

4. It takes as long as it takes. Many survivors have told me that their family members cannot understand why they just can’t “get over it.” A few women I have spoken to have told me that they have been expected to attend family gatherings where the perpetrator from their childhood is present, live in the same neighborhood where the rape took place, or have been told they need to “forgive and forget.” Being told this can be a form of re-victimization in the form of invalidation of the survivor’s internal experience. Memories live deep in the cells of a person’s body and it cannot be predicted when a feeling, smell, color, or sound will ignite that memory into a flame. Survivors can learn ways to manage the responses that occur in their bodies and maybe even lessen how often they are triggered, but it takes as long as it takes and each person is different. To expect someone to be “over it” is often a way a family member tells someone that they don’t like their behavior which leads to………..

5. Families often behave like crabs in a bucket. If you put one crab in a bucket, it can easily climb up the side of the bucket and get out. If you put a few crabs in a bucket, as soon as one starts to climb up the side the others start to grab on and pull the escaping crab back down to the bottom. It looks like a free for all, with all the crabs pulling each other down. This often happens when one person in a family system is trying to learn new skills to manage her trauma or is making changes to be a healthier human being. One person who is making changes can throw off the whole family system and everyone struggles to bring that person back in line with the family dynamics even when that dynamic has been harmful to everyone involved. Speaking up about abuse, getting clean and sober, getting a higher education, or learning to speak one’s personal truth can often lead to being pulled back into the bucket unless there is plenty of positive support to help climb the side. The survivor may find it easier to go back into the bucket for a while, but as long as there is support available, she may eventually find her way to the top and out of the grasping reach of the dysfunctional system.

NAMI | Dissociative Identity Disorder (formerly Multiple Personality Disorder)

2011-04-26T12:12:00.000-07:00

The link below is to an excellent fact sheet about Dissociative Identity Disorder. There has been some disagreement in the mental health community regarding the disorder. However, it is agreed that there are different ego states that arise during periods of stress that seem to have their origins in childhood trauma. These ego states continue to operate into adulthood as a survival/coping mechanism.

NAMI Dissociative Identity Disorder (formerly Multiple Personality Disorder)

The 7 P's of Men's Violence by Michael Kaufman and Why Knowledge of the Impact of Trauma Cannot be Used to Justify Male Violence

2011-04-22T11:18:00.000-07:00

I have had a few people mention to me that they are concerned about the possibility of society (and defense attorneys) using knowledge of trauma responses as a way to excuse or justify the behavior of batterers. It is very important that we continue to address the batterer's pattern of asserting power and control in the relationship as primary and recognize the privilege and patriarchal systems that continue to perpetuate this behavior. Michael Kaufman's 1999 paper on The 7 P's of Men's Violence discusses this and provides context to understand how male violence is more involved that just a trauma response. The link to Dr. Kaufman's blog is below.

The 7 P’s of Men’s Violence

Vicarious Trauma: An Interview with Golie Jansen, Associate Professor, Department of Social Work, Eastern Washington University

2011-03-29T12:22:00.000-07:00

From The Research & Advocacy Digest, A Publication of the Washington Coalition of Sexual Assault Programs, 2004

WCSAP: What originally led you to do this research project?

G: During my conversations with therapists who worked with sexual assault survivors, I noticed that they made statements and discussed some behaviors that made me question how the work was affecting them. For instance, I heard about instances of therapists saying they were shopping during every lunch break, needed drinks to relax when they got home or just stated that they were not involved in much of anything. So, I started wondering if they were experiencing vicarious trauma because of their work. I also started to question whether the organization had a responsibility to address some of those negative aspects of sexual assault work with their workers. In reading the literature pertaining to vicarious trauma I wanted to determine whether organizational support made a difference in how it mitigates vicarious trauma. Although there is much literature pertaining to vicarious trauma, there is very little literature on the relationship between organizational support and vicarious trauma, so I set out to conduct a research project on the topic.

WCSAP: Can you describe how you designed your research project?

G: We used two standardized instruments: 1) the Traumatic Stress Institute’s (TSI) Belief Scale and 2) the Measure of Perceived Organizational Support, which measures how satisfied workers are with their organization and their perceptions of support they receive from them. These two measures give us a good idea about the relationship between perceptions of support and whether that support has any influence over how vicariously traumatized they are. We distributed the surveys at WCSAP’s annual conference to a variety of participants, including advocates, educational specialists, managers, community outreach specialists and therapists and had a 40% return rate, which is pretty high.

WCSAP: We know your study is still being analyzed and refined, and will be submitted for formal publication in the near future, but can you tell us what your preliminary findings are?

G: Preliminary findings indicate that participants were definitely experiencing vicarious trauma as a result of this work, but we also are finding that when people perceive their organizations to be supportive, they experience lower levels of vicarious trauma. At this point in the analysis, our hypothesis has been strongly confirmed; this study is leading us to believe in the relationship between organizational support and how much this support can mitigate the severity of vicarious trauma. This information is very much needed because it provides recommendations for organizations on how to manage their programs to mitigate or even prevent the effects of vicarious trauma.

WCSAP: Based on your preliminary findings, what are some recommendations that you would give to sexual assault organizations, their workers and management? What is crucial for them to understand?

G: My recommendations are as follows:

• It is important for organizations to understand their role as the managers of all this and to not place the burden of dealing with it on the individual therapists and advocates.

• Younger, less experienced workers may need more training since we’re finding that they tend to be more vicariously traumatized than more experienced workers.

• Organizations have an obligation to inform and a duty to warn those coming into the field of the potential occupational hazards of the work. This can be done as part of the hiring process so they can make informed choices about whether to continue. Organizations can also set this practice up in their personnel protocols. They should, however, not only stress the hazards, but ways advocates can protect themselves and discuss what the organization will do to help minimize the most negative effects.

• Provide more training on trauma in general to students and sexual assault workers so they are aware of its impact. Universities often don’t emphasize this, which ultimately does a great disservice to those going into the work. Consequently the workers have limited exposure regarding the nature of trauma but then find themselves dealing with extremely traumatized people. This also speaks to the need for more intensive staff development.

WCSAP: Those are great recommendations. Is there anything else you would like to add about this topic?

G: One of the ways that vicarious trauma impacts people is that is affects their worldview, spirituality and sense of identity. Someone may initially be an idealistic person who sees the world as a place where things are fair or where people are basically good. But by doing this work you only work with the atrocities that people tell you. Consequently, you may begin to shift the notion of what your worldview looks like and find yourself becoming more cynical, and the whole idea of hope becomes lost. The question then arises, if I as a therapist or sexual assault advocate lose hope, how can I instill it in people who are most vulnerable? How can I demonstrate that there are ways to address it; that there are antidotes? Also, if we don’t see great success in the work, we may think “I’m a bad therapist” or “I’m a bad advocate.” These are issues that agencies can help workers address. Staff meetings and consultation can help people begin to identify ways they are being affected and develop strategies to deal with them, like fostering self-care routines.

I also want to remind people that even though we hear and see atrocities, it is important to remember that people are doing incredible, beautiful and heroic things out there in the world, every day. You can embrace both the atrocities and the goodness. It’s important to keep a balanced perspective.

I have completed another research project by interviewing 15 sexual assault workers from all over the state. It was amazing to see how those workers who have stayed in this field for ten or more years talked about the joy and satisfaction this work gives them. Many of them said that spirituality now had a big place in their life as a result. In doing this work they gained a deeper understanding of what life is like, what relationships really are and how beautiful the world is. So we also need to begin to talk about post-traumatic growth and how resilient we are. This work can deepen our sense of connection in the world because we can overcome trauma and suffering. However, one won’t come to this place if they don’t address the harmful and hurtful aspects of the work, which ultimately can be damaging to our clients.

Women, Trauma, and Self Blame

2011-03-07T09:40:00.000-08:00

When working with female victims of trauma, we often come across women who hold a lot of regret and self blame in regards to their actions. It may not be immediately evident to the advocate working with the mother, however, once the women engages in a relationship with an advocate or other service provider, or has the opportunity to work on her relationship with her children, she may begin to voice a sense of failure, disappointment, loss and grief over the years spent using substances.

According to Dr. Stephanie Covington, an expert in women, trauma and substance abuse; “women are strongly attuned to connections and relationships. Because healthy connections are crucial for women, their psychological problems can be linked to disconnection or violation (Miller, 1976). Women frequently begin to use substances in ways that initially seem to make or maintain connections, in attempts to feel connected, energized, or loved when these feelings are otherwise missing in their lives. They may begin to use alcohol or other drugs to alter themselves to fit the available relationships -- typically, in order to please their male partners. They change themselves to maintain the relationships. Women also use substances to numb the pain of non-mutual, non-empathic, and violent relationships. They may turn to substances to provide what their actual relationships are not providing, such as energy, a sense of power, emotional and physical comfort, and relief from confusion. Addicted women often are paired with men who disappoint them by failing to provide emotional and financial support (including support for their children) and who wind up in jail. These women take solace from their disappointment through drug use. When a woman is disconnected from others (in non-mutual relationships) or involved in abusive or other traumatic relationships, she experiences a “depressive spiral” that includes diminished vitality, disempowerment, confusion, diminished self-worth, and a turning away from relationships (Covington & Surrey, 2000).”

Trauma survivors are well tuned-in to the attitudes and judgments of others and tend to internalize messages they receive from their partner, their family, and society. An abusive partner is likely to have planted the seeds of self blame by accusing her of being a bad wife and mother, weak, or keeps her isolated from any persons or activities who could possibly increase her self esteem or empower her to live a life free from abuse.

Tribal messages from family also impact a women’s view of her self. Due to the experience of trauma she may not be able to live up to the standards of womanhood that were imprinted on her throughout her childhood. She may also be grieving the loss of the dream she had of relationships, marriage and motherhood and blaming herself for her perceived failure in achieving those dreams. Societal expectations also play a large role in reflecting disapproval or failure when a woman does not fulfill her role in a respectable way.

“What is less well understood is the impact of trauma on a woman’s capacity to mother. The wounded mother is often the blamed mother. For many of these women, mothering means struggling to parent your child while at the same time struggling to recover. A history of past trauma can affect how a woman experiences parenting and how effective she is as a parent. There are several major parenting issues for trauma survivors:

• Feelings of shame, guilt, and inadequacy can interfere with parenting.

• Interaction with a child can trigger a mother’s traumatic past.

• The mothers are at risk of becoming overprotective of their children.

• At the other extreme, they may be neglectful in order to avoid being “triggered” by their children.

• Addicted mothers may have been inadequately nurtured themselves. (Covington, 2007).”

In order to assist women in resolving their issues surrounding self blame, it is important to help them learn about and establish strong boundaries. Once they have a sense of how their boundaries were violated by the abuser, they can begin to understand how much responsibility was theirs and how much of the blame has been unjustly placed on them. They can also see the part that the trauma had in their addictions and can be given new choices that help to empower them and move forward. By helping them understand that the choices that they made in the past may have been the best they could do under the circumstances. They may be able to move past the regrets and work towards living a new life without the hindrance of self blame. This takes patience with one’s self and constant reminders about mindfully living in the present.

Trauma survivors tend to judge their past behavior on who they are now instead of being able to see who they were. If their children, partners, family, or society are telling them that they are to blame for their actions women can become disheartened. It is important to remind them that recovery is a journey and that others may not choose to join them and instead remain in a place of blame and regret. By moving forward and looking on the past with compassion, they can begin to heal from wounds of blame and regret and become engaged in new relationships that reinforce the person she is in the here and now.

Resource:

Covington, Stephanie, PhD, LCSW, Working with Substance Abusing Mothers: A Trauma-Informed, Gender-Responsive Approach, A Publication of the National Abandoned Infants Assistance Resource Center, Berkeley, CA (Volume 16, No.1, 2007)

Changes in the Field of Addictions and Trauma

2011-02-14T11:40:00.000-08:00

At the beginning of February, I attended the 32nd Annual Training Institute on Behavioral Health and Addictive Disorders in Clearwater, FL. The main theme running through this year’s institute appeared to be the mind/body connection and how it pertains to trauma and substance abuse. It was a three and a half day conference, packed full of presentations. Rather than summarize each of the keynotes or workshops, I am going to give you an overview of the overall themes (intended and unintended) of the conference and how they pertain to the work of the Open Doors Project here in New Hampshire.

To Diagnose or Not to Diagnose – More than one speaker at the conference commented that there is frustration in the addictions field with the current system of diagnosing patients based on the DSM-IV (Diagnostic and Statistical Manual). It was strongly stated that labeling patients with a diagnosis leads to treating of the diagnosis rather than the person. In fact, many diagnoses lead to stigmatizing of the person and tend to have a cumulative affect resulting in a person having many diagnoses over their lifetime with none being removed from their record. It is also important to note that many diagnoses do not take a person’s trauma history into account, denying the person the possibility of healing.

In the past year, I have seen a few women for whom the treating of the diagnosis rather than the individual failed to resolve issues and created more. In two cases, the women were in their fifties and had a long list of diagnoses that they had accumulated since their late teens and early twenties. Both had been sexually abused as children and, when they started to have strong reactions to their trauma, they were both medicated heavily and, in one case, hospitalized for significant periods of time. The woman who was hospitalized was sexually assaulted during her stay and another had years of her life that she could not recall due to the amount of medications she had been taking. It was only when they found trauma informed professionals who recognized the basis for their symptoms and could provide trauma services did they begin to heal.

The addictions field seems to be far ahead of the mental health field in recognizing trauma as a root cause of substance abuse. The mental health field is currently restrained by the dictates of the insurance companies to provide diagnoses that justify payment for services and the pressure of pharmaceutical companies to medicate based on diagnosis.

There is a lot of work to be done in order for changes to be made in the systems that provide paid services to persons with mental health and substance abuse issues. However, it was nice to know that the conversations about the needed changes are taking place.

Mind/Body Medicine – The mind/body connection has been a major topic of discussion at most of the conferences relating to trauma and substance abuse that I have attended over the past couple of years. The connection between trauma and substance abuse has become mainstream knowledge, more so than in the field of mental health. Along with this has come the knowledge that modes of treatment need to move beyond medication and traditional psychotherapy. Mindfulness based stress reduction, spirituality and meaning making, exercise, chiropractic, therapeutic massage, Reiki, acupuncture, and yoga and Chi Gong are gaining wide recognition as being beneficial to the recovery process for trauma survivors who have been using substances or process addictions (i.e. porn, over/under eating, gaming, gambling) to self medicate the effects of trauma in their lives. Many treatment centers in the country are incorporating these modalities into their programs because they recognize the importance of engaging the whole person.

The Most Important Element of Healing from Trauma – The Therapeutic Relationship. Research is showing what counselors and advocates have known for a long time. It is not the mode of treatment, the therapeutic milieu, or the medication that has the most effect on a person’s ability to heal from trauma. It is the relationship between the therapist (or advocate) and the person who has been traumatized. The components of the relationship include empathy, compassion, and non-judgment. Dr. John Briere of the University of Southern California www.johnbriere.com highly recommends mindfulness training for counselors as a means of assisting them in holding a space of compassion and non-judgment in the relationship with the survivor. This idea has been also been discussed by Judith Herman in her book, Trauma and Recovery. She states that "trauma occurs in relationship. Therefore, healing from trauma must occur in relationships."

How does this apply to our work with survivors of domestic violence and sexual assault?

First of all, we do not need to be intimidated by the list of diagnoses that a person may give us when they walk through the doors of our agencies and shelters. These are just labels that have been given to them in response to their behaviors on the day they were diagnosed and a limited history. The diagnosis is not the person and by looking at them through fresh eyes without the lens of the diagnosis we can meet them with compassion and empathy.

It is also becoming more evident that providing opportunities for women in shelter to engage in exercise, creative arts (journaling, drawing, fiber arts), yoga, Chi Gong, Reiki, or mindfulness based stress reduction can decrease reactions to possible triggers. These activities also increase a sense of empowerment as the survivor begins to learn ways to manage stress without the use of alcohol or drugs.

I hope the above generates discussion and opportunities to expand services to survivors. I understand that budget constraints play a big part in the provision of services, but there are many volunteers in our communities who would love the opportunity to provide a service to our programs.

Book Review - Fried: Why You Burn Out and How to Revive by Joan Borysenko, Ph.D.

2011-01-25T13:24:00.000-08:00

I have been under the weather the past couple of days and was fortunate to have Fried by Joan Borysenko at the top of my reading pile. Dr. Borysenko used the social network, Facebook, to gather input from her Facebook Friends (FBFs) to write about people’s experiences with burnout. By combining the input of her FBFs with research about burnout she was able to give a comprehensive view of the experience of burnout and the possibilities that come with surviving the experience. The information she provides would be extremely helpful to anyone working in the field of domestic violence and sexual assault.

Dr. Borysenko uses the allegory of Dante’s Inferno to map the progression of burnout from the descent into hell to the rise to Paradise. In the first chapter she provides the stages of burnout with the first stage being “Driven by the Ideal” and the last stage as “Physical and Mental Collapse.” I was extremely affected by the quote she provided from Thomas Merton’s Letter to an Activist which I think is very applicable to the work we do in our work to end violence against women and children.

“Do not depend on the hope of results. When you are doing the sort of work you have taken on, essentially apostiolic work, you may have to face the fact that your work will be apparently worthless and even achieve no result at all, if not perhaps results opposite to what you expect. As you get used to this idea you start more and more to concentrate not on the results but on the value, the rightness, the truth of the work itself.”

In this first section on the stages of burnout, Joan Borysenko provides writing exercises to help determine where a person may be on the continuum. In other chapters she addresses the “depression industry” that fails to recognize the effects one’s life history and prefers to medicate symptoms rather than address trauma and grief and may have actually done more harm than good. I found this section particularly interesting.

Dr. Borysenko also discusses the Adverse Childhood Experience studies of Dr. Vincent J. Filletti and outlines how childhood experience effects out ability to maintain our physical and mental health. She also encourages the use of McClelland’s Thematic Apperception Test and the Meyer’s Briggs to determine temperament and how one responds to stress. It was not necessary for me to take the TAT to know where I would fall and I found it helpful in validating the work I currently do. Dr. Borysenko recommends the use of such tests as a means of finding out whether or not one is working in a situation that will lead to increased risk of burnout.

Dr. Borysenko’s wisdom and stories from her own life are beautifully intertwined with the wisdom of the FBFs that she invited to participate in discussion regarding burnout and the revival that occur once a person makes the journey from Hell to Paradise and the recognition that we can let go and move one to a new life with even greater excitement and productivity.

I hope readers will find this book as wonderful as I did. I plan to refer to it often

I will end with a quote Dr. Borysenko included by John Milton (from Paradise Lost): “The mind is its own place, and in itself I can make Heaven of Hell, a Hell of Heaven.”

Trauma and Anticipated Loss – Why do Survivors Sabotage Their Own Efforts for Change?

2011-01-18T10:44:00.000-08:00

When I am consulting with advocates about survivors with whom they are working, I often am asked “why does it seem like just when everything is going right for someone, that it all falls apart again? or “why is it so hard for some trauma survivors to plan for the future?” This post is going to describe two phenomena that occur in the minds of complex trauma survivors and will hopefully explain why. These phenomena also apply to persons in recovery from long term addictions. This is not surprising, since most persons with severe and long term addictions are also survivors of trauma.

Anticipated Loss

Trauma survivors are experts at loss. The first traumatic event was also the first loss. Losses may include death or absence of a loved one, loss of a sense of safety, loss of important beliefs, loss of a home, or loss of a job. As these losses pile upon each other, the victim begins to anticipate new losses around the corner. This leads to attachment issues: either lack of attachment or clinging to relationships or both (the come here/go away relationship). When loss is seen as a common occurrence, the person begins to anticipate loss even when there is no evidence that loss will occur.

Anticipated loss can lead to sabotaging one’s own efforts to move forward. Anticipating future losses can feel like walking on eggshells. The anxiety and fear is so great that the person will subconsciously take action that will cause the loss to occur sooner. This often occurs in relationships. The person may be so sure that the relationship is going to end that he/she will end it or take action that will cause the other person to end it. Anticipated loss can also keep a person from doing anything to move forward. They may not look for a job, apartment, or a relationship because of the anticipated loss of the job, home, or relationship.

Persons addicted to substances and who have had a long history of cycling in and out of recovery, experience the same thing. The anxiety of possibly relapsing, having life change, and experiencing success and then losing it, can cause some people in recovery to relapse just before the positive change occurs. This has often been called “giving up before the miracle happens.” I once counseled a woman who had lost her nursing license due to stealing and using drugs from the hospital where she was employed. She was working hard to maintain her recovery and working closely with the licensing board to regain her license. However, just before she was due to regain her license she would relapse and would have to start the process all over again. This happened twice and we talked about anticipated loss as part of her relapse prevention plan. Her fear of the unknown and the potential loss, though, won out over her desire to regain her nursing license.

Anticipated loss of a counselor, advocate, case manager or other important person can also lead to subconscious sabotaging of efforts to move forward. It is very important to ensure the person that support services are still available as a person moves on into their positive future. The best thing that we can do to help a trauma survivor move forward is to talk about the possible anticipated loss and provide support. If a person is aware that what they are experiencing is due to the past trauma she may be able to use skills and support to be able to move through the anxiety without taking action that could lead to loss.

Sense of a foreshortened future

The other phenomenon that occurs in many trauma survivors is a sense of a foreshortened future. In other words, some trauma survivors are very aware of their mortality after having their life threatened on numerous occasions. When someone subconsciously believes that her life is in danger and that she will die at any time, it is difficult to plan for the future. This emotional state continues long after the threat of death has passed and can lead to poor follow through when making plans for the future. A person who has a sense that they are not going to live long will find it difficult to make long range plans. She is completely focused on her day to day and moment to moment survival.

When working with someone who is a trauma survivor it is helpful to recognize that anticipated loss and a sense of a foreshortened future can lead to behaviors that may be defined as difficult, manipulative, or non-compliant. It is more productive to recognize that the person is fearful of the future since her only experience has been negative. It may even be helpful to discuss what is possibly happening with the person. Give her kudos for being able to survive so far and let her know that support will be available to help ease losses in the future. We cannot guarantee that losses will not occur. They are a part of life. However, we can help the person recognize their own fear of loss and provide a sense of safety and support.

Violence, Mental Illness and Stigma

2011-01-11T10:33:00.000-08:00

Since the shooting in Arizona on Saturday, I have noticed a lot of press attention given to the possibility that the young man who shot Rep. Giffords and killed six other people has a mental illness. This has led to conjecture on the part of the press and others that the mental illness is what caused Jared Loughner to engage in such a horrific act. This is concerning because it continues to perpetuate the myth that mentally ill people are violent.
SAMHAS (Substance Abuse and Mental Health Services Administration) provided the following information on their website.

“A consensus statement signed by more than three dozen lawyers, advocates, consumers/survivors, and mental health professionals reads in part: “The results of several recent large-scale research projects conclude that only a weak association between mental disorders and violence exists in the community. Serious violence by people with major mental disorders appears concentrated in a small fraction of the total number, and especially in those who use alcohol and other drugs.” (Monhan, J. and Arnold, J., 1996)

In addition:

• “Research has shown that the vast majority of people who are violent do not suffer from mental illnesses.” (American Psychiatric Association, 1994).

• “Clearly, mental health status makes at best a trivial contribution to the overall level of violence in society” (Monahan, John, 1992).

• “. . . [T]he absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill.” (Mulvey, 1994)

• “Most people who suffer from a mental disorder are not violent — there is no need to fear them. Embrace them for who they are — normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support.” (Grohol, 1998)

• “Compared with the risk associated with the combination of male gender, young age, and lower socioeconomic status, the risk of violence presented by mental disorder is modest.” (Policy Research Associates, December 1994)

People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime. (Appleby, et.al., 2001)

“A study by researchers at North Carolina State University and Duke University has found that people with severe mental illness — schizophrenia, bipolar disorder or psychosis — are 2 1⁄2 times more likely to be attacked, raped or mugged than the general population.” (— Chamberlain, Claudine. “Victims, Not Violent: Mentally Ill Attacked at a Higher Rate,” ABC News “

Societal attitudes toward the mentally ill, including stigma, tend to increase discrimination. President’s Freedom Commission on Mental Health found that stigma leads persons not living with mental illness to avoid living, socializing, or working with, renting to, or employing people with mental disorders – especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopeless. People with mental health issues internalize the public attitudes and will often conceal symptoms or fail to seek treatment.

There is still much work to be done in regards to the effects of the media pundits’ and politicians’ hate speech on the minds of vulnerable people, people who have been raised in an atmosphere of abuse, bigotry, and violence. However, I encourage the media to put aside the possibility of mental illness existing within the perpetrator and explore instead the effects of negative and hateful rhetoric on minds that have been isolated due to media’s own perpetuation of the stigma of the mentally ill. It is so important to remember also that most violent people are not mentally ill and few mentally ill people are violent.

Book Review – Life After Trauma: A Workbook for Healing by Dena Rosenbloom, Ph.D. and Mary Beth Williams, Ph.D. (2nd Edition) 2010, The Guilford Press.

2010-12-30T13:13:00.000-08:00

It is difficult to find workbooks for trauma survivors that are as well thought out as Life After Trauma by Drs. Rosenbloom and Williams. I usually approach workbooks or curriculums for support groups with some trepidation, fearful that the book will promote the telling of one’s trauma story or engaging in reconciliation with the abuser. Life After Trauma quickly dispelled my fears and I found it to be very sensitive in its approach and development of safety for the trauma survivor.
The workbook is primarily for use by an individual but could easily be adapted for group work. However, the ability to take the book at one’s own pace makes it particularly valuable for someone who may feel a need to move through the book thoughtfully and take breaks as needed. I would recommend that anyone who wishes to work with this book use it an excellent adjunct to individual therapy with a therapist who has specialized training in working with trauma survivors.
I was particularly impressed with the book’s progression from recognizing and coping with triggers to understanding reactions to trauma, ending with strategies on how to develop safe and secure relationships and heal for the long term. There are regular check-ins throughout the workbook that provide breathers and the opportunity for the survivor to assess whether or not she/he is able to move on.
The authors appear to use cognitive behavioral trauma- focused therapy techniques to develop strategies for survivors to use in addressing beliefs about the abuse or traumatic event. A strength based approach assists survivors in understanding how trauma has affected their self esteem and how they can gain value, esteem, power, and intimacy in their lives.
The appendix offers valuable information for trauma survivors on how to choose a doctor or other health practitioner and plan for appointments. It also has an excellent bibliography of books, articles and websites. Suggestions for find a therapist for trauma is also included along with a section on how mental health professionals can use the workbook with a warning to non-trauma specialists to not evoke or examine traumatic memories.
Dena Rosenbloom, Ph.D. is a clinical psychologist in Glastonbury, CT and Mary Beth Williams, Ph.D. is an LCSW working in private practice in Warrenton, VA. Dr. Williams is widely published and is an instructor for the Office for Victims of Crime at the U.S. Department of Justice.

Trauma and Shame

2010-12-15T10:36:00.000-08:00

Trauma victims, particularly those who experienced traumatic events in childhood, are often reluctant to talk about what happened to them for a variety of reasons. Keeping the secrets buried are often due to a deep sense of shame. Because of the intense personal nature of interpersonal violence, victims are often left believing that there is something horribly wrong with them that caused the event to occur and this shame remains within them for years.

Shame and guilt are two separate emotions. Guilt is feeling bad about something that you did. Shame is feeling bad about who you are. Perpetrators are experts at manipulating the victim into believing that the traumatic act was because of whom she/he is and that if they were any different it wouldn’t have happened. The perpetrator’s accusations could range from “you were so beautiful and innocent I just had to have you” to “if you hadn’t been in that place, wearing that particular clothing, being who you are I wouldn't have done what I did." The victim is left feeling as if the violence occurred because of who they are rather than who the perpetrator is.

Shame is common in young children. In early childhood, the brain has not developed the capacity to logically understand the actions of others. Children are unable to think through events to have an understanding of their victimization. Their thinking is very ego-centric, resulting in a belief that “if I was just smart enough, strong enough, pretty enough” bad things would not happen to me and people would love me. This accounts for the prevalence of super heroes in our culture and the rising amount of children’s literature containing young people with special powers to fight evil while grownups are either bystanders or enemies.

Shame is perpetuated when there is little support after the traumatic event. This could be due to the family’s desire to keep a secret or the belief that one must be strong and maintain a good public image of the family unit at the cost of the individual.

I was told the story of a woman who as a five year old girl was taken to her grandfather’s funeral without being told ahead of time the nature of the occasion. She was led to the coffin and held up to see her grandfather for the last time. She told me that she remembered feeling something break inside of her and she immediately became afraid. When she tried to talk to her family about the fear she suddenly felt she was told to keep quiet and judged for her feelings. She grew up believing that fear was something that you avoided and, if you felt any fear you hid it for the sake of the family’s image. She said that she has grown to associate this fear with funerals, although she has no difficulty with death. Her fear appears to be based in the belief that she will do something that will cause others to be angry with her.

Intense shame can lead to isolation, use of drugs and alcohol to numb the pain, and developing survival skills to get needs met. These may be seen as negative by others, but may be productive in many ways. The woman above told me that she learned that when she was afraid in the middle of the night, she could wake up her baby sister and make her cry so that their mother would come and rock the baby. Then the young girl would be able to go to sleep to the sound of her mother rocking her sister. Telling her mother that she was afraid was too scary and meant she would have to let her mother know she was afraid, a cause of great shame in her family.
A lot of survivors do things that seem unproductive in their attempt to keep their secrets because of the shame it involves. To let someone know your secrets sets you up to be re-victimized if that person sees you for who you think you are. This possibly translates into “imposter syndrome,” an overwhelming self doubt that results in a fear that others will find out who you really are. This can lead to disorganization, procrastination, and possible under achievement or over achievement. It is all about keeping the secret/s.

It all comes back to remembering how trauma occurs in relationship and the healing occurs in relationship (Judith Herman). It takes finding a safe relationship in which a person can release their secrets and discover the truth within their story for healing to take place. Once this sense of shame is lifted, the person is more empowered to move forward knowing that they are not responsible for what happened to them and can take control of their life.

Surviving the Holidays

2010-11-30T12:01:00.000-08:00

The holidays are often a difficult time for trauma survivors. Family activities, while joyous times for some people, are often difficult reminders of the past and can cause distress. For some survivors, the holidays are anniversaries of traumatic experiences. For other survivors, it may mean being in the presence of the sexual perpetrator or the abuser.

Survivors may not always be aware of how they are being triggered or may feel guilt and shame for not being able to rise to the same level of excitement and anticipation that others feel during this period. Even if they seem to have recovered well from past trauma, they may begin to have more problems with sleeping, over or under eating, increased anxiety, and a sense of impending disaster.

Here are some tips to help survivors manage stress during this time:

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.

Moderation in consumption of food, alcohol, and activity can be a very valuable for surviving the holidays.

Please feel free to add any other ideas you may have in the comment section below.

Forgiveness and Recovery from Trauma

2010-11-12T11:38:00.000-08:00

I recently had a discussion with a few advocates on the idea of forgiveness and its place in healing the effects of trauma. I have had a few incidences in my work over the years to discuss this with both survivors and advocates and thought that it would be meaningful to generate some more thoughts on the subject.

The idea of forgiving the perpetrator for many survivors is an abhorrent idea. When presented with the idea in a support group curriculum or self-help book a survivor may have many responses. “Why would I forgive him? He hasn’t apologized!” “If I forgive him, that means I have to let him in my life again?” “What? Forgive? That would mean I would have to condone what happened? I can’t do that. First you tell me it was wrong and now I have to forgive?” “I must be a horrible person if I can’t forgive.”

Healing from trauma is a process and so is forgiveness. The process of recovery from trauma has many stages and forgiveness is only a part of one of those stages. Forgiveness may also be something that occurs further along in the healing, after there has been separation from the perpetrator and more manageability of one’s life and emotions.

In Trauma and Recovery, psychiatrist Judith Herman (1997) defines trauma as a disease of disconnection. In her book she describes a three-stage model for recovery – safety, remembrance and mourning, and reconnection.

Early in recovery a survivor is primarily working on issues regarding safety. Forgiving the abuser can often feel unsafe. It may feel as if a crack is being opened in a door that the survivor is working very hard to keep shut. If she is still experiencing feelings of love toward the abuser she may feel that forgiveness would increase her vulnerability and decrease her safety. During this early stage, controlling the environment, both internally and externally, is the most important task. Being able to establish appropriate boundaries with everyone in her life is a part of this task and forgiveness may blur that boundary. This stage is focused on the present and lasts as long as necessary for the survivor to develop skills to reduce the impact of triggers, alleviate anxiety and depression, and negotiate safety in the greater world.

During the remembrance and mourning stage the women is stabilized and begins to focus on the past. She often begins to acknowledge her losses and mourns the loss of the relationship or the dreams that were associated with her relationship. She is using the skills learned in the first stage to self-soothe while she comes to term with the impact of the trauma on the life she thought she would have. It is during this time that she may need to start to forgive herself – not for the abuse – but for what she may perceive her role to have been in the trauma. Many survivors carry a sense of guilt and shame in regards to their abuse and how they may have handled the situation. Hopefully, she will be able to recognize that she did the best she could under the circumstances and can now move on, stronger in knowing that she survived.

If forgiveness of the perpetrator is going take place, it is probably during the third stage – reconnection. This reconnection refers to developing a new self and creating a new future. It does not mean reconnecting with the perpetrator. Forgiveness is often described as a state of “letting go,” a process of releasing the past and moving forward into the future with a light load. It is not an action toward the abuser, but is rather an internal process of living life without resentments, anger or indignation. It is the recognition that until we “let go” the abuser still has power over us. Forgiveness is really not about what it does for the other person, but what it does for the survivor. The perpetrator never needs to know.

Forgiveness is also an action that cannot be forced onto the survivor. It is not to be a prescribed or demanded expectation. This is a process that the survivor comes to of her own choosing and in her own time. She will be able to let go of the past when she feels safe stepping into the future.

New Resource Added to Valuable Links - Stop the Storm

2010-11-08T05:56:00.000-08:00

I would like to introduce you to the blog http://stopthestorm.wordpress.com/ It is a wonderful resource. This blog is written by a 59 year old survivor of childhood maltreatment who is also a cancer survivor. She has done extensive research on trauma and how it has affected her ability to be in the world. She does an excellent job of describing her responses to triggers and how trauma has influenced her relationships. I highly recommend that you check it out.

Effects of Maltreatment on Brain Development

2010-11-05T07:18:00.000-07:00

There have been a few requests lately for more information on how trauma affects a child’s brain and the child’s ability to form attachments and learn. The following is a summary of an article, Understanding the Effects of Maltreatment on Brain Development, published by the US Department of Health and Human Services’ Child Welfare Information Gateway www.childwelfare.gov/pubs/issue_briefs/brain_development

Thanks to the relatively recently developments in the study of brain development including functional magnetic resonance imaging, there is now evidence to show that brain function is altered significantly. “…genetics predisposes us to develop in certain ways. But our experiences, including our interaction with other people have a significant impact on how our predispositions are expressed. In fact, research now shows that many capacities thought to be fixed at birth are actually dependent on a sequence of experiences combine with heredity. (Shonkoff and Phillips, 2000).”

An infant is born with almost all of the brain neurons that it will ever have. As the brain developed in the fetus these neurons began to specialize, developing specific tasks for the lifespan of the person. This development continues after birth and on into adulthood. The first regions to develop are those concerned with bodily functions and maintaining life. “But the majority of brain growth and development takes place after birth, especially higher brain regions involved in regulating emotions, language and abstract thought. Each region manages its assigned functions through complex processes that involved chemical messengers (Perry, 2000a).”

Plasticity is the term used to describe the brain’s ability to change in response to stimulation. This is dependent on the stage of development and the specific region of the brain that is affected. The part of the brain that is “wired” to respond to the human voice or facial expression anticipates the exposure and when this does not happen, the brain will discard these pathways. The brain will discard pathways that are not being used and develop other pathways that are needed for survival.

There are sensitive periods for the development of certain capabilities. “For example, infants have the genetic predisposition to form strong attachments to their caregivers. But if a child’s caregivers are unresponsive or threatening, and the attachment process is disrupted, the child’s ability to form any healthy relationships during his or her life may be impaired )Perry, 2001a).

Babies are born with implicit memory which means they have a perception of the environment that can be recalled in unconscious ways (responding to the sound of mother’s voice). Explicit memory is tied to language development and provides children around the age of 2 with the ability to talk about themselves in the past or future or in different places or circumstances. However, children who have been abused or suffered other trauma may not be able to retain the explicit memories that they need to be able to tell about their trauma. Instead, they will experience the implicit memories such as bodily or emotional sensations that manifest as nightmares, flashbacks or other uncontrollable reactions.

Children can learn to tolerate moderate stress and greater amount of stress can be tolerated if he/she has a positive relationship with an adult caregiver. However, without this positive interaction in significant amounts at critical periods, the brain can be altered by the toxic stress. Specific effects depend on the age of the child, whether the trauma was one-time or chronic, the identity of the abuser, and whether there is a dependable nurturing adults present, the type and severity of the abuse, the intervention, and how long the maltreatment lasted.

“Altered brain development in children who have been maltreated may be the result of their brains adapting to their negative environment. If a child lives in a threatening, chaotic world, the child’s brain may be hyperalert for danger because survival may depend on it. But if this environment persists, and the child’s brain is focused on developing and strengthening its strategies for survival, other strategies may not develop as fully. The result may be a child who has difficulty functioning with a world of kindness, nurturing, and stimulation.”

Children who are exposed to long term and severe abuse, either emotional or physical/sexual, will develop responses such as a persistent fear response, hyperarousal, dissociation and disrupted attachment (inability to form relationships). The neural pathways have formed these responses as a means of surviving the impact of the trauma. However, these responses also result in increased susceptibility to stress, excessive help-seeking and dependency or excessive social isolation, and the inability to regulate emotions. The effects are cumulative and can lead to life long difficulties in interpersonal relationships.

“Some of the specific long-term effects of abuse and neglect on the developing brain can include (Teicher, 2000): diminished growth in the left hemisphere, which may increase the risk for depression; irritability in the limbic system, setting the stage for the emergence of panic disorder or posttraumatic stress disorder; smaller growth in the hippocampus and limbic abnormalities (areas of emotions and memories in the brain), which can increase the risk for dissociative disorders and memory impairments; impairment in the connection between the two brain hemispheres, which has been linked to symptoms of attention-deficit/hyperactivity disorder.

The U.S. Department of Health and Human Services Children’s Bureau (2009) encourages professionals to promote five “protective factors” that can strengthen families, prevent abuse and neglect, and promote healthy brain development: nurturing and attachment, knowledge of parenting and of children and youth development, parental resilience, social connections, and concrete support for parents.

For additional information go to www.nhcadsv.org to access the recent publication, The Mental Health Needs of Children Exposed to Violence in their Homes.

Editorial Response to Glee Actresses Posing for GQ Magazine

2010-10-21T07:50:00.000-07:00

This past week GQ magazine printed photos of Lea Michelle and Dianna Argon of the very popular FOX television series, Glee. These photos are part of the latest issue of GQ. The photos depicted Lea and Dianna as high school students in various states of undress or exposure. In most of the photos they were wearing parts of cheerleader uniforms (though I have never seen a cheerleader in pink spiked heels). In a couple of the photos, they pose with Corey Monteith, another actor on the television show, draped over him in sexualized positions. Corey is fully clothed in all photos and appears to be depicted as the character he plays on the television show.

I have searched and have yet to find a response to the photo shoot from anyone in the feminist or child abuse community. A statement by the Parents Television Council responded to the photos by stating "It is disturbing that GQ, which is explicitly written for adult men, is sexualizing the actresses who play high school-aged characters on 'Glee' in this way. It borders on pedophilia. By authorizing this kind of near-pornographic display, the creators of the program have established their intentions on the show's direction. And it isn't good for families.” GQ responded with "The Parents Television Council must not be watching much TV these days and should learn to divide reality from fantasy," Jim Nelson, editor-in-chief of GQ, said. "As often happens in Hollywood, these 'kids' are in their twenties. Cory Montieth's almost 30! I think they're old enough to do what they want."

I think that GQ is missing the point. I have few objections to Lea and Dianna posing for GQ or any other magazine if they are portraying adult women. The irresponsibility occurs when the photos depict them as high school students and, as in this case, very sexualized high school students.

Looking at GQ demographics we quickly find the age group, 25 to 34, makes up

38% of the readership while 29% of the readership belongs to the 35 to 49 years old

group. The 18 to 24 year olds make up 24% of the readership while the 50 to 64 year

old males make up only 8% and the 65+ age group makes up only 1%. 91% of the

readers are under 50 years of age. Over 36% of the male readers graduated college

while another 37% attended college. 64% of the males have an income of $50,000 or

more, 11% have an income of $40,000 or more, 8% at $30,000 or more and the

balance are the $20,000 or more at 7% and the $10,000 or more and the less than

$10,000 having 10% of the male readership between them. Clearly, the worldview of

GQ is through the eyes of a young, educated, and wealthy American male. (Media and Culture as Manifest in Male Individualism, Bozark, 2003)

My concern is how these American males are viewing adolescent girls. What Lea and Dianna and GQ magazine have done is to set up our teenage daughters and granddaughters up for continuing to be seen as objects of sexual desire for males over the age of 25. It doesn’t matter that Lea and Dianna are in their twenties, they were explicitly depicting adolescent girls in these photos.

Lea Michelle stated in an interview that she had been dealing with body issues and that she enjoyed being able to pose for these photos. She also stated she was surprised at what the photographers were able to talk her into doing. Her statement suggests that she was manipulated into some of the poses. I think that Lea could have taken a more responsible approach and 1) thought about how media had contributed to her issues regarding her body 2) been more pro-active and responsible for what was happening in the photo shoot. I would not be as concerned if she had been responsibly posing as the adult woman that she is, though I would still be concerned with how media presents women as objects and demands perfect bodies.

GQ’s response shows the ongoing irresponsibility of the media in regards to what it sells to its readers. By saying that the PTC is unable to separate fantasy from reality, it is showing that it does not understand that what it is selling to adult males is a fantasy of American teenage girls that sets them up for victimization in a number of ways.
I am an avid watcher of Glee. I find that its portrayal of the struggles of adolescence is spot on and it is willing to take on a number of controversial issues including teen pregnancy and homosexuality. The cast is talented and the musical numbers are entertaining and often inspiring. This recent incident with GQ, however, will now make me think even more about how media depicts teenagers. I will also use this as a teachable moment with my teenage granddaughters. If it is out there, it needs to be discussed.

Fetal Alcohol Spectrum Disorder and Complex Trauma

2010-09-17T12:29:00.000-07:00

A couple of weeks ago I attended a day long workshop on Fetal Alcohol Spectrum Disorders (FASD) present by Dr. Susan Adubato Ph.D. and Dr. Mary DeJoseph of the New Jersey Regional FASD Diagnostic Centers. The following will give you a brief summary of what FASD is and then I will discuss how this effects the work we do with survivors who are using alcohol.

From the website http://www.fascenter.samhsa.gov/

What is FASD

FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. Each year in the U.S., as many as 40,000 babies are born with an FASD. The cost to the nation for FAS alone is about $6 billion a year.

The term FASD

The term FASD refers to a spectrum of conditions that include fetal alcohol syndrome (FAS), fetal alcohol effects (FAE), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD). Although disorders within the spectrum can be diagnosed, the term FASD itself is not intended for use as a clinical diagnosis.

Fetal Alcohol Syndrome has been an evolving issue. Initially, from the 1950’s until the mid 90’s FAS was the term which applied to those children who were born with certain facial characteristics - thin upper lip with a small philtrum (the midline groove in the upper lip that runs from the top of the lip to the nose), low birth weight, small eye openings, and small head circumference. However, as neuroscience and the ability to study fetal development has advanced, it is now known that the physical characteristics of FAS do not need to be present for a child to be born with FASD. When and how much drinking occurred during fetal development influences what the effects will be.

The most serious symptoms of FASD are the invisible symptoms of neurological damage that results from prenatal exposure to alcohol. These include: attention deficits (with or without hyperactivity, memory deficits, difficulty with abstract concepts (math, time, money), poor problem solving skills, difficulty learning from consequences, poor judgment, immature behavior, poor impulse control. Adults with FASD have difficulty maintaining successful independence. They have trouble staying in school, keeping jobs, or sustaining healthy relationships. Without appropriate support services, these individuals have a high risk of developing secondary disabilities such as mental illness, getting into trouble with the law, abusing alcohol and other drugs, and unwanted pregnancies. Children and adults with FAS are also quite vulnerable to physical, sexual and emotional abuse (Teresa Kellerman of the FAS Community Resource Center 2005). This is very similar to the issues faced by persons with a history of complex trauma.

This presents a challenge. FASD is considered to be a birth defect that is organic in nature and needs to be treated differently than you would someone with complex trauma. How are we to know that difference? We more than likely don’t. However, there is the likelihood that we are working with survivors who have FASD in addition to dealing with trauma. Knowing the family history is the only way to know if it is possible and it can only be diagnosed by a doctor who specializes in FASD.

Along with the generational abuse that occurs in families, we can now ascertain that the legacy of growing up in an alcoholic family may include FASD in addition to complex trauma. I have to admit that I find this information a little overwhelming. It explains why there appear to be some survivors who continue to have difficulty problem solving and making changes even when we provide support and empowerment. This may explain why some survivors have difficulty making decisions, processing information, and developing new healthy relationships long after the trauma has ended and they are living in a safe environment and not experiencing triggers or flashback.

I would be interested in hearing how you feel this information plays a part in the work that you do, your response to survivors with complex trauma who grew up in alcoholic families, and how you respond to pregnant women who are using alcohol.

According to the research, there is no safe amount or safe time during a pregnancy for a woman to drink alcohol. Many women have already incurred damage on the fetus even before they know they are pregnant. Does this information change your thinking in regards to choice when it comes to using alcohol, particular for women of childbearing age?

Contact me for more information or do a search for Fetal Alcohol Spectrum Disorder.

Where Does She Belong?

2010-09-03T10:19:00.000-07:00

In this post I would like to address some of the comments that I have heard over the years in regards to opening shelter doors to women who have substance abuse and mental health issues. I have tried not to editorialize in most of my blog posts, however, this post may stretch that boundary. If you are a staff member or volunteer with a domestic violence program, I invite you to use this article as a way to generate discussion with other staff members.

During the 1990’s I worked with the YWCA in Norfolk, VA to implement the Women and Recovery program to provide shelter and transitional housing to victims of domestic violence who had substance abuse issues. I also worked with the Virginia domestic violence coalition to provide training and technical assistance to other programs in the state to increase access for women with substance abuse issues.

At that time, many programs were screening women out of shelter based on when they had last had a drink or used drugs. Some programs had a requirement of 24 hours of abstinence whereas others had a 30 day requirement. My argument was that many staff in those programs would not be able to access shelter under those restrictions.

My goal was to educate in regards to the safety needs of victims who were self medicating due to violence in their lives. People started to realize that a woman was unable to get clean and sober while living with an abuser who was using her substance use as a means to control her and who tightened control if she tried to become sober. We also understood how some systems of recovery further disempowered women and how much fear, stigma, and shame existed for women who used drugs.

There were staff members who stated their opposition and one executive director said to me “I do not want those type of women in my shelter.” I responded with “you already do. They just know that their safety and security is at risk if you find out so they do everything they can to hide it.” In the same way that victims have had to hide money, keys, clothing and important paperwork from their abuser, victims with a drug or alcohol problem knew they needed to hide their use from shelter staff in order to remain safe.

I have seen shelters become more understanding of the use of alcohol and drugs to self medicate the effects of trauma in women who come into shelter. Shelter staff are more willing to work with survivors to access recovery programs and provide plans to remain safe and sober. They understand that without other resources and skills to manage anxiety, fear, and sleeplessness, the woman does not see another choice but to use.

The challenge now is to address the stigma and attitudes in regards to sheltering persons with severe mental illness. The comments I hear now are – “She doesn’t belong here. She is mentally ill.” “Her primary issue is not domestic violence. She doesn’t belong here.” “She is scaring the other clients. She doesn’t belong here.”

Where does a battered women who has a mental illness (that is more than likely a response to trauma) belong?

The domestic violence movement has consistently seen that violence against women is perpetuated due to systems that fail to respond to the needs of battered women and their children. The movement not only worked to develop programs that provided safety and shelter to women, but also worked to make changes in the institutions that were created to maintain public safety. Over the years, the domestic violence movement has made institutional, society, and ideological changes that made it safer for women in their homes and made it safer for her to leave.

What this means is that the women who used to seek shelter now have resources that provide safety without needing to leave their home or, if they do leave, they are able to live safely elsewhere.

There are still failures in the systems, but now the systems actually exist and the number of women whose primary issue upon entrance to shelter is domestic violence is fewer. Domestic violence may be a contributing factor but once safety needs are met, it is no longer the main issue. The long term effects of trauma, whatever form they take, become the main issue along with housing, financial, and transportation needs.

Because of the current crisis in the mental health system women have a more difficult time in accessing services to address their mental illness. Women may also choose not to engage in the mental health system because it has not met her needs, overmedicated her, did not validate her trauma, and possibly re-victimized her or colluded with the abuser.

So, again I ask – Where does she belong?

If the domestic violence movement has a history of keeping women safe while working to change or partner with systems, then she belongs with us. In the same way that we have kept battered women safe while we worked with police officers, judges, and social services to develop laws to protect, we are called to protect battered women with mental illness while we work to promote collaboration and changes that can protect her and assist in her recovery from trauma.

By saying she doesn’t belong, we are re-victimizing her. By recognizing she does belong with us due to the nature of her being a woman who has been abused, our goal becomes changing how we respond to ensure her safety, the safety of others in the program, and the safety of staff? It takes education and willingness to move outside our comfort levels in order to meet her where she is and find ways to increase her choices. If we don’t, what other choices does she have?

Cultural Influences and Response to Trauma

2010-08-20T07:07:00.000-07:00

“A broad understanding of culture leads us to realize that ethnicity, gender identity and expression, spirituality, race, immigration status, and a host of other factors affect not just the experience of trauma but help-seeking behavior, treatment, and recovery.”

- National Child Traumatic Stress Network

As we broaden our service response to immigrants and refugees, victims of human trafficking, and children and grandchildren of persons who have experienced trauma in this country and others, it becomes apparent that the need for more information on how to respond to trauma survivors from a cultural perspective is crucial. Not only is it necessary to understand the trauma that has occurred within cultures, but it is also important to have an understanding that how cultures respond to trauma can impact the ability of a survivor to recover from complex trauma.

Culture is not limited to one’s ethnicity or birthplace, but also relates to age, disability, religion and spirituality, social class, sexual orientation, indigenous heritage, immigration or refugee status, and gender and sex.

Laura S. Brown, author of Cultural Competence in Trauma Therapy, states that being culturally competent involves being aware of our own personal relationship to each of the above identities and to be attentive to the phenomenon of dominant group privilege.

“Privilege lends power to one’s biases; if I am a lesbian biased against heterosexual people, I may suffer from being prejudiced but I lack the social power to declare all marriage between other-sexed persons illegal. The heterosexual person, biased against me has the privilege and power to legislate against me. Acknowledging one’s privilege can be a trust-engendering and relationship-building action in therapy (advocacy). Ignoring it or pretending that it does not matter will eventually undermine trust and endanger the working alliance of therapy (advocacy). Pg. 41

The ability of a person to recover from trauma is dependent on a number of factors. How culture views the traumatic event is one of the factors. A young woman raped on a college campus in this country faces many obstacles in her recovery but also has access to sexual assault crisis services and medical care. If she chooses to let her parents know of the event, she may or may not receive support. However, if she is living in a Middle Eastern or African country, there may be a possibility that the rape occurred as an act of war resulting in the loss of status for herself and her family and possibly her death at the hands of a family member.

In some Central American countries (and others) families have had sons and daughters “disappear” or killed by the government or people posing as authority. When they immigrate to this country they are often suspicious or frightened of anyone in a government agency or in authority because of this. If a social worker or advocate is unaware of this, they may see the fear as resistance or noncompliance.

One mistake that is made by advocates/therapist/case managers is assuming the cultural identity of another person. Persons of mixed racial heritage are often identified with a group with whom they may not choose to belong or proudly identify as a member of a group that others may not recognize as a possibility. Gender identity is often confused with sex when gender identity pertains to gender roles and sex is the biological makeup. Sexual orientation is a biological response. Assumptions in regards to race, ethnicity, gender, sex and sexual orientation can lead to re-victimization of a trauma survivor.

The effects of trauma can be transmitted across generations. Children of holocaust and/or genocide survivors have grown up in a family that recognizes that their ethnicity/religion/tribal affiliations have made them the target of extremists. This can lead to either a denial of their family roots or an increase in affiliation in order to maintain the cultural identity of the victimized group.

The group’s experience in the greater world can also determine how they respond to help. If the predominant and privileged culture is descendant from the same culture that perpetuated the abuses, it may be difficult for a family to seek help outside of their own affiliation. One example of this is the American Native. Their desire to maintain services and affiliation within the tribe is a result of trying to preserve their culture and their distrust of the predominant (conquering) culture. Keeping in mind a group’s history as an oppressed people can help us understand their reluctance to seek services. This phenomenon is also reflected in populations of immigrants living together within communities. It is very important to them to maintain their cultural affiliation and maintain a sense of safety within their own communities.

Within seemingly homogeneous cultures can be a number of identities that respond to trauma differently. In New England, the Yankee culture has a strong identity with a belief in the idea of “pulling one’s self up by the boot straps” and moving on without a lot of discussion of the event. Rural populations respond differently than urban and within each of those, there may be subsets of identities that respond differently. It becomes increasing important to learn as much about a person’s identity and affiliations as possible in order to be aware of any implications due to racism, classism, poverty, sexism, ageism, homophobia, et.al. and, as said before, be aware of any privilege or oppression that exists because of your own identity.

As it is very difficult to discuss all of the implications in regards to cultural trauma and competencies I highly recommend Laura S. Brown’s book, Cultural Competence in Trauma Therapy, Beyond the Flashback (APA Publishing, 2008). Even if you are not a therapist, this book is an excellent resource for expanding your understanding of the influence of identity on a person or a group’s experience of trauma.

4th National Conference on Women, Addiction, and Recovery – Thriving in Changing Times, Chicago, July 26-28, 2010

2010-08-02T11:57:00.000-07:00

I attended the 4th National Conference on Women, Addiction and Recovery in Chicago last week. There were approximately 700 people in attendance, mostly women, and the agenda was full and motivating. It was sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), Treatment Alternatives for Safe Communities (TASC, Inc.) and The ATTC Network. The focus of the conference was to support, engage, and motivate so that providers are able to continue to thrive in the changing environment and continue to provide excellent services to women and their children who are impacted by substance abuse. The following is a synopsis of the plenaries and the workshops that I attended.

The Honorable Pam S. Hyde, J.D. of SAMHSA and Carol McDaid of Capital Decisions presented open plenaries on the state of behavioral health and the future of the mental health and substance use disorders field post parity and health care reform. The major point was that mental health and substance abuse treatment coverage under health reform will be covered equal to medical coverage under all insurance plans. This will extend coverage for a number of people who were not covered before.

There was a video message from the Hon. Tammy Duckworth, M.A., Assistant Secretary for Public and Intergovernmental Affairs at the U.S. Department of Veterans Affairs. She noted that the number of women returning from Iraq and Afghanistan who have mental health and substance abuse disorders is increasing and their needs are complex, some having experienced sexual assault by fellow servicemen. The impact of their deployment on their families is also significant and the Ms. Duckworth expressed the commitment of the VA in providing the needed resources for these service members.

On Tuesday, Lisa Najavits, Ph.d., discussed Emerging Developments in Trauma and Addiction. She introduced the follow-up to her program, Seeking Safety, which will be coming out in the next year. It is called Seeking Change and moves beyond the areas addressed in Seeking Safety by helping the trauma survivor to address the actual traumatic events by moving through three steps – Establishing Safety in Body and Environment, Reconstruction of Trauma, Social Reconnection.

Francine Ward, J.D., presented her personal story of recovery. Francine was raised in poverty in South Bronx and eventually became a prostitute and addict in Las Vegas before being hit by a car when she was in her late 20s. She currently has over 31 years of sobriety and is a Georgetown University graduate and is practicing law. Her message is that recovery is possible if you are willing to do the foot work and if there is someone in your life that is willing to love you to the point where you can love yourself.

Gil Kerlikowske, M.A., President Obama’s Director of the White House Office on National Drug Control Policy discussed the White House’s commitment to family centered treatment as a major part of the office’s strategy to control drug use and trafficking in the United States. Mr. Kerlikowski has been visiting treatment programs throughout the country and listening to providers and consumers express their concerns and needs for more holistic means of addressing the issue.

On Wednesday morning, Jean Kilbourne, Ed.D, presented “Deadly Persuasion: Advertising, Addiction and Relationships.” In the same way that she has previously shown us in Killing Us Softly, Dr. Kilbourne was able to illustrate how advertisers use the psychology of addiction to target the 30% of people who drink 90% of the alcohol in this country. She noted that advertisers do not actually want people to drink responsibly because if everyone in this country drank what would be considered responsibly, then alcohol sales would decrease by 80%. Ads that show alcohol as sexy and desirable are playing into the addicts feelings that alcohol is their lover and friend. She also showed how advertising is directed to children in order to keep the number of consumers stable or growing. One shocking aspect that she discussed was how television and magazines basically sell the public as product, i.e. “if you advertise your beer in our magazine we can guarantee that you will have a certain number of readers who will see your ad and possibly buy your product.”

The workshops at this conference were well planned to provide time for lecture and discussion or to spend time with an expert in the field. On Monday, I attended a lecture on “Women, Addiction & Personality Disorders” given by Drs. Karen Dodge and Caterina Iapaolo of the Hanley Research Center in Florida. The premise was that substance abuse often presents with the same characteristics as a personality disorder and once the person becomes sober, the characteristics will diminish. They demonstrated this through case studies and research statistics. It was noted by many of the audience members that the same characteristics were reactions to trauma and that in each of the case studies trauma had occurred during the person’s childhood. The researchers had not made the same connection, but it was exciting to hear that the audience was well aware of trauma and its impact and were able to bring that information forward.

Lia Gaty, LCSW, from Iowa presented “Attachment Rhythms for Women in Trauma Recovery.” Through the use of emotionally engaging mirroring games she illustrated the rhythm of attachments through the states of attachment, disruption and repair.

Dr. Stephanie Covington, Dr. Sherri Green, and Niki Miller (of NH DOC) presented “A National Women’s Peer Recovery Support Initiative” and stressed the importance of gender responsive treatment programs that are trauma informed. The focus of the discussion was the increasing availability of peer support services. We discussed the development of a national leadership initiative that will train recovering women to be peer supports to women who are just becoming clean and sober. It was also discussed how this could be a great opportunity for domestic violence programs to have additional support for women in shelters. The domestic violence movement has had a long tradition of peer support and this can be expanded into enhancing services to trauma survivors with substance abuse issues.

On Tuesday morning I attended a workshop and facilitated discussion on “Racial/Gender Identity Development: Thriving in the Stages of Recovery.” Dr. Mary Henderson and Carolyn Ross of TASC led a lively discussion on the stages to developing racial and gender identity and how that influences a person’s recovery from drugs and alcohol. The audience was very diverse and the facilitators created a safe space for people to share from their own experience regarding how they and clients they have worked with have dealt with issues regarding race and gender identity.

On Tuesday afternoon I attended a tea with Dr. Stephanie Covington, author of A Women’s Way Through the 12 Steps” and four comprehensive, integrate, gender-responsive curricula that relate to the issues in the lives of women and girls, including trauma and substance abuse. She answered questions specific to curricula and more general questions regarding trauma informed care for women who are survivors of trauma. I found it validating to hear from other professionals about their concerns and their recognition that services have to be trauma informed in order to meet the needs of substance abusing women.

The conference was also very focused on providing a healthy environment for all attendees. On Tuesday evening, Joan Borysenko, a licensed psychologist, Harvard trained scientist and a pioneer in mind/body medicine led a work shop, “Revive: Creating Synergy in Mind, Body, Spirit and Work,” which gave participants to discuss what gives them joy, what stresses them out, and provided an opportunity to set goals for the future. All of this was done in an atmosphere that created a chance to meet new people and engage in lively conversation.

This conference is held every two years and it has not been decided where it will be held in 2012. It was encouraging and validating to see that trauma was a focus of a number of workshops and it is my hope that this will be expanded even more in the future. The conference planners also provided many opportunities to explore Chicago and continue discussions after hours. I have posted links to various websites mentioned at the conference on this blog.

Adverse Childhood Experiences, Attachment and Resiliency

2010-07-19T11:20:00.000-07:00

When talking about trauma, I am frequently asked about the effects of trauma on children, and if the damage can be reversed. The answer is not simple and a lot of factors contribute both to the effects of complex trauma on the child and to the ability to recover.

One of the first studies to address the effects of childhood trauma is the ACE – Adverse Childhood Experiences – study began in the 1980s and continues to this day. “The ACE Study is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente. Led by Co-principal Investigators Robert F. Anda, MD, MS, and Vincent J. Felitti, MD, the ACE Study is perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life.” (http://www.acestudy.org/).

The study was initially begun to study obesity and weight loss. However, after finding many people regaining weight after a significant loss, the researchers began to search for clues into the reasons people began to use food, alcohol and drugs as coping mechanisms long after the weight issues were address. The researchers compiled a list of nine adverse childhood experiences and developed a point system which related to a person’s likelihood of having serious difficulties in adulthood. The nine ACEs are

1. Recurrent physical abuse
2. Recurrent emotional abuse
3. Contact sexual abuse
4. An alcohol and/or drug abuser in the household
5. An incarcerated household member
6. Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
7. Mother is treated violently
8. One or no parents
9. Emotional or physical neglect

The more exposure to an ACE before the age of 18, the greater the likelihood of adverse affects as an adult. The research subjects were primarily from working class families and members of a HMO. In another ACE study that focused on childhood exposure to domestic violence, the authors found that individuals exposed to domestic violence in childhood had a two to six times greater chance of having experienced other childhood adversities. In addition, exposure to domestic violence in childhood was associated with a higher risk for self-reported alcoholism, illicit drug use, IV drug use and depression as an adult. (Felitti et al 1998, Dube et al 2001)

In addition to the extent of the history of trauma, another factor in resiliency and recovery is support and validation. This is best illustrated in the following stories:

Anna and her friend, Bridget, are seven years old, and playing outside after school one spring afternoon. Suddenly a car swerves around the corner and a gang of young men in the car start shooting at another group of men on the corner. One of the bullets hits Bridget and she is killed on the spot in front of Anna.

Anna’s family and community respond to the violence by supporting her and offering her additional counseling as needed. Her family recognizes her need for additional support and continues to check in with her on a regular basis. In addition, the community takes measure to ensure the safety of children in the neighborhood.

Sarah, also seven years old, walks five blocks to school each morning. Most mornings she is followed by a group of sixth graders who throw rocks at her, call her names, and grab at her clothing and backpack. When she tells her parents they call her a “baby’ and tell her to “toughen up” and “get over it.” The abuse continues for the full school year.

Of these two children, even given the severity of the incident, Anna is more likely to recover and have fewer symptoms of PTSD in the future. Sarah, however, will likely develop some symptoms and seek ways to escape from the emotions and fears that continue to plague her.

If the situations were reversed and Anna was not receiving validation and support, she may continue to experience nightmares and other repercussions of witnessing a traumatic death. If Sarah received support, validation, and advocacy from her parents, she may be able to recover from the effects of the abuse.

The brain is significantly affected by neglect and trauma in childhood. The following picture shows a brain of a normal three year old as compared to another three year old that has experienced extreme neglect. The brain development has been significantly impaired. The good news is that the brain has resiliency and can make positive gains once the child is placed in a home where he/she is validated, supported, and given the chance to develop positive attachments.

This relationship provides an enduring emotional bond and determines future relationships and self-regulation. It is a secure “container” that provides for basic needs and safety, and gives the freedom to explore and learn as opposed to being unavailable, lacking in safety and security. This relationship increases the child’s ability to develop trusting relationships and coping skills.

Studies on brain development have also revealed that the ability to dissociate during times of stress develops during childhood. Dissociation is the ability to psychically leave the situation and lose memory of the even. This may be due to the brain not having developed enough of the pre-frontal cortex (thinking brain) to be able to develop other skills. Dissociation may continue into adulthood.

In a future blog, I will address how cultural influences can shape a person’s viewpoint and ability to recover from complex trauma.

Domestic Violence, Trauma and Mental Health Conference Overview

2010-06-29T09:13:00.000-07:00

On June 24, 2010 in Nashua, NH and June 25, 2010 in Meredith, NH, close to 250 members of the mental health professions and advocates from New Hampshire domestic violence and sexual assault programs met for the Mental Health, Trauma & Domestic Conference. Sponsored as a part of the Open Doors to Safety project of the NH Coalition Against Domestic and Sexual Violence, the goals of the conference included enhancing services of both mental health and DV/SA agencies to survivors with mental health issues, build a bridge between the two disciplines by using trauma theory as a common language, and start a collaborative process between existing services.

Terri Pease, Linda Douglas, Carole Warshaw and Grace Mattern

Carole Warshaw M.D. and Terri Pease Ph.D. of the Domestic Violence and Mental Health Policy Initiative and the National Center on Domestic Violence, Trauma and Mental Health were the primary speakers for the conference and were sponsored by the National Network to End Domestic Violence (see links to the left). The following is my attempt to outline some of the topics that were discussed.

Why Address the Issues of Domestic Violence, Trauma and Mental Health?

Domestic violence can have serious mental health consequences and abuse and violence play a significant role in the development and exacerbation of existing mental health disorders.
Through the Adverse Childhood Experiences Study (Felitti et. al. 1998) it has been found that the great number of risks (physical, sexual, psychological abuse; witnessing violence toward parent, household members with substance abuse, suicide attempts or incarceration) encountered in childhood, the greater the likelihood of experiencing poor health, alcohol or drug abuse, or mental illness as an adult.
Batterer’s use MH issues to control their partners by control meds and/or treatment and undermining sanity. Often, since symptoms of trauma are misdiagnosed as mental illness, the batterer is able to use the symptoms against the victim by way of stigma, poverty, discrimination and institutionalization.

Issues of Collaboration: Concerns of DV Programs and Survivors

Availability and Accessibility –

Linguistic and cultural appropriateness
Priorities, time and Cost
Transportation and Childcare
Abuser Control of Insurance

Service Quality

Choice of provider
Providers knowledge of DV
Trauma informed vs. trauma competent
Need for gender specific services

Trauma Theory

Trauma theory normalizes the responses that humans experience when exposed to traumatic events. It reframes many symptoms of PTSD and borderline personality disorder as adaptations and survival strategies necessary for survival in a life of complex (ongoing) trauma. Trauma theory also integrates developmental, biological, emotional, cognitive, spiritual and relational domains and challenges both DV and MH providers to expand their skill base and build a broader response to survivors of trauma.

Carole Warshaw M.D. also presented information based on research in the field of neuroscience to explain how the brain and body reacts when experiencing trauma or reminders of the trauma. Similar information is presented in previous blog postings so I will not cover it here.

In order to increase the mental health clinicians’ knowledge of what domestic violence and sexual assault advocates do, I, Linda Douglas, gave a short presentation outlining the aspects of empowerment, advocacy and privilege. As advocacy and empowerment are discussed in other blog postings I will not review here. The issue of privilege and how it pertains to the survivors confidentiality will be covered at another time.

Carole and Terri provided a forum to discuss clinical implications for mental health clinicians. Issues regarding documentation, safety planning and the dynamics of power and control were discussed along with the counter transference, transference and the parallel process that occurs in the therapeutic relationship.

On both days a case was presented and participants were asked to work together to determine what services would be needed for a survivor who is experiencing domestic violence currently and has adaptive behaviors due to complex childhood trauma. It was during this time that domestic violence advocates and mental health clinicians were able to discuss what they can do in the context of their programs and also began to identify gaps in services in their area. Hopefully, steps were taken to continue to discuss collaboration within their communities, with mental health clinicians recognizing that DV/SA advocates are doing trauma informed work with survivors and that mental health services would be valuable in providing assistance to survivors who are dealing with the affects of complex trauma.

This post can in no way cover all the important aspects of this conference. If you desire any more information, please feel free to email me with your questions or make comments below. In addition, I have provided the following bibliography for your use.

 Warshaw, C. Domestic Violence, Trauma and Mental Health. Encyclopedia on Interpersonal Violence. (C. Renzetti and J. Edleson (eds.). Sage. Thousand Oaks, CA. 2008
 Warshaw, C., Brashler, P., and Gill, J. Mental health consequences of intimate partner violence. In C. Mitchell and D. Anglin (Eds.), Intimate partner violence: A health based perspective. New York:
Oxford University Press (2009)
 Warshaw, C., Brashler P. Mental Health Treatment for Survivors of Domestic Violence. In C. Mitchell and D. Anglin (Eds.), Intimate partner violence: A health based perspective. New York: Oxford University Press (2009)
 Herman, JL. Trauma and recovery: The aftermath of violence: domestic abuse to political terror. New York: Basic Books; 1992.
 Davies J, Lyon E, Monti-Catania D. Safety planning with battered women: Complex lives/Difficult choices. Thousand Oaks: Sage; 1998.
 Markham DW. Mental illness and domestic violence: Implications for family law litigation. Journal of Poverty Law and Policy. 2003;May-June:23-35.
 Clark C, Young MS, Jackson E, et al. Consumer perceptions of integrated trauma-informed services among women with co-occurring disorders. J Behav Health Serv Res. Jan 2008;35(1):71-90.

The Brain Talk II - Traumatic Memories

2010-05-24T11:12:00.000-07:00

I have been doing a lot of reading lately on how the brain stores memories. Most of the information is written by scientists and psychologists/psychiatrists in the field of neuroscience and is not written for the lay person. In order to understand it myself, I have translated the information into metaphors and hope that this helps my readers understand how the brain handles traumatic memories.

There are two types of memory – explicit and implicit. Explicit memory is related to events that are easily related using language. It involves facts, descriptions, concepts and ideas. It is explicit memory that enables us to tell our life story, narrate events, put experiences into words, construct a chronology and extract a meaning (Rothschild

2000, 28-29). It is easily stored into the language centers of our brain and is easily recalled. It is as if we take the memory of the event and place it tidily in one file folder, in one file drawer, into one file cabinet.

Implicit memory involves automatic states within the brain and operates unconsciously. It is implicit memory that we use when we do something we have done many times before and we no longer need to think about the action it takes, such as walking, brushing our teeth, or riding a bicycle. There may be a bridge between the two types of memory if there is a need to make sense of the unconscious action, such as trying to identify why a certain body response occurs when a person is triggered by a reminder (conscious or unconscious) of a traumatic event.

Explicit memory is also dependent on when the event occurred in a person’s development. If the brain has not developed full language and narrative abilities it may only store the event in the areas of the brain responsible for the body’s responses to the trauma.

Here is my example – When I was a year and a half old I was toddling in my grandmother’s kitchen. Someone had placed a freshly brewed (boiled/percolated) cup of coffee within my reach on the kitchen counter. I caught my finger in the handle of the cup and the hot coffee spilled down my neck and chest, resulting in third degree burns. My throat started to close up and by the time we arrived at the hospital I need to have a breathing tube. I had numerous surgeries to repair that damage which required that I be wrapped up in bandages for about six months.

I have no explicit memory of the event. The language areas of my brain were not developed. I have no visual memory of the event. All I know of that day is what my mother told me. As an adult, she was able to store the event in an area of her brain that allowed her to develop a narrative.

I have implicit memories of the event. When I was five, my mother tried to get me to wear a red hooded sweatshirt that had a tight neck. I had a complete meltdown. She tried this twice over a period of a week and then connected that I was reacting to the sensations of feeling out of control and having something over my face. As I developed, I was able to make meaning of the body memories (implicit) and have reduced the effects. I no longer have intense responses to having something over my face and around my neck. I find it uncomfortable but am able to adjust accordingly.

Even after the language and meaning making centers of the brain are developed, when traumatic events occur, our brain is flooded with large amounts of chemicals. This chemical overload will shut down the areas of the brain responsible for the explicit memories and the memories are then stored in the areas that govern sight, smell, hearing, and other body sensations. These memories are fragmented and stored in multiple areas as if the memory was torn into hundreds of puzzle pieces, placed in multiple file folders, and tucked in various file drawers. The result is that the person is unable to recall the memory in chronological order and may even mix up memories from different events, much like finding unconnected puzzle pieces and Legos in the Monopoly and Clue game boxes. It is very difficult for the person to figure out where the piece actually belongs.

What results is a survivor who cannot tell her story in a way that makes sense to the police, court or advocate. The survivor may mix up different events, be unable to relate when the incident happened, who was there, or even have blocked out certain parts of the event. For law enforcement and lawyers, who require a cohesive, sequential narrative, this can be frustrating. This may even result in a survivor being re-victimized by a system that does not understand trauma.

As advocates our job becomes assisting the person in putting together the pieces of the puzzle. Being triggered by the telling of the event is a common occurrence. It helps if the advocate can find a safe, quiet place before a court hearing where the victim can tell her story as it comes to her. Once most of the pieces are the table, then both the victim and the advocate can attempt to put them in order. Trying to have the person tell the person in chronological order right at the start would be like trying to put a puzzle together starting at the upper left corner and moving to the right and then back to the left piece by piece. The process may actually take sorting, putting a group of pieces together, discarding the pieces from another puzzle, and then trying to put the picture together. There may still be some holes when all is done but the story is there.

Finding a way to explain this process to a survivor is also helpful. You can try to find your own metaphors and make this information more accessible. Trauma survivors are often frustrated and re-traumatized by the difficulties they experience when trying to remember and make meaning out of their experiences. By understanding what is happening and having a tool box of skills to use to manage the emotions and body sensations that arise out of being triggered a victim can move to being a survivor and will be more empowered as she is able to manage and make sense out of her memories.

The following are some suggestions from the Bristol Crisis Services for Women (UK) for managing triggers or body memories of trauma –

Grounding:
• stamp your feet, grind them around on the floor to remind yourself where you are now
• look around the room, noticing the colors, the people, the shapes of things
• listen to the sounds around you: the traffic, voices, the washing machine, etc.
• feel your body, the boundary of your skin, your clothes, the chair or floor supporting you
• have an elastic band to hand - you can 'ping' it against your wrist and feel it on your skin
• tell yourself that feeling is in the now, the things you are re-experiencing were in the past.

Take care of your breathing: breathe deeply down to your diaphragm; put your hand there (just above your navel) and breathe so that your hand gets pushed up and down.

Count slowly to 5 as you breathe. When we get scared we breathe too quickly and
shallowly and our body panics. This causes dizziness, shakiness and more panic.
Breathing slowly and deeply will stop the panic.

If you have lost a sense of where you end and the rest of the world begins, rub your body so you can feel its edges, the boundary of you. Wrap yourself in a blanket, feel it around you.

My Brain Talk

2010-05-13T12:41:00.000-07:00

This is a short version of my “brain talk” that is part of most presentations I give on trauma.

The brain is an amazing organ. Every time I get ready to present about what happens within the brain during a trauma event I am in awe of how the brain really works to try and protect us from harm. However, when exposed to chronic trauma the brain eventually goes into overdrive and ends up wearing down both the brain mechanisms that are meant to protect and the physical body.

Imagine that you are driving through a residential neighborhood on a beautiful spring day. Suddenly, you see a soccer ball bounce into the middle of the street just a few car lengths ahead of you. What is the first thing that you do? I hope that you answered “I slam on the brake!”

Did you think about slamming on the brake? Did you consciously think to yourself “Hmmm, there is a ball. There may be a child somewhere behind it. I should put on the brake. Yes, I will put on the brake.” NO – you probably just slammed on the brake and thought about it afterward. That was your amygdale engaging.

The amygdale (the doing center of the brain) is a small kidney shaped piece inside of your brain that becomes flooded with cortisol and norepinephrine during times of extreme stress. The message is sent down the brain stem and spinal cord to whichever part of the body needs to act and completely bypasses the thinking part of the brain (the frontal cortex or forebrain). In lesser amounts cortisol improves cognition and attention and stimulates the front cortex (the part of the brain behind your forehead and above your eyes). However, in large amounts, the cortisol causes the frontal cortex to shut down and the amygdale does all the work. Once the danger is over (someone has held back the children and removed the ball from the street) the frontal cortex and the amygdale can go back to a normal state.

EMTs, military personnel, and other people talk about times when they didn’t think about how to respond but just went into automatic mode during times of danger and extreme stress. This is what happens to persons who are experiencing trauma in their lives and when the danger is chronic. The frontal cortex basically stops and says “I am not even going to stop and think about things any more because this person needs to be on constant alert and ready to act.”

This explains why survivors of trauma appear to always be on guard, hyper-vigilant, ready to fight or flee, and appear to be constantly afraid. This also is the reason why some people are not able to engage in a relationship with a provider. The person’s brain has gone into a default mode of constantly being prepared for danger. The survivor has probably had few experiences of being engaged in safe relationships and may not have grown up in an environment that leads to the ability to make choices other than those needed for survival. In fact, perpetrators were probably caretakers and had said that they were only doing what was good for the person or that they were just trying to help.

Another important point to know is that if the survivor grew up in an unsafe or hostile atmosphere he/she did not have the opportunity develop normally. Most or all of development was focused on maintaining safety and survival in the environment in which he/she grew up. Some of the behaviors we may observe may seem strange or counter-productive in a safe environment. However, in their environment, these behaviors were skills to maintain safety.

Here are two examples:

In the book, The Cellist of Sarajevo by Steven Galloway, the author describes how during the siege of Sarajevo in 1992, people in the city of Sarajevo had to change how they traveled about the city. There were snipers in the mountains around the city who were shooting at people as they crossed streets on their way to get water or bread. People would congregate on street corners to decide whether or not it was safe to cross. They would cross in large groups or one by one. They would often run in a zig-zag pattern in order to be a harder target to hit. If someone who grew up or lived in a war zone such as this for a long period of time, even when they moved to a safe place, they may continue to cross the street in the same manner. For them it is an ingrained survival skill. For observers it may seem strange or a means of attracting attention.

Another story is of a personal nature. When I was in sixth grade I was bullied by a boy in my class who was two years older than the rest of us. He always waited until the math teacher came into the class as he appeared to sense that she was timid and would not stop him. He would get out of his desk and roam around the room during the math hour. At some point, sometimes once a week and sometimes not for a week or so, he would come up behind me and drive the point of his elbow into the middle of my back. I eventually was able to talk to a school counselor and it stopped. The repercussions did not end there. When I went into seventh grade I was placed in a remedial math class.

Because I had been focused on the boy and his whereabouts and was in fear of his attack, I had not learned sixth grade math. Fortunately, because I was in a nurturing environment, had my feelings regarding the bullying validated, and the abuse had stopped I was eventually able to move quickly back up to a higher level math class within the first semester of seventh grade.

The other part of the story is what I know about the boy. He came from a family of about eight children and his parents were alcoholics and known to be violent. Since he was two years older than the rest of us it is evident that he had been held back and had difficulties learning. This was more than likely because he was focused on survival at home and not on learning at school. He did not graduate from high school. I can only speculate on what the rest of his life has been like.

This story took place forty years ago. These days he probably would have been diagnosed with some sort of conduct disorder and possibly attention deficit disorder. Underneath it all, though, was the ongoing trauma in his life and that he was probably in a default mode of survival which made it difficult for him to learn anything else. This is why we may know people who have street smarts, can read faces and emotions, and have difficulties in new environments because they are looking for danger and how to manage (usually considered “manipulation”) the systems in which they are involved.

I hope this helps explain what is happening in the brain of persons who have had ongoing trauma. In future posts, I will write about how attachment and nurturing can have an impact on children who have experienced trauma and also how culture can affect a person’s response to traumatic events.

BOOK REVIEW Creating Sanctuary - Toward the Evolution of Sane Societies by Sandra Bloom

2010-04-29T09:20:00.001-07:00

Creating Sanctuary - Toward the Evolution of Sane Societies by Sandra Bloom 1997, Routledge Publishing

Creating Sanctuary is an excellent book to have on the shelf at any program providing support to victims of complex trauma. Sandra Bloom’s book is over ten years old but I found it to be a refreshing look at trauma and how organizations can build and sustain a sanctuary for victims.

According to her biography on the Drexel University website, Dr. Sandra L. Bloom is a Board-Certified psychiatrist, graduate of Temple University School of Medicine and recently was awarded the Temple University School of Medicine Alumni Achievement Award. In addition to her faculty position at the School of Public Health at Drexel, she is President of CommunityWorks, an organizational consulting firm committed to the development of nonviolent environments. Dr. Bloom currently serves as Distinguished Fellow of the Andrus Children’s Center in Yonkers, NY.
From 1980-2001, Dr. Bloom served as Founder and Executive Director of the Sanctuary programs (see link at left), inpatient psychiatric programs for the treatment of trauma-related emotional disorders. n partnership with Andrus Children’s Center, Dr. Bloom has established a training institute, the Sanctuary Leadership Development Institute, to train a wide variety of programs in the Sanctuary Model®. The Sanctuary Model® is now being applied in residential treatment programs for children, domestic violence shelters, group homes, homeless shelters and is being used in other settings as a method of organizational development.
Dr. Bloom is a Past-President of the International Society for Traumatic Stress Studies and in addition to being the author of Creating Sanctuary: Toward the Evolution of Sane Societies and she is co-author of Bearing Witness: Violence and Collective Responsibility.

This highly readable book is broken down into five sections. Section one is a comprehensive view of trauma theory that reviews the research done by a number of experts in the field of trauma and neuroscience. She includes the physical, cognitive, emotional, social, and behavioral responses and discusses the innate need for the survivor to make meaning out of the trauma that has occurred. By telling the stories of trauma survivors, Dr. Bloom demonstrates how a victim’s life can become completely organized around trauma in their thoughts, feelings, behavior and meaning making. Section Two responds to the question “if traumatic experience is so damaging, and human history has been so traumatic, how have we survived and thrived?” by explaining how our attachments to each other and our social groups that follow us from cradle to grave help survivors heal from trauma. Section Three discusses the social in psychiatry and how some treatment milieus and concepts have not served trauma survivors well. Dr. Bloom speaks to the impact that feminist theory has had on psychiatry and how it facilitated a shift to a more relational and empowerment based model of meeting the needs of trauma survivors.

In sections four and five, Dr. Bloom takes the reader beyond the usual scope of trauma as an interpersonal issue that is healed within one to one relationships and encourages us to examine reconstruction society as a whole within a sanctuary model. She lists shared assumptions that encourage the reader to look beyond diagnosing and treating to engaging in the creation of healing sanctuaries. This includes assessing burnout, vicarious trauma, and practices within the organization that may limit the abilities of advocates and others in providing support.

The last section, “Toward the Evolution of Sane Societies”, documents the significant trauma that occurs within society as a whole and addresses how the world at large contributes to trauma. This book was written well before September 11, 2001 and it would be interesting to have an update in regards to Dr. Bloom sees the terrorism and the responses of our government as contributing to the traumatization of individuals and societies. According to Dr. Bloom, the globalization of trauma and the effects on individuals needs to be addressed beyond the scope of individual organizations. It requires social changes, changes in the way we do business, changes in the classroom, recognizing justice as a force for healing trauma, creating an emotionally literate population, and being willing to bear witness and move beyond just being a bystander.

The depth of this book in addressing the issue of trauma can at times be overwhelming and challenging. However, Dr. Bloom does an excellent job of outlining the issues surrounding traumatized societies and addressing it by creating a model for sanctuary in our organizations, social service agencies, and political institutions.

This book is being added to the NHCADSV library and is also available on Amazon.com or through your local bookseller.

Using Right Brain Activity to Build Resilience and Assist Recovery from Trauma

2010-04-12T12:56:00.000-07:00

I went to a conference this past week and was reading Sandra Bloom’s book, Creating Sanctuary – Toward the Evolution of Sane Societies, on the plane and became a little discouraged as I was reading her chapter on Trauma Theory. I was particularly impacted by the following paragraph on pages 28 and 29:

“Evidence also exists that the massive secretion of neurohormones at the time of the trauma may deeply imprint the traumatic memory (Van der Kolk 1994, 1996c). The neuroscientist Le Doux (1992) has termed this ‘emotional memory.’ In studying the influence of fear in particular, he has shown that emotional memory appears to be permanent and quite difficult, if not impossible, to eliminate although it can be suppressed by higher centers in the brain (Le Doux 1992; 1994). This ‘engraving’ of trauma has been noted by many researchers studying various survivors (Van der Kolk 1994; Van der Kolt and Van der Hart 19931).”

This imprinting of the traumatic memory and the flooding of chemicals into the amygdale (doing center of the brain) appears to make it almost impossible for a survivor of trauma to be able regulate their emotions and they will continue to respond to life events and relationships as if the trauma is ongoing. If this is so, how can advocates possibly hope to be able to work with and assist survivors in making positive changes in their life?

Fortunately, the Self and Family Conference provided some answers so that I was able to return feeling less discouraged and more empowered.

Using Right Brain Activity

There were a number of speakers, including Stephanie Covington, Judy Crane of the Refuge, and Cardwell Nuckols who spoke on using right brain activities to calm down the spin cycle of the amygdale, move away from the constant interpretive cycle of the left brain, and empower the survivor by engaging them in activities in which they can gain some competence and make meaning out of their experience.

The left brain is responsible for trying to make sense of the world and the perception of self. For trauma survivors, trying to make sense out of trauma can keep them in a cycle of constantly responding to the world as if the trauma is ongoing. By engaging in right brain activities, i.e. art work (collages, painting, drawing), music (drumming, dancing), exercise (yoga, Tai Chi or Qi Gong) and writing (poetry and short stories), a person is able to engage the brain in other activities that generate competency, slow down the left brain activity that keeps them in constant hyperarousal.

Judy Crane of the Refuge (see links to the left) gave a couple of dramatic examples. She told the story of a woman who had been severely sexually abused by her grandmother when she was three years old. This woman was given the materials and support to create a figure out of soda cans and Marlboro cigarette packs (her grandmother smoked Marlboros and drank a lot of diet coke). The woman put pieces of paper in the cans that described how she felt. She was given permission to show her work and then she used Judy’s golf cart to flatten the cans. The work that went into the can sculpture enabled her to be able to create, move out of the left brain, and feel empowered.

Another client of Judy’s was using self cutting as a coping mechanism. She was given red and black paint and was encouraged to use this as a way to focus her pain rather than causing self injury as the self harm was disrupting to the other inpatients. Within a few weeks, the client had gone from cutting herself to creating significant art that showed her progression from hurting to healing.

There is a lot of research out there about the calming effects of yoga, Tai Chi, and even aromatherapy. I was also given information on Soul Collages (see link to the left) and integrative medicine (I hope to expand on this in the future).

The Healing Relationship

There is more and more evidence in the mental health field that the primary catalyst for healing in trauma survivors has little to do with the mode of treatment. It is the “therapeutic relationship.” In domestic violence and sexual assault work we can refer to it as the “healing relationship.” Being as genuine, empathic, and knowledgeable of the impact of trauma on survivors as we can, we can assist them in beginning the road to recovery. This is difficult to do in situations when the survivor is still being impacted by the activities of the abuser, but can open the gateway to slowing down the hyper activity in the left brain and increases their sense of safety and trust in the advocate.

Another note: Anyone Can Provide Trauma Informed Services

Stephanie Covington, PhD. was quick to discuss how any provider can be trauma informed. In addition to speaking around the country about her programs for women, trauma and recovery, she also has talked to other providers about how to be trauma informed. She has even met with her dentist’s office to discuss how they can be more trauma informed i.e. explaining to the patient in advance each move and being responsive to how the weight of the apron worn during x-rays could be triggering. The dental office changed their procedures to be more trauma informed and uses these procedures for everyone so there is no need to question patients about their trauma history.

The conference was very informative and I hope to write more over the next few weeks about what I learned from experts in the areas of trauma, substance abuse, and mental health.

Combining Feminist Relational Advocacy with Reflective Practice

2010-03-29T08:11:00.000-07:00

Summary of the Feminist Relational Advocacy Model by Lisa A. Goodman et.al.

The following is a summary of the paper Feminist Relational Advocacy: Processes and Outcomes from the Perspective of Low-Income Women with Depression by Lisa Goodman, Catherine Glenn and Angela M. Borges of Boston College, Amanda Bohlig of the University of Wisconsin, Madison, and Victory Banyard of the University of New Hampshire. It will be followed by a brief discussion on how this model can be combined with reflective practice (see blog post of March 15, 2010) to increase advocacy effectiveness.

In the article, Goodman et.al., refer to the woman to whom advocacy is provided as the “partner”. This eliminates any perceived power or control in the advocacy relationship.

Principals of Feminist Relational Advocacy –

1. Valuing the woman’s narrative – By developing a relationship through which the advocate can come to understand and respect the woman’s perspective and the reasons underlying her choices an advocate will be able to recognize the partner’s authority to know and name what she needs, and highlight her strength and autonomy without ignoring the multiple factors that limit her range of choices. This may mean a radical approach on the part of the advocate if the woman is in a position of needing non-traditional assistance. As Goodman et. al. state, “if a woman cannot get out from under her ten bags of laundry, then the most valuable thing an advocate may do is help her devise a better system for doing laundry, or even do her laundry with her.”

2. Honoring mutuality and the development of a genuine relationship – Until it is acknowledged that any actions taken by the advocate or the survivor must occur within the context of a trusting and committed relationship many survivors will not share their real needs. Components of a genuine, healing relationship include authenticity, shared power, mutuality, and openness.

3. Emotional and instrumental support are intertwined and inseparable - Just as individuals with greater levels of emotional wellbeing feel more energized to work towards changes in their external conditions, greater access to resources may well increase individuals’ emotional wellbeing.

4. Attention to external forms of oppression as sources of distress – Instead of imposing diagnostic labels on women’s emotional distress, feminist relational advocates, work to understand its roots in social conditions. The model expresses an understanding that poor women’s distress as a reasonable response to unreasonable situations, or even as an expression of resistance to institutional oppression. “Does the woman take the job that will enable her to leave the welfare rolls, but require that her young children be unsupervised? Does she leave the abusive boyfriend and give up the only secure housing situation she has ever known?”

Combining Feminist Relational Advocacy and Reflective Practice to Transform Advocate/Client Relationships

What is reflective practice? - Reflective practice is a way of being that values and enacts ongoing personal awareness of the advocate’s contribution to the tenor and quality of the interpersonal encounter, while also holding in mind the multiple contributions of the other. This includes the ability to use non-judgmental awareness and to reflect on one’s own and other’s mental states, looking inward while looking outward, and is focused on the autonomic and emotional reactions of the self and other. (Michael Morgan PhD)

What do we know about the person with whom we are engaging? This helps to understand their personal narrative and contributes to informed advocacy. The following list factors that influence the advocates relationship and may open doors to understanding responses that the partner may have when responding within the advocate/partner relationship.

Age
Gender
Race
Cultural Background
History
Trauma History
Children? Relationship with?
Living Situation
Supports and Connections/Relationship Patterns
Education
Cognitive issues? (Traumatic brain injury, developmental disabilities or trauma related cognitive isses)
Medical issues?
Coping skills
How does the above influence the person’s ability to cope?
How does what we know influence our perceptions?
What does she say she needs? How does she ask? Does she ask for specific help or does she use other ways to express her needs?
What can the advocate provide for the survivor? How can this be provided?
What can the advocate do to help make changes to the system in order to help the survivor?
How can the advocate maintain safety and respect in the relationship?
How can the advocate care for her/himself in order to be able to maintain safety and respect?

By exploring the answers to these questions and viewing through the Feminist Relational Advocacy Model you can build the advocate/partner relationship, understand the effects of trauma, and be able to address issues that are blocking the process of advocacy and healing within that relationship.
The above issues are best reflected upon in a group setting with people who may also have contact with the partner. This provides a wider view of the person and what she brings to the advocate/partner relationship.

Trauma Stewardship - A Book Review by Anne Johnson, WISE DVS

2010-03-16T12:32:00.000-07:00

Trauma Stewardship by Laura van Dernoot Lipsky with Connie Burk. Las Olas Press. 2007.

I love you and I value the work you do; Read this book. This was the message from my sister when she sent me Trauma Stewardship for my birthday last summer. I didn’t read it right away because I’m rarely interested in “self-help” books. Reading is often an escape for me, and I knew the book would be an invitation to critically explore my experiences. This fall I finally felt ready to open the book. The words and message leapt off the page - I felt understood, validated, heartened, and energized. I am introducing it to you because I think it will speak to many of you at DCYF and DV-SV crisis agencies.

My sister was a student of the author, Laura van Dernoot Lipsky, in the Masters of Social Work Program at the University of Washington in Seattle. My sister is a case manager for homeless AIDS patients, and I am a physician and anti-violence advocate. We find comfort in each other. We commiserate often about our clients and patients and the sorrows of life we experience through them. When we are left raw, disillusioned, or cynical after a particularly hard situation, we often ask larger questions about the sustainability and effectiveness of our work. Is our fight really making the world a better place? Can we see hope? Are we too exhausted to keep going?

Bearing witness to the suffering of others impacts us. This is what Lipsky calls our “trauma exposure response.” Others have pathologized this response by calling it “burnout”, “compassion fatigue,” and “secondary trauma.” We hear many touchy-feely messages about “self-care” and “ways to avoid burnout.” Taking care of ourselves is incredibly important, but many of the suggested coping mechanisms are shallow platitudes or at most, band-aids. They leave us feeling insulted. Taking a bath and drinking tea are really going to help me after I’ve witnessed the effects of horrible violence on innocent children? In contrast, Lipsky’s book offers a whole-life and whole-work method to create insight and resilience as we do our important work. She gives us a framework and language to elucidate how we are inwardly and outwardly affected. She helps us understand ways to honor ourselves and the people we serve rather than vilify our inevitable reaction to seeing and hearing about human suffering. She defines this “Trauma Stewardship” as “the entire conversation about how we come to do this work, how we are impacted by our work, and how we subsequently make sense of and learn from our experiences.”

The first section of Trauma Stewardship explains how the exposure to trauma affects us all on an individual level. I appreciate that the author looks to the newest trauma research and discusses how trauma changes our body and spirit, not just our emotional or cognitive state. She goes further to discuss how organizational culture and societal forces are also sensitive to trauma exposure. The message is again holistic. If we can cultivate awareness of the effects of trauma exposure at all levels of our work, healthy change becomes attainable as well. Not only are we able to nurture ourselves, but our new understanding gives us tools to positively change institutional culture and society as a whole.

In the second section, Lipsky names and explains very recognizable reactions we all have at one time or another as we encounter human trauma. Lipsky respectfully normalizes and validates these responses. She explains the details and reasons for feelings of hopelessness, diminished creativity, numbness, minimization, avoidance behaviors, guilt, and addiction, to name a few. These are not responses to fear and condemn, as if feeling them means we are burned out or weak. Instead, we are encouraged to cultivate a simple awareness in an effort to map our individual (as well as organizational) trauma exposure response. Throughout this process, the author reminds us to have deep compassion and patience for ourselves. She even reaches out to CPSWs especially as bearers of some of the most intense trauma exposure.

In the last section, Lipsky gathers wisdom from a variety of spiritual practices to give us options to care for the many parts of ourselves. Whereas other proponents of “self-care” often focus solely on an individual, “balancing” practice, Lipsky doesn’t assume that there is any one answer for many individuals trying to stay resilient. She recognizes that we need to cultivate passion and understand how we operate within our workplace. Readers will take away their own healing strategies that speak to them at the present moment.

Lipsky peppers the book with hilarious New Yorker cartoons. She recognizes the value of humor and irony in the face of pain and suffering. She also includes a number of 2-3 page first-person accounts of workers’ career paths in the helping professions. These honest confessionals hearten the reader. They send the message that we are not alone and we all go through both difficult and joyful times as we learn to understand ourselves and the systems in which we work.

This is a book to be read straight through or in small doses. It can be read again and again, with new insights at each return. It is supportive and loving. Many times it brought me to tears – tears of relief and thankfulness that someone (both the author and my sister) cares about my work so much that she would give me this gift. So, to all you CPSWs and DVS advocates: I care about you and I value the work you do; Read this book.

Transforming Advocacy through Reflective Practice

2010-03-15T11:08:00.000-07:00

The other day I was participating in a webinar presented by the Domestic Violence and Mental Health Policy Initiative and was encouraged to contemplate on the use of “reflective practice” in our work with people who have been affected by trauma. This appears to be a vital component in providing trauma informed services. In this blog post I am going to talk about how we can apply reflective practice to our daily work, how it may help us increase our effectiveness as advocates and how it may also help ease some of the effects of vicarious trauma. I will be applying information from the webinar and from a presentation by Michael Morgan, Ph.D., LMFT of the University of Wyoming called Transforming Counselor Education Through Reflective Practice given at the ACES Annual conference in October 2009.

What is reflective practice?

Reflective practice is a way of being that values and enacts ongoing personal awareness of the advocate to the tenor and quality of the interpersonal encounter, while also holding in mind the history and contributions of the other person. According to Michael Morgan this includes a “moment to moment non-judgmental awareness and the ability to reflect on one’s own and the other’s mental states and have the ability to look inward while also looking outward.”

By being mindfully reflective we take a step back from a situation and consider as much as we can before taking further action. This would include being aware of our own and the other’s relationship patterns, life experiences and unmet needs, cultural norms and personal values, coping skills, and preferred way of being. We may not be aware of all that the other person is managing in a particular moment, but, as advocates, we are aware that most, if not all, of the survivors we are working with are dealing with the effects of trauma in their lives. How they are managing these effects are determined by their life history, cultural background, current health and living situation, their stage of development, and current supports.

“How you are is as important as what you do.” Dr. Jeree Pawl

Advocates want to be helpful and empowering in the work that we do. Reflective practice emphasizes the “being” of our work. Being helpful depends, in part, on our awareness and regulation of our own processes as well as our being able to perceive what is happening in the mind of another.

Example: Heather is an advocate who has been working with a survivor, Mary, and preparing her for a protective order hearing. Mary has been focused on being able to retain custody of her children and her place of residence. She appears to be disorganized at times. A day before the hearing Mary admits that she has been involved with the local DCYF (a referral was not made by them) and is currently under investigation for neglect due to Mary’s drug use. Mary admits to occasional drug use.

Through reflective practice, Heather is able to be mindful of her own beliefs and attitudes regarding substance abuse and is able to recognize what about Mary’s drug use may trigger Heather’s own issues. The advocate is also able to recognize that Mary’s withholding of this information may be due to her trauma history (told not to tell family secrets), her fear of losing the advocate’s help (has been abandoned in the past by caretakers) and her fear of losing her children. Heather uses reflective practice to be able understand her role in the relationship as the advocate and is able to put aside feelings of frustration due to Mary’s withholding of important information. Heather is able to not take the issue personally and maintain a good relationship. By being nonjudgmental and able to reflect on her own attitudes and beliefs, Heather is able to help Mary with the immediate crisis and eventually be available to work with Mary in regards to finding help for her substance abuse issues.

“Do unto others as you would have them do unto others.”

It is vital to reflective practice that it be incorporated into the culture of the programs in which we work. When supervisors and agency directors provide a safe place and relationships that promote safety, respect and the ability to be vulnerable then advocates are free to do the same for shelter guests and clients. Being given the time and space to engage in reflection can decrease the effects of vicarious trauma and promote an atmosphere of empowerment that then encompasses the survivors with whom we work.

A reflective culture in our programs can be done as follows:

Ongoing awareness work (values, experience, patterns, preferences)

• Along: mindfulness practices, journaling, holistic wellness, body scan

• With others: personal counseling, reflective supervision

In reflecting upon on our work with others the following questions may be helpful:

How do you feel related to the other (likes, dislikes)?

When have you felt/responded similarly? Who do they remind you of? What personal experiences come to mind?

What do you bring to your work with this client (currently, historically)? How can this be an asset or liability?

What does it feel like to be in this person’s body? What is meaningful to this person? Why?

What does she need?

We have a baseline of understanding based on our knowledge of trauma and how that affects a person behaviorally and cognitively By applying reflective practice to our work we are more able to act rather be reactionary.

In closing, remember that no matter how difficult it is to work with a survivor, it is more difficult to be them. Through reflective practice we will be able to be more mindful and be able to engage in healing relationships.

Book Review - Violent Partners by Linda G. Mills, J.D., PhD.,

2010-03-08T13:19:00.000-08:00

Linda Mills’ biography states that she is a lawyer and social worker and the founder of the Center on Violence and Recovery at New York University. She admits that she grew up in privileged, attending Beverly Hills High School in California.

In order to establish her expertise in the area of interpersonal violence, Linda Mills tells her tales of intimate partner violence in high school and college. She considers her family’s “high tolerance” for her maternal grandfather’s verbal abuse as part of the reason she stayed in one of her relationships past the point she feels she would have otherwise.

In Violent Partners, Linda Mills is very critical of the domestic violence movement and states specifically that in her experience and in the experience of others that domestic violence advocates see their primary goal as convincing the victim (most likely a woman) to leave her abuser. She relates the history of the domestic violence movement and a few case histories in order to make her point that the domestic violence movement is not meeting the needs of the partners in intimate partner violence. Indeed, she explicitly works to make the case that both the abuser and the victim are active participants in the ongoing abuse and by not addressing the needs of the abuser and encouraging the victim to leave the domestic violence movement has failed in its endeavors to end intimate partner violence.

Dr. Mills also relates a number of cases and research in order to support her premise that women are just as violent as men. One case history is about Brenda Aris, a woman who killed her husband after fifteen years of abuse. Dr. Mills states that the fact that Mrs. Aris appeared to premeditate the murder of her husband (she was at a neighbor’s home, saw the gun, stole it and then shot her husband multiple times after a period of intense abuse on his part) is sufficient evidence to show that Mrs. Aris was as much of an abuser as her husband. Dr. Mills does not speak to the trauma of the victim or its effects on the children. She goes on to speak about the daughter of Brenda Aris and her violent behavior as an adult as another indicator of the violence of women.

Dr. Mills cites extensive research done my Murray Strauss, an UNH researcher known for his tendency to use data without context to further the belief that women are just as violent as men. She also states (pg. 33) “As anyone who regularly watches the reality show Cops can tell you, the police often arrive on the scene to discover a drunk and mutually combative couple yelling at each other, shoving each other, and hotly declaring that the other person started it.” She also cites the increase in arrests of women since mandatory or preferred arrest policies have been adopted as further proof that women are just as violent as men.

In her chapter, The New Grassroots Movement, Linda Mills appears to promote the work of SAFE (Stop Abuse for Everyone), founded by Jade Rubic to serve “those who typically fall between the cracks of domestic violence services: straight men, gays and lesbians, teens, and the elderly”; SAFE New Hampshire founded by Lee Newman who specifically states he feels like “a watchdog” to ensure that domestic violence advocates in New Hampshire are doing their job; and Violence Anonymous, a program that uses the 12 Step model of Alcoholics Anonymous, and encourages the attendance of couples.

Dr. Mills also encourages couples counseling (long considered risky for survivors by the domestic violence movement) and other group programs including peacemaking and healing circles for anyone involved in a violence relationship.

Linda Mills denies that she blames the victims, but states the following (pg. 204) “the problem is: that batters as adults were usually victims as children, we teach men to become abusive – they aren’t born that way; and that all of us, men and women, are responsible for making people violent. I also started to recognize that many of us were far more complicit that we realized in contributing somehow to a violent dynamic – that mothers and wives, as often as fathers and husbands, could do an enormous amount to reduce violence if we were willing to understand how we all played a role in it.”

Amidst her criticism of the domestic violence movement, her promotion of alternative “new grassroots movements” and her own healing/peacemaking circles, Linda Mills does an injustice to the many victims who have been empowered and led to the road of recovery by the advocates in domestic violence programs throughout the country. She does not appear to encourage dialogue with the domestic violence programs and she is strongly supported by many of the father and men’s rights groups throughout the country.

There may be a place for the type of information she is providing but she appears to be making broad generalizations based on one-sided (and sometimes shoddy anecdotal i.e. Cops) research in order to justify the abuse that occurred in her own life. It is concerning that she is receiving so much press and media coverage (she has appeared on Oprah and the O’Reilly Factor) without representation by the domestic violence movement.

Creating Emotional Safety for Trauma Survivors with Mental Health Issues

2010-03-01T10:49:00.000-08:00

One of the most frequently asked questions I receive when providing training on trauma informed services for survivors of domestic and sexual violence is “What can we do as advocates to help people feel safe?”

The National Center on Domestic Violence, Trauma and Mental Health (see Valuable Links to the left) has provided some excellent information on creating a sense of safety for trauma survivors with mental health issues that I have paraphrased and combined with a few tips of my own to assist advocates. At the end of this post I will be providing more information about an upcoming training provided by the NCDVTMH.

What is emotional safety?

Emotional safety has been defined as “a feeling that your inner most thoughts, feelings and experiences are, and will be, honored as one honors themselves. You need not prove, nor impress; you just simply are. When it is present you feel open, even at ease, and fluid with the spontaneity of a healthy child.”

“The environment we create communicates our beliefs about the people we serve. When DV programs work to increase access for women with psychiatric disabilities or who experience the mental health effects of trauma, the way we offer services and the environment that we create can have a great impact.”

Validation

One of the most important things that we can provide to a survivor is validation of her experience. By providing information about trauma, triggers and trauma responses we may be able to create a sense of safety. A lot of childhood trauma survivors have been told that they were not hurt, were crazy, needed to get over it, caused it, or made it up. To have someone communicate to them that they have been hurt and are dealing with the effects of the trauma can be a first step in the healing process.

“Many people who have gone through such frightening experiences have trouble turning their minds away from what happened. It makes sense that you would feel jumpy and preoccupied, that you might still be trying to work on making things turn out better.”

“Sharing what we know about trauma, about triggers and about how people respond to trauma increases the sense of control and autonomy that survivors in our programs may feel.”

Creating a welcoming environment

The arrangement of the physical environment in both the shelter and the crisis center can have a calming or disrupting effect on the survivor. A lot of clutter or activity can increase anxiety and make it very difficult for the person to focus. By having areas which accommodate a variety of feelings, interactions and behaviors we can make our programs more accessible.

“We have different kinds of spaces here in the shelter – a room where people can sit quietly to collect their thoughts, safe spaces outside to work off some energy, and materials for people who want to draw or paint to express themselves.”

Providing choices within the environment can also assist in establishing a sense of safety. When meeting with someone in the crisis center, court waiting room, or a public place a sense of safety can be provided by merely providing the person with a choice of where to sit. Some survivors find it very important to sit where they can see any entrances, others are more concerned about their personal space and do not want to sit too close to other people, and some may want to sit where they can’t be seen by anyone coming through the doorway.

In a shelter these choices may be limited at times, but if you are able to reduce restrictions and rules and increase personal choice a survivor may respond in a positive way and be able to continue to make empowering choices. Some choices may be as simple as which bed they want to sleep in to how they choose to contribute to work with others to make a safe and caring environment. This can be difficult when shelters have guests who have experienced a lot of complex trauma. Staff sometimes may fall into the pitfall of trying to control rather than support. It is also staff’s responsibility to model ethical communication and communicate with each other regularly so that shelter guests know that they are being supported by all staff.

Note: Please see the Washington State Coalition website to the left for more information in their resources section on how to move from the use of rules to an empowerment based model of rights and responsibilities.

It is also important to give survivors as much information as possible so that may feel more in control. There is a fine line, however, between enough information and information overload. Try to provide information both verbally and in written form. Know that you may have to repeat yourself as the trauma may affect how a person processes information.

“Make sure you say your name, perhaps writing it down in case she has trouble remembering it.
Speak clearly – your normal way of speaking may sound like an ‘accent’ to someone else, even though you sound completely normal to yourself.
Be sure to check back with her. Some people may be embarrassed to admit that they don’t understand all that you have said. Saying something like ‘I hope I said that clearly. Was there anything I said that didn’t quite make sense?’ can ease that embarrassment. It shows that you understand that it is the advocates’ responsibility to offer support and information in ways that survivors can use.
Avoid secrets and surprises. Being transparent about our work means telling people what we are going to do, letting them know who makes decisions and how our program operates. By staying on track as advocates we continue to use the skills, caring and commitment that we offer to any survivor, whatever the symptoms or struggles of the survivor living with the symptoms of trauma and/or mental illness. It is easier for advocates to do this when they (and their supervisors) are clear in understanding that the survivor’s response is not personal.”

To better meet the needs of survivors with mental health issues, it is important to assist them in reaching out to local mental health programs and peer support providers. Collaborative efforts can increase a sense of safety for the survivors when they realize that DV/SA programs and mental health providers are knowledgeable of each other’s services and ensure that none of us are trying to do everything.

On June 24, 2010 in Nashua, NH and on June 25, 2010 in Meredith, NH, Carole Warshaw and Terri Pease from the NCDVTMH will be providing trainings to mental health providers on meeting the needs of survivors with mental health issues. This conference is open to all mental health therapists, clinicians, and psychologists working with domestic violence survivors. Domestic violence advocates will be present all or part of the day in order to participate in discussions regarding enhancing community collaboration. The conference is free and includes lunch and CEUs. For more information please contact me at linda@nhcadsv.org

Can Understanding Trauma Help Advocates Feel A Little Less “Manipulated”?

2010-02-04T12:32:00.000-08:00

Let’s face it. Everyone once is a while we work with a survivor who manages to pushes our buttons, argues every point, doesn’t show up on time or at all and accuses you of not helping her, has burned bridges at a few agencies in town, and has not always told you the truth. Sometimes before, after or during the time you are with her you get this little feeling in your gut that you are being used, manipulated or just plain jerked around and you confide to a co-worker that you really dread going to court with this person. You may even use the label “borderline” when describing the person. All of this ends up making you feel like a horrible advocate and you start to wonder whether or not it is time to get that job in the florist shop (You know the job I am talking about – the person in the back who gets to make all the arrangements but doesn’t have to relate with the public at all. Yes, that job. The job that is all peaceful and pretty without all the drama and hair pulling.) .

The first thing I want to let you know is that no matter how bad it gets, it helps to remember that it is harder to be her than it is to work with her and all of the emotion and drama that you see on the outside is just a small percentage of what is happening inside her head. Most of that chaos can be explained by understanding how she has developed skills and behaviors in response to trauma and that the trauma may be more complex than she has been willing or able to divulge to you or anyone else.

Before I break this down into the top complaints that advocates, mental health and substance abuse clinicians, and case managers have had over the years and provide an explanation as to why the action may be occurring let me give you a brief review of what trauma does to the brain.

When the brain experiences a traumatic event the “doing” center of the brain, the amygdale, is activated into fight, flight or freeze mode. The pre-frontal cortex or frontal lobe, the “thinking center” assesses the danger and will tell the “doing” center to back down and resume normal activity. However, after many traumatic incidents (complex trauma) the “thinking” area of the brain will stop assessing, assumes the person is always under attack, and will not stop the “doing” center from going into fight, flight or freeze. Therefore, the person is in a heightened state of anxiety and hyper vigilance most of the time and develops strategies to manage that state that would seem foreign and/or maladaptive to the rest of us.

Keeping that information in mind, let’s take a look at some of the things that we often see as barriers to working with a person.

1. Not showing up, showing up late, or canceling at the last minute.

There are a couple of reasons related to trauma that this may happen on an ongoing basis. First of all, if a person has been subject to complex trauma over the course of his/her life, it is highly likely that the focus has been on personal safety and survival rather than learning skills that we often take for granted, such as keeping calendars or managing multiple appointments. We often assume that the person we are working with has the skills necessary to follow through when they may not. Their skills have to do with how to survive a potential threat, not making an appointment.

Secondly, meeting with a provider of services can be a trigger. If the reason the person is meeting with you is somehow related to a traumatic experience, then the thought of the appointment can be a reminder of the event and increase her anxiety. Other triggers could be present. She may have to drive or walk near a place an incident occurred. She may be in danger of seeing his perpetrator in the neighborhood near your office. She may not even be aware of the trigger, she just knows that meeting with you is very anxiety provoking and the appointment becomes something to be avoided. In addition, not being able to articulate why this is happening is probably why you do not receive the call. Avoidance of triggers is a survival skill.

2. Lying, telling half-truths, withholding information
The more I learn about the trauma done by perpetrators, the effects of trauma on the lives of survivors and how they are often re-victimized by bureaucratic systems and overworked, burned out staff, the more I realize that lying and withholding information is a learned skill that comes of out of self protection. If my safety depended on my ability to tell a good lie, I would become a great liar. If my basics needs and my children’s lives were dependent upon my withholding some information about my substance abuse or the whereabouts of my abuser, then I would withhold that information. If my perpetrator told me that if I told anyone about what happened then I or someone I love would be harmed, I would not tell.

Where we, as advocates, become frustrated is when we know that we are here to help and that we do not necessarily present a threat to the person and she continues to lie. Remember, in order to remain safe she has had to stop “thinking” about whether or not telling the truth is an option. She remains in “doing” mode and her survival skill is lying.

3. Accuses you of not helping.

After years of complex trauma, the survivor continues to live in survival mode. She is not able to process whether today is much better than yesterday. She wants things better now and she also doesn’t believe it will ever happen. She has been promised change by her abuser, her caretakers (often the same people), and other agencies and providers. After all of this, things are not getting better. She is still in pain. She is still frightened, hyper vigilant, and struggling to live in a world in which she does not feel safe. She feels that she has no reason to trust you or anyone else and she doesn’t trust life when it does seem to be improving.

Getting help, feeling better, making positive changes and living a new life can be terrifying to a trauma survivor who has lost a lot. The further she moves toward goals the more anxious and frightened she may become, because now she has more to lose. Safety in home, body and relationships is not something to be trusted in the mind of some trauma survivors. This takes time and an ongoing atmosphere of safety and trust in relationships.

Keeping you at a distance and not trusting you to help are survival skills.

So what do we do when working with survivors who are very committed to using their survival skills? We remember that trauma occurred in relationships and that recovery will need to take place in relationships. We can’t expect the survivor to manage recovery all on her own and we cannot take her use of survival skills personally – even when she accuses us of being the problem. Not taking it personally does not mean that we do not use appropriate boundaries to keep from being abused by the survivor. This is our opportunity to model setting boundaries, maintaining equanimity, use our basic advocacy skills, and letting the person know that we understand why they are in survival mode. We may not see immediate change in the person’s behavior, but we may find ourselves responding in ways that cause us less distress and the survivor may find herself following our lead. And, hopefully, we can put off that flower shop job a little longer.

Does understanding Trauma influence how we advocate and use the empowerment model?

2010-01-25T07:03:00.000-08:00

Over the past few months I have been challenged to think about my view of the empowerment model and what advocacy means when we have a stronger understanding of how trauma affects the lives of survivors of intimate partner violence. I have had a number of conversations with program directors and advocates on this topic and would like to invite readers of this blog to engage their co-workers in this discussion at their agencies or by commenting on this post.

WISE of the Upper Valley has an excellent position paper on the empowerment model that I have added to the links to the left. This definition can be the starting point for discussions as to what empowerment means to you and your program.

Empowerment is a multi- dimensional, social process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes. This process creates the power to use these choices in his or her own life, community and society, with individuals acting on issues that they define as important.

What strikes me first about this definition is the idea that empowerment is a process and is multi-dimensional. I would like to challenge you to consider what the role of the advocate is in that process. As a process, empowerment is not necessarily something that you can hand the survivor at the first meeting and have the expectation that they will then be able to move forward and make choices.

From a trauma informed perspective, we have learned that due to being in survival mode for many years and dealing with the repercussions of ongoing trauma or the effects of extreme childhood, many survivors have been unable to develop skills and obtain the knowledge that they need in order to be able to transform their lives. Advocacy means that we work to provide a safe place and “empower clients by providing information, tools, resources, and opportunities, and work with clients respectfully, recognizing that the system is confusing and overwhelming to a victim of violence. (WISE)”

I have heard a wide range of responses to idea of what empowerment means when it comes to working with survivors of violence who have been self medicating with drugs and alcohol or who may have a mental health issue. Some advocates may see the drug use as a choice and that under the empowerment model there should be no intervention. Other advocates may be on the other end of the continuum and feel that empowerment means that you confront the person and strongly encourage them to seek counseling.

Knowing what we know about trauma and empowerment, we can find a point on the continuum that works for both the advocate and the survivor. By remembering that the person’s drug use is a primary coping skill, we can begin to advocate and empower by introducing her to new coping skills and support her in choosing her own way. This may mean that she will choose to continue to use but we will have done an advocates job by “providing the information, tools, resources and opportunities” to make different choices at some time in the future.

I often comment that empowering survivors can feel as if we are on the side of a train track watching the survivor stand on the track as a train comes barreling toward her. We are calmly telling her that she has the choice to step to the left of the track, the right of the track or stay on the track. Our job does not end there. We cannot grab or push her off the track, but we can provide the information she needs in order to make a decision about which way she goes. Because of the trauma, many survivors are very afraid and uncertain of what lies on the side of those tracks and actually may choose to deal with the train that they know. However, as they continue, they will carry the knowledge and respect they received from the advocate and will be able to make different choices in the future.

I would also like to encourage discussion as to what advocacy means. Advocacy means different things to different people, Last week I was holding a six month old baby so that a mother could feed her other two children. I strongly feel that this was advocacy. Anything that provides the space for another person to be able to meet her needs can be considered advocacy. Yes, I know that outside of the shelter she would need to be able to figure out how to feed twins and a two year old, but at this time she was still dealing with the trauma of her IPV and the stress of being in new surroundings. By holding that child I was able to give her breathing space to take the next step. On another day or time, it may have been better for her to have problem solved for her self but on her first day in shelter an extra hand helped her navigate just a little better and she was able to make decisions about the care of her children.

Over the years I have learned that the most important thing I learned in my counseling classes was Maslow’s Hierarchy of Needs. In the hierarchy we learn that the most basic needs of food, shelter and clothing need to be attended to first before a person can be empowered to move up the hierarchy to personal and spiritual fulfillment. For us, advocacy begins at that bottom level of the hierarchy. If a person has been traumatized, as all of our survivors have, she will be focusing solely on her survival on a day to day basis and the more we facilitate the provision of the basic needs the sooner she will be open to moving toward empowerment.

In closing, I encourage you to use this article as a means to carry on with the discussion regarding empowerment and the role of advocacy.

Looking Ahead to the New Year

2010-01-15T11:08:00.001-08:00

A lot of developments are occurring in 2010 for the NH Open Doors to Safety Project. First of all, I would like to welcome three new member programs to the project. Staff development will begin at Rape & Domestic Violence Crisis Center (RDVCC) in Concord, YWCA Crisis Service in Manchester and Sexual Assault Support Services in Portsmouth. I am very excited about working with the staff at these programs as they appear to be very excited about the additional training and support they will be receiving. I am always impressed by the level of dedication and compassion I see in program advocates. It is not an easy job and they are always looking for ways to improve how they can empower trauma survivors.
This will now bring the total number of participating member programs to eight, more than half of the fourteen programs in New Hampshire. I hope to bring on another program or two by this summer.
Cross trainings of CPSWs at the local Departments of Children, Youth and Families will be beginning during the month of February. I have met with Misty Kennedy at the Department of Professional Excellence which oversees training for DCYF and we will be revising training descriptions and objectives so that the trainings that I facilitate for department staff will provide them with credits towards their learning plans. Suzette Indelicato at Starting Points has organized a training for DCYF staff in Conway and there will also be a training for staff at the department in Claremont. This contact was facilitated by Turning Points Network. Local domestic violence and sexual assault advocates are always encouraged to attend and join in on the conversation.
In addition, John Morris at the Department of Health and Human Services’ Homeless Providers office and I will be scheduling trainings on Trauma and Homelessness for NH homeless services providers.
We are getting closer to finalizing the date for the conference in June with the experts from the National Center on Domestic Violence, Trauma and Mental Health. There will be two one-day trainings for mental health providers and DV advocates during the week of June 21st. One day will be in Nashua and the other will be in Plymouth. We are still working on what the final agenda will be and will notify everyone as soon as we have the dates and the agenda set.
Thank you so much to those advocates who are taking the time to read and pass on the information they find on this blog. One advocate even posted it on Facebook!! I will continue to work on posting weekly so please check regularly to see what else is going on with the Open Doors to Safety project.

Finding “A Woman’s Way Through the Twelve Steps”

2010-01-11T12:57:00.000-08:00

When I first started working with survivors of intimate partner violence who were self medicating the pain of the violence there was a lot of criticism in the domestic violence community of the traditional 12 Step programs. This has continued over the years due to survivors continuing to be victimized within the 12 Step programs and the traditional approach maintained by substance abuse therapists who promote the 12 Step model. The empowerment model of domestic violence seems at odds with some of the steps which require a person taking a look at their “character defects” in order to take responsibility for their actions. Also, within the rooms of AA and NA, members can become emphatic in regards to beliefs that a person must be torn down before they can be built back up again. As we well know, survivors of violence have experienced that tearing down within their relationships and may find some interpretations of the 12 Steps to be another means of external forces exerting power and control in the life of the person using substances to cope.

The traditional approach to substance abuse treatment requires that the “addict” admit to having a disease, be willing to admit that they are powerless, take responsibility for their part of the problem and make sobriety a priority. In the trauma informed, empowerment model based approach, the advocate supports the survivor in making safety a priority and recognizing that the trauma the person has experienced has contributed to the increased use of substances or processes that mask the symptoms of the trauma. The survivor is also supported in knowing that they are not responsible for the trauma which led to the substance use.

Oftentimes, DV advocates are reluctant to address issues of substance abuse due to seeing the use as the person’s choice and her way of coping with her life. However, many times survivors see this as the only choice and an advocate can be of assistance in educating her as to other ways she can manage her life, increasing her self confidence and possibly leading her to the point where she can eventually see that there are other choices besides drinking or using drugs. It is not the role of the advocate to judge a survivor’s use of the substance, but be able to assist the survivor in maintaining safety and becoming personally empowered by having new choices available.

Another reason that DV advocates may be reluctant to address issues of substance use has to do with the lack of resources available to women to maintain their safety and sobriety and the fear of having a women revictimized within the recovery community. There are a few things that can be done to increase safety and make the 12 Step model more empowering for survivors. There are a number of different types of peer support programs for women in recovery but none are as prevalent and available as the 12 Step program. We have a number of women currently involved in the program coming into our agencies and it is valuable for us to have an understand of the model in order to converse with them about how recovery can be empowering.

First of all, in order to educate a woman about safety issues in regards to attending 12 Step meetings the following recommendations can be made:

1) Do not disclose where you staying to anyone in the group or reveal the name of your abuser.
2) If you go to a group and someone there knows the abuser, leave immediately and do not return to that meeting.
3) Try not to be predictable in which meetings are attended every week. A stalker may use a local meeting schedule as a way to follow a woman from meeting to meeting.
4) Do not accept rides from people you do not know or be the only passenger.
5) Attend “women’s only” groups as much as possible.

In A Woman’s Way Through the Twelve Steps, Stephanie S. Covington Ph.D. takes each of the 12 Steps and interprets them in a way that can be very valuable in working with survivors of trauma who are trying to find a way to manage their sobriety through the use of the support a 12 Step program can provide. In addition to the text, A Woman’s Way Through the Twelve Step, there is a workbook that can be used by someone working her way through the steps. See www.stephaniecovington.com for more resources.

Here is a very brief review of the steps and how they can be interpreted and used within the empowerment model I encourage you to read the book yourself since I cannot possibly cover all of the points here. . It is important to note that the steps are a process that can take years and should not be rushed. It is often recommended that the first three steps take a year or more and that the remaining steps be done as the person is ready. By using a workbook and a facilitated group, however, the steps can be done in a shorter period of time and then done more comprehensively at a later date.

• Step One – We admitted were powerless over alcohol – that our lives had become unmanageable.
This step is primary about becoming aware of how life has become unmanageable due to the use of the substances. We know as advocates that trauma may be the source of the unmanageability and we want to remind survivors that they are not responsible for the abuse in their lives. By acknowledging their lack of power in some areas of their lives (i.e. the actions of their abuser) they can then become free to act in areas where they do have power.

• Step Two – Came to believe that a power greater than ourselves could restore us to sanity.•
Step Three – Made a decision to turn our will and our lives over to the care of God as we understood Him.
These two steps generate a lot of resistance for survivors and advocates alike due to the suggestion that life will be better if we just had over power and control to another outside entity, This can raise fear and trepidation for someone who wants to regain power and control over her own life, especially when religion has been used as an excuse to perpetrate ongoing abuse.

Stephanie Covington encourages us to consider the use of the group as a higher power, particularly a group of women who have had the same struggles and who have found their way to empowerment, safety and sobriety. She also encourages women to find their own definition of God/Goddess/Higher Power and recognize that we do not need to be held to the constraints of a childhood religion that does not empower women.

• Step Four – Made a searching and fearless moral inventory of ourselves.
This step has been a block for most persons involved in 12 Step programs due to the fear of facing some of the demons of the past. The main points to remember are that this inventory is a process and not an event. It takes as long as it takes and not everything needs to be addressed in the first inventory. Also, Stephanie Covington encourages women to do an inventory of “Assets and Strengths” and “Challenges and Limitations” rather than the traditional inventory of “character defects.”

• Step Five – Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
Done with an empowering approach this step can provide what many of our survivor support groups do. It helps the person put an end to secrecy, helps them find that other people feel the same, assists with self-acceptance and self forgiveness and starts the survivor on the road to celebration and gratitude for their assets and strengths and the support they receive from a community of women.

• Step Six – Were entirely ready to have God remove these defects of character.
This step provides the opportunity for a survivor to use “letting go” rituals to release some of the challenges and limitations she may believe about her life. By this time she may have learned enough about how the trauma has affected her that she will be able to release some of the coping skills that are no longer needed due to the development of new strategies.

• Step Seven – Humbly asked Him to remove our shortcomings.
This step is about relinquishing those former coping skills and recognizing how there is strength available to move forward. The word ‘humbly” often gets confused with humiliation. However, in this step humility means having a strong sense of who we are, realizing our limitations and acknowledging our strengths.

• Step Eight – Made a list of all persons we had harmed and became willing to make amends to them all.
This step is about relationships and the power of being able to recognize what we are responsible for and what others are responsible for. It is helpful to have a sponsor or therapist work with the survivor on this step as it is very easy to get off balance and start taking responsibility for the actions of others.

• Step Nine – Made direct amends to such people wherever possible except when to do so would injure them or others.
Personal responsibility can be a key to empowerment. The 12 Step program encourages direct and honest amends and this can only be done after the strong, balance approach in Step Eight. It is also mentioned that amends can be “living amends,” treating some with more respect or kindness than in the past. It also requires a willingness to accept whatever the person’s reaction may be to the amends. This about making amends, not necessarily about receiving forgiveness.

• Step Ten – Continued to take personal inventory and when we were wrong promptly admitted.
This step encourages staying present in the moment. As in Step Four, it is recommended to use the balanced approach of making an inventory of “Challenges and Limitations” and “Strengths and Assets.”

• Step Eleven – Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
– “Prayer is an act of either reaching out to a Higher Power or going inward to a deeper knowing. Just as we described God our own way in Step Three, we can also come to prayer however we like.” Stephanie Covington

• Step Twelve – Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all of our affairs.”
This step is an invitation to continue practicing the principles of the 12 Step program and inviting others to explore the support of the program.

This review is not necessarily a recommendation of the 12 Step program but is more of a means to help advocates be more informed about the model. Given how it is often the only type of support a survivor has for her recovery from substance use, it is valuable to be able to talk to survivors about how it can be used in an empowering way.

The Fallacy of Co-Dependency and Addiction in Regards to Seeking Safety

2009-12-30T09:21:00.000-08:00

I was having a conversation with a program director yesterday and it was brought up that there is still language in the mental health community in regards to intimate partner violence survivors being labeled as “addicted” to their abusers. This led to a discussion regarding co-dependency, addiction and being a person living with an abusive partner in her life.

The definition of addiction, “the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma,” does a disservice to the survivors for whom we advocate and does not address the cycle of violence and the desire for the woman to manage her life in a way that keeps her and her children safe. According to the definition of addiction, separation from the habit causes trauma due to the loss and the physical effects of separation. Certain habits, skills, and coping mechanisms may be developed in a relationship in order to attempt to manage the abuser and the violence but these are in no way a sign that the person is addicted to the abuser. If anything, she is addicted to maintaining her safety and is hyper vigilant of the abuser’s activities in order to maintain that safety. This hyper vigilance is a result of complex trauma, not of an addiction.

The term “co-dependency” over the years has evolved and is often used when describing a victim of intimate partner violence who remains living within the cycle of abuse. As a movement, domestic violence advocates work hard to keep from labeling victims with descriptors that blame the victim. The original concept of codependency was developed to acknowledge the responses and behaviors people develop from living with an alcoholic or substance abuser. Like the term “addiction” however, “co-dependency” does not take into consideration the hyper vigilant behavior that arises from the complex trauma of abuse. Someone who is labeled co-dependent is attempting to control another person’s behavior in order to feeling in control and may blur boundaries in order for that to occur. However, a victim of violence has had her boundaries violated by another and has developed behaviors in order to maintain her safety. Again, these behaviors are not due to co-dependency but are survival skills developed while experiencing trauma.

When we think about what trauma does to the brain we understand a little more about how addiction and co-dependency differ. When the brain experiences a traumatic event the “doing” center of the brain, the amygdale, is activated into fight, flight or freeze mode. The pre-frontal cortex or frontal lobe, the “thinking center” assesses the danger and will tell the “doing” center to back down and resume normal activity. However, after many traumatic incidents (complex trauma) the “thinking” area of the brain will stop assessing, assumes the person is always under attack, and will not stop the “doing” center from going into fight, flight or freeze. Therefore, the person is in a heightened state of anxiety and hyper vigilance most of the time and develops strategies to manage that state that would seem foreign and/or maladaptive to the rest of us. To the victim, these strategies feel like the only way to maintain safety. This is not about being co-dependent or addicted it is about wanting to be safe.

While the trauma is occurring and the survivor is developing her skills to maintain safety she may be unable to focus on skills and behaviors for daily living. As stated above, the “thinking” area of the brain has allowed the “doing” center to take over. What we see as manipulative, co-dependent, or addictive behaviors are actually necessary skills to maintain safety and until the chemicals that have flooded the “doing” center of the brain find a healthy way to release and the “thinking” brain can function normally again, these skills will remain as the primary method of maintaining safety. This work cannot occur while trauma is still occurring and requires safe, healthy relationships with advocates and therapists who understand what is happening from a trauma-informed viewpoint. There are many modes of treatment that work to return the brain and body to balance and I recommend that you search out therapists in your area who understand trauma and trauma treatment.

Update on Project to Date

2009-12-21T12:47:00.000-08:00

Over the past six months there have been approximately twenty three trainings at five local domestic violence crisis center programs to educate advocates about substance abuse, mental illness and trauma and how it affects the empowering work we do with survivors of trauma. In addition, a couple of community collaboration efforts have been organized in areas where very little inter-agency contact had been occurring. Outreach has been made to local homeless programs, social services agencies, private therapists and the department of corrections. Additional training has been offered and accepted by many of these agencies as interest and a desire to know about trauma-informed services grows. In one case, the local domestic violence and homeless shelter programs came together for training on trauma and homelessness and are now collaborating to review policies and procedures in order to have a common voice in the community about providing trauma informed shelter services.

Prevention Innovations, a consulting, training and research unit of the University of New Hampshire, has provided their expertise in evaluating the project and is currently forming focus groups with consumer survivors to determine how crisis centers are meeting their needs.

Over the next few months, another three to four crisis centers will be coming on board the Open Doors project. These centers will receive the same training as the initial five projects and community collaboration will be a goal for their catchment areas. New Hampshire has fourteen crisis centers and the plan is for all fourteen centers to have received training before the end of 2011.

We are currently in the beginning stages of planning for a state-wide mental health and trauma training for domestic violence programs and interested mental health clinicians/therapists for sometimes next summer with Carole Warshaw and Terri Pease. A mailing list of therapists is currently being compiled in hopes to reach out to as many providers as possible.

The most exciting part of the initiative is the ongoing conversation about providing trauma informed services to survivors and involving as many community partners as possible. The NH Coalition Against Domestic Violence and Sexual Assault is dedicated to making this a part of its messaging and becoming a voice for trauma survivors.