Cultural Influences and Response to Trauma

“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

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

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

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

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

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

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.