Chapters 4–6
As stated in Chapter One and throughout the Relational Section, building healthy relationships is the ultimate goal of The Mandt System. The focus is on all relationships between stakeholders in the workplace. There are three core skill sets that were introduced in Chapter One: engage, listen, and protect. These three skill sets are needed to develop healthy relationships, and they are needed to provide healing to people with trauma histories and to direct the implementation of behavior change plans. There are regulatory structures in place to ensure that caregivers do listen to individuals receiving services, that they do engage with them, and that they protect the emotional, psychological, and
physical health of all people. These skill sets are needed to empower caregivers to create, sustain, and strengthen the culture of the organizations, so all people can say, with full meaning, that In this place and with these people, I feel safe™.
The Conceptual Section now focuses on using these skill sets and developing competencies. The three models of Maslow’s Hierarchy of Needs, R.A.D.A.R., and the crisis cycle will continue to be used to frame the skill sets of engage, listen, and protect. Three additional core competencies are introduced in chapters on trauma informed services, positive behavior interventions and supports, and regulatory and legal issues. By using the above models and skill sets, caregivers can now co-manage with the individual being served.
Chapter Four, Trauma Informed Services, was written to help caregivers better co-manage and support individuals served. The data available shows that the vast majority of individuals served have histories of significant trauma. New research also shows that many of the caregivers supporting these individuals have their own trauma histories. In addition, the concept of secondary trauma demonstrates the retraumatization that can take place when caregivers intervene to address behaviors of concern.
Understanding the neurobiological impact of trauma and how to support “bottom up” regulation of the brain are two of the topics addressed in this chapter, which is written in an accessible format so all caregivers can understand and benefit from the information. If you are not already a therapist, this information will not make you a therapist. This chapter was reviewed by two Ph.D. level clinicians, a mental health therapist, and a trauma survivor.
Chapter Five, Positive Behavior Interventions and Support, was written primarily to help people
implement behavior support plans, not to write them. Research demonstrates that almost any plan will work to change the behavior of people if caregivers implement the plan with fidelity to the instructions in the plan. The more people know about positive behavior support and the reasons behind how a plan is written, the easier it will be to help the people writing those plans by giving them the information they need, and the easier it will be to implement the plans once they are written. Written in straightforward, accessible language, the information has been reviewed and approved by two board certified behavior analysts (BCBAs) and a psychologist.
Chapter Six, Regulatory and Legal Issues, has a primary focus of understanding the role of regulation specific to the topic of behavior change and responding to situations where there is an immediate threat to safety due to aggressive behavior. Understanding the role, context and purpose of regulations provides caregivers with a firm base from which to do their work with more fidelity. The legal issues surrounding situations where regulations may not have been met are discussed. This chapter was reviewed by two people with extensive backgrounds in the regulation of human service programs in Canada and the United States.
CHAPTER FOUR
Trauma Informed Services
Section 1
Overview
The Mandt System® curriculum has been designed to build healthy relationships in the workplace. This chapter will teach that psychological, emotional, and physical abuse as well as other forms of trauma are present in many people in our society, and even more within the ranks of the individuals served in various settings such as schools, hospitals, residential programs, and many others. As such, trauma is discussed in many of the curricula taught by The Mandt System® and is addressed as part of the RCT curriculum.
In this chapter, please be aware that these discussions on trauma need to be open, transparent, and respectful. Some of the information presented could potentially cause sadness and/or distress to participants in the event. If this is the case, participants are encouraged to take time to process their feelings and any of their own trauma history. The Mandt System, Inc., strongly encourages certified instructors to do the same when teaching their students. The Mandt System, Inc., disclaims any liability for causing such sadness or distress.
Learning Objectives
Upon completion of this chapter, participants will have:
1. Identified the effects of trauma on people.
2. Differentiated between the two types of trauma.
3. Recognized that different traumatic events will affect individuals in different ways and will affect the type of supportive response needed.
4. Identified the internal and external factors that influence resilience to trauma.
5. Developed an understanding of the ways in which
trauma early in life affects development.
6. Chosen supportive
interventions which support the whole person, not just focusing on the person’s specific behaviors in response to the trauma.
7. Understood the importance of trauma informed services in preventing possible retraumatization.
8. Developed an awareness of retraumatization as a negative consequence of using
restraint and strategies to minimize it.
Mandt Purpose For Trauma Chapter
The data about the number of people who have experienced some form of trauma is
staggering. In psychiatric
hospitals, 92% of the individuals served have a history of
severe abuse or neglect. Data shows that 55% of children in specialized educational services have a history of abuse or neglect.
The goal in this chapter is to increase the awareness of the neurobiological effects of trauma and to create and sustain environments in which people can say In this place and with these people, I feel safe™. The material taught here is sub- clinical and does not teach any clinical or therapeutic skills.
The chapter is designed to help organizations become “trauma sensitive,” or put another way,
“trauma informed.” Everything an
The two forms of trauma that are the topic of this chapter are acute episodic trauma and betrayal trauma.
Acute episodic trauma is just what the name implies. It is an event that can have devastating effects on people and can threaten their lives. It is also an event over which they have little or no control and is often, but not always, the result of natural disasters.
Betrayal trauma (Freyd, 1991) is the personal experience of interpersonal violence and occurs when caregivers such as family members, coaches, teachers, therapists, clergy (priest, rabbi, imam), or other caregivers betray the trust that they will keep their charges safe physically, psychologically and emotionally. Examples include, but are not limited to, sexual
Betrayal trauma can take many forms. Some forms are easily seen and understood, such as physical and sexual abuse.
While significant events such as sexual abuse are traumatic, other forms of abuse also can have terrible effects. In 1936, Dr William A. Bryan wrote: “There is a type of psychological abuse of mental patients which may be more disastrous than any kind of physical abuse. By this I mean the tactless treatment of the patient, the refusal of small desires and requests, and the abuse of power that is necessarily conferred upon the individual who is in charge of a ward of mental patients”
(Bryan, 1936).
In Chapter One, information from Albert Bandura and Glenn Latham was presented demonstrating that the majority of interactions between people are negative. The interactions
Section 2
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It is, as Bryan said, an abuse of the power caregivers have as a result of their positions.
Caregivers have a great deal of power over those in their care, whether in a natural home, foster home, psychiatric hospital, classroom, or other setting.
The betrayal of trust is greater when the power differential between the caregiver and the individual is greater, which is why abuse in early childhood is often more damaging than in later childhood or adulthood.
The trauma which occurs within institutions is also exacerbated by this power differential (Smith
& Freyd, 2014).
The fact that people like Dr.
Bryan recognized this more than 80 years ago gives hope that awareness can result in change.
Equally true, however, is the fact that things have not changed in 80 years. Betrayal trauma continues to be a significant concern and this chapter is designed to shed light in the darkness and bring forth the hope Bryan and others have written about.
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The Mandt System® adapted this chart to help explain the model. In the lower left hand quadrant, where there is a low level of relationship between people and a low level of risk of dangerousness and/or death, the perception people have is that they are, generally speaking, safe. Examples include driving to work or school in traffic when the weather is good and there are no car accidents or delays. Walking on a safe street in a safe neighborhood is another example of a situation in which there is a low level of relationship with others and a low level of risk.
level of dangerousness and/or death increases dramatically.
In this case, the level of
relationship did not change but the level of risk did. It is from situations such as this that acute episodic trauma can occur.
Not all people will develop traumatic responses to these events. Factors that contribute to the development of traumatic responses include prior history of trauma, the severity of the event, whether or not there were serious injuries and/or death, and most important, the degree of social support. The more social support a person has, the easier it will be for them to make
the exact same time someone else is also backing out, and each person is in each other’s blind spot. There is a “crash” and both people get out to make sure the other is alright. The degree of effect the accident has is dependent on the relationship between the parties involved.
The higher the level of relationship, the greater the effect can be on human beings.
On the vertical plane of the quadrant, the faster the two cars were going, the greater the likelihood of injury and the more severe the impact of the trauma could be.
Betrayal trauma, however, has
High level of dangerousness and death
High probability of mental health concerns
Acute Episodic Trauma
“Abnormal level of risk”
Random violence, flood, hurricane, fire,
car accidents, etc.
Betrayal Trauma
“Abnormal level of risk”
Physical, sexual abuse, neglect by “caregiver,” witnessing violence to someone the
person cares about.
“Normal level of risk”
Living in a stable household, attending a stable school.
“Normal level of risk”
Driving in traffic, walking on a safe street, good weather.
Low relationship with the person
High relationship with the person
Safety Safety
Low level of dangerousness and death
Low probability of mental health concerns
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Each region of the country, and indeed the world, has different risk factors for acute episodic events.
As discussed earlier, the impact on people will vary from person to person based on a variety of factors.
Organizations have a responsibility to the people they serve, and the caregivers who serve them, to prepare for traumatic events. That is why your organization conducts fire, tornado, and other evacuation drills. Even though they may never happen, organizations prepare for them “just in case.” Preparing is a management responsibility and is often put into the laws and regulations that govern services.
When events occur that are out of control, it is much like being in an earthquake. An individual’s foundations are literally shaken in an earthquake and figuratively shaken in other acute episodic traumatic events. These reactions are often disturbing to people, and while these reactions may feel or look unusual, they are typical of what people do and are to be expected. They are normal responses to abnormal situations.
If and when people experience these events, caregivers want to meet basic human and safety needs. This may involve CPR, first aid, or calling 911. They should strive to provide services and supports in ways that do not retraumatize people.
Responding to acute episodic trauma
Prepare, Stabilize, and Recover:
These are the three “prongs”
which the American Academy of Experts in Traumatic
Stress (AAETS) recommend organizations use as they provide services and supports when acute episodic traumatic events occur in different geographical areas. Their website is http://www.aaets.org.
When an organization joins AAETS, it sends the organization
a wealth of material on how to prepare for acute episodic traumatic events.
FEI Behavioral Health is an excellent resource for communicating with people after a crisis has occurred in order to support them both immediately after a crisis situation and in the process of moving toward the ability to recover from the event.
FEI has a 35-year history of helping people and organizations prepare for and respond to a wide variety of crisis events.
Their parent organization, The Alliance for Strong Families and Communities (http://www.
alliance1.org), along with FEI, provides needed services to human service organizations across the nation.
A robust network of experienced counselors makes FEI one of the country’s leading providers of the Employee Assistance Program.
FEI has partnered with The Mandt System® to provide Mandt System® training in organizations that are part of the FEI network of providers.
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Notes:
Adverse Childhood Experiences (ACE) Study
As described earlier, when people who are trusted betray that trust, the effects of abuse and neglect are even more harmful for the individual. It should also be emphasized that it is the subjective experience of trauma—the person’s own perspective—that determines if people have been wounded by the abuse and/or neglect.
When working with individuals who may have a trauma history, caregivers should not judge someone whom they believe has been abused or neglected.
It is the person’s perception that gives the event the power to harm them. There are so many stories of woundedness in the world!
The data is appalling and will be presented later in this chapter.
“Universal precautions” in trauma means that caregivers will
interact with every person in a treatment, educational, or other human service setting as if they have been exposed to one or more of the Adverse Childhood Experiences (Gentile, 2014).
In 2000, the Centers for Disease Control (CDC) and Kaiser-
Permanente Insurance (KPI) jointly published the Adverse Childhood Experiences (ACE) study. Almost 17,000 people who were covered by KPI were asked if they had experienced four or more adverse childhood experiences, as follows:
• Recurrent physical abuse
• Recurrent emotional abuse
• Sexual abuse
• Living with someone who was an alcohol or drug abuser
• Living with a family member who was currently or had been incarcerated
• Living with someone who is chronically depressed, suicidal, has been institutionalized, or had a diagnosis of a mental illness
• Experiencing emotional or physical neglect
• Living with one or no biological parents
Please note that growing up in a single parent household is not, in itself, an ACE.
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Notes:
Results of ACE study
In this study, only one-third of the almost 17,000 middle class Americans said they had no ACEs.
When people “do the math,” 200 million people in the US have grown up in environments that with one or more adverse childhood experiences.
The results of the study showed that the lowest percentage of people reporting trauma identified emotional abuse (10%), followed by sexual abuse (21%), and physical abuse (26%).
acestoohigh.com/got-your-ace-score/
The results of the data on reports of abuse and neglect is staggering. The data in specialized services is even more daunting. Studies result in different ranges, with earlier studies (Craine et al., 1988) showing 51% of female patients in a psychiatric hospital had a history of sexual abuse, while later studies showed 92% of patients in psychiatric hospitals. About 85% of people affected by intellectual disabilities who also lived in large institutional settings and 55% of students in specialized educational settings report that they were exposed to adverse childhood experiences.
Lifelong effects of ACEs
The ACE study began when Dr. Vincent Fellitti was directing a clinic to deal with obesity while working with Kaiser Permanente Health System in California. He found that over half the people quit the program despite progress being made, and he began to listen to his patients. Out of this experience he and Dr. Rob Anda from the Centers for Disease Control devised a study to look at the general health effects and medical concerns that occurred as a result of adverse childhood experiences.
Data from the ACE study and subsequent research (Brown, 2009) showed that people with six or more ACEs had a lifespan that was, on average, 20 years shorter. The effects of ACEs on health (Tacket 2002; Middlebrooks et al., 2008; Danese et al., 2009) are becoming more evident. The emphasis has been on the mental health effects of trauma, and while that is important, it is equally important to understand the general health effects.
The social isolation due to the ways in which ACEs manifest themselves later in life (Caspi et al., 2006) is related to the social isolation felt by people with behavioral challenges (Australian Psychological Society, 2011; Pitonyak, 2012). The medical concerns and social isolation among people with high ACE scores result in increased mental health concerns as noted by multiple studies (Middlebrooks &
Audage, 2008; Lanius & Vermetten, 2009; Brown et al., 2009).
The end result is a decrease in the quality of life of people who have a history of ACEs. The woundedness within people,
though, is just that, within people. It is not only patients and clients and students and residents who have histories of ACEs. All people are affected.
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Results:
Abuse:
Emotional 10%
Physical 26%
Sexual 21%
Neglect:
Emotional 15%
Physical 10%
ACE score of four or more:
12X more likely to attempt suicide.
7X more likely to become an alcoholic.
10X more likely to have injected street drugs.
The wounded classroom
Schools are the first
organizations that face the effects of ACEs. In a study done in Washington State, out of a classroom of 30 students, only six students had no ACEs. Five students had 1 ACE, and six students had 2 ACEs. There were three students with 3 ACEs, seven had 4 or 5 ACEs, and there were three students with 6 or more ACEs (Anda, 2012) The numbers in this study indicate a high need for trauma informed classrooms (Saltzman, 2009;
Ngo et al., 2013).
In Mandt language, this was translated into needing structure that is focused not on time but on tasks, and sets transitions in school settings functionally via short, structured activities that have high probabilities for successful completion in short time frames. Unfortunately, most schools are time- and not task- oriented and as a result many of these children had difficulty in school settings.
Caregivers must really focus on the neurological changes that take place, and the “bottom up”
regulation of behavior rather than “top down,” discussed later in this chapter.
Healthcare workers and ACEs
“You can only give what you have”
is a phrase used in The Mandt System® to emphasize the need to support caregivers so they can support others. While looking at supporting individuals with histories of trauma, understand that caregivers are just as likely,
if not more so, to have histories of trauma in their lives.
In a national survey of psychologists (Pope & Feldman-Summers, 1992), 70% of female and 33% of male psychologists had a history of sexual abuse in childhood. This rate is similar to a survey done in 2010 (Mulder et al., 2010) of health care workers in Ontario, Canada, in which 68% of the respondents indicated they had experienced abuse prior to the age of 13.
It is the experience of faculty in The Mandt System, Inc., that people come into human services because they genuinely care for others, and sometimes they have an additional motivation of wanting to find out more about themselves. If caregivers are unaware of their own trauma history, they may inadvertently respond in ways that are harmful to others and/or to themselves (Center for Substance Abuse Treatment, 2000). Being aware of these issues and supporting caregivers is part of what it means to be a trauma informed culture.
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The wounded workforce
Data from the previous page was used to extrapolate a conservative estimate of the history of adverse childhood experiences that may be present in the workforce. Out of every 100 employees:
• 40 will have no adverse childhood experiences. This does not mean that they will have no problems or issues at work! It does mean, however, that their issues (if they have any) are probably not related to histories of trauma.
• 37 of these people will have histories of having 1 or 2 adverse childhood experiences. Again, this does not mean these employees will have problems or issues at work, but if they do,
supervisors have to be aware of the potential interaction between trauma history and work performance.
• 20 people in this hypothetical group of 100 employees will have a history of exposure to 3 or 4 ACEs. People in this group, and in the group of three people with 5 or more ACEs, will have a higher likelihood of absenteeism and self-reported problems at work (Anda, 2006).
The more ACEs a person has, the more likely it is that their behaviors under stress may revert back to “old” coping behaviors. Learning how to affirm feelings and choose behaviors, is vitally important for all individuals with histories of trauma.
Employers are not permitted to address the pre-existing conditions of employees they have hired, and by OSHA law, medical concerns must be separated from personnel decisions. Based on what is known, though, it is imperative that as organizations develop trauma informed workplaces, that employers take into account the trauma histories of caregivers. To answer questions from employers, caregivers must themselves feel safe in the relationship and know that their answers will not “get them in trouble.”
Employers must support caregivers so that caregivers can support others. It is for this reason and others that The Mandt System, Inc., offers workshops in “Corporate Culture Change” and “Supporting
Successful Leadership.”
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ACEs around the world
Since the publication of the ACE study in 2000, researchers in other countries have begun to investigate the connection between adverse childhood experiences and adult behavior.
While the statistics vary in terms of the exact percentages of exposure to adverse childhood experiences, the pattern and trend are consistent. As one set of researchers stated, “Our results indicate that individuals who do not develop health harming behaviors are more likely to have experienced safe, nurturing childhoods. Evidence-based programs to improve parenting
and support child development need large-scale deployment in the eastern European Region”
(Bellis, et al., 2014).
The research indicates that it is not just the eastern European region that needs programs to improve child development, improve parenting skills, and increase safety for all people.
Another group of researchers assessed the effect of ACEs in the UK. The researchers found that, in the UK, ”modeling suggested that 11.9% of binge drinking, 13.6% of poor diet, 22.7% of smoking, 52.0% of violence perpetration, 58.7% of heroin/crack cocaine use, and 37.6% of unintended teenage
pregnancy prevalence nationally could be attributed to ACEs”
(Bellis et al., 2014).
In a study conducted by the World Health Organization of almost 60,000 people in upper, middle, and low income countries, the distribution of childhood adversities (similar, but not identical, to the ACE study) was surprisingly consistent. The reports also supported the finding that the younger the age of the child who experienced childhood adversities, the more likely it was that the person would develop mental health disorders (Kessler et al., 2010).
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Trauma Informed Cultures
In order for the work of caregivers to be effective with individuals, the culture itself must be informed about trauma at all levels of the organization. While this approach has been present for many years in mental health services (Huckshorn, 2006), it is now being discussed in relation to intellectual disability services (Keesler, 2014) and schools (Daniel & Salzman, 2013).
The stated goal of The Mandt System® is to build healthy relationships, and that has been the goal since the first Mandt System manual was written in 1978. When people can say that
“In this place and with these people, I feel safe™”, they are less likely to engage in what the researchers quoted above call
“health harming behaviors.”
That is a primary responsibility of organizations and caregivers working within them. However, caregivers can only give what they have.
Creating trauma informed cultures requires more than just training in this chapter.
There must be a commitment throughout the organization, including the governing board and administration, to trauma informed services.
Providing trauma informed services is a subclinical approach that provides information to all caregivers in an organization. The goal is to have a trauma informed service system so that everything
knowledge of the neurobiological effects of trauma, how prevalent trauma is, and the concept of recovery into everything they do.
Recovery is the concept that all people want to recover from the trauma and they may not know how to do so.
This approach minimizes the potential for revictimization and leads to services that are represented by two important words, hospitable and engaging.
Hospitable places are where people feel safe. The word comes from the same Latin word used for the word “hospital.” It is a place of healing. Organizations need to create environments where people say “In this place and with these people, I feel safe™”.
The second word, engaging, means that people are in charge of the process of their own recovery. The recovery model in mental health puts people receiving services in charge of the process of their own recovery. For more information on the recovery process, see http://mhrecovery.com/
definition.htm.
Examples of counterparts to this model would be person-centered planning in developmental disability services and the individual education planning process in special education services.
WE CARE
culture and external forces from regulatory and funding bodies.
Creating a culture of wellness must start with a commitment to the model of wellness. The acronym “WE CARE” provides the structure for wellness to move from the beginning of an idea to the experience of a work life well lived.
Wellness — The concept of wellness builds on the Four Walls of the House model by integrating the physical, emotional,
psychological and social health of a person. Wellness models at the Mayo Clinic support this integrative approach to individual medicine and to incorporate wellness. In Chapter One, in the graded and gradual hierarchy of interventions, the statement was made that “What you believe leads to how you behave.” Wellness is what The Mandt System® believes in. This is our starting point and our goal. The goal of wellness will be achieved when all the measurable components of that goal are in place. An old and true adage is that people cannot manage what they cannot measure. For cultures to change there must be a pathway that can be marked with signs by which they can measure the person’s progress.
Empathy — To achieve wellness, people need to be connected to each other at an emotional and not just a cognitive level.
Health care professionals have
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how much you care.” Empathy provides people with the sense of being connected with, not just to, others. Empathy is the bridge between people that transforms sympathy to compassion.
Compassion — Compassion empowers healing to transform lives. Compassion invites and empowers others to cross the bridges they build together from the lives people have, to the lives people want to have. Compassion is not only with individuals in care, it is with each other first and foremost.
Achievement — Achievement is not an individual process or event.
In order to achieve wellness, a person must be empowered to
achieve through the empathy and compassion of the health care professionals serving them.
Achievement of wellness occurs only when there is mutual support between all the stakeholders in healthcare, supporting each other so they can, together, support individuals they care for.
Respect — Respect must
permeate the health care system.
Respect does not have to be earned. It is given freely to all people simply because they are people. Respect is unconditional.
It is a right that does not need to be earned.
Engagement — Respect is a pre-requisite to engagement, the invitation for people to participate
in and, whenever possible, direct the process of their own healing.
Without engagement, individuals receiving services may not be able to achieve their goals because of a lack of investment in the process of healing.
The recovery model
Everyone who has had an experience of abuse or neglect wants to recover from those experiences and live their lives to the fullest. These internal factors within the person and the external factors within the organizational culture interact with each other.
Both internal and external factors must be present in order to support the person.
Internal Factors External Factors
Hope is deep inside human beings, and they seek out people who promise to heal them. Hope is a central feature of the Spiritual wall in the Four Walls of the House model and is central to recovery
First is a commitment to basic human rights and the freedom from aversive interventions.
Abuse and neglect often result in a feeling of
powerlessness. Empowering people through simple actions such as giving choice on a regular basis leads to empowerment.
Second, is the creation of a positive culture of healing, recognizing the woundedness of people. Part of this positive culture is the use of Positive Behavior Interventions and Supports, in a way that invites rather than coerces behavior change.
One of the most important things, if not the most important, is to be connected to other people. In one study in Vermont, people who were psychiatrically hospitalized for treatment of schizophrenia were interviewed an average of 32 years after discharge. The researchers found that 2/3 of the former patients showed no signs of schizophrenia and were not taking any
medication. Upon further investigation they found that the most important factors in their recovery was having a safe place to live and meaningful social relationships (friends) in their lives. (Harding et al, 1987)
This recognition leads to an
organizational commitment to what is known as a “recovery oriented” system of providing services and supports. In this approach, the job is not just to teach or rehabilitate, or provide therapy, but to do these things within a system that is centered around the person.
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Supporting the recovery model
Martin Pistorius was 12 years old when, for unknown reasons, his entire body began to shut down. After two years, he was considered to be in a permanent vegetative state. For the next 12 years, he was aware of his condition and unable to communicate with anyone until a direct support caregiver advocated for a communication system for him. Over time, he was able to regain much of his physical function and always had his keen intellect.
In his book Ghost Boy, Pistorius writes about the “three Furies”
that haunted him. While the cause of his condition remains unknown, it was not the result of betrayal trauma. However, he did experience betrayal trauma in his life.
The first of the Furies was frustration at “constantly being reminded he couldn’t determine his own fate.” All his choices were made for him, and he could not communicate the
custard at lunchtime for years.
He was unable to communicate in any way that others could understand, and his frustration grew year after year.
The second of the Furies was fear, which Pistorius calls the
“sister of frustration.” When his parents went on holidays with his brothers and sisters, he would stay in a care home in which he was frequently abused. He could not tell anyone this, and his fear of going to this place built and built prior to each visit. It was a terror from which he tried once to escape by burrowing his way into a plastic bag so he would asphyxiate. But his body lacked the strength to move his head into the bag. Fear was a constant companion.
The worst of the Furies, he writes, was loneliness. He writes that loneliness “could slowly suck the life out of me even as I sat in a room surrounded by people.” He was always alone even in a room full of people because no one responded to him.
One day, his father talked to a man who had become disabled
same position for hours. After hearing this, his father paid more conscious attention to how his son sat. He writes about his father taking care to position him in his wheelchair after that: “Each time he did, loneliness went snarling back to her solitary cave because when my father showed that he was thinking about me, we defeated loneliness together.”
The job of the caregiver, whatever their role, when they relate with people who have been wounded in some way, is to LISTEN using the active listening skills learned in Chapter Two. Assume every person served is trying in some way to communicate, and caregivers need to listen to their behavior, their facial expressions, the tone of voice (especially paralanguage), and their visual behavior. Caregivers also need to actively PROTECT them in the environments in which they live, learn, work, and play. Active protection means that the caregiver’s R.A.D.A.R.
is always on them to maintain
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help the person develop insight into their triggers and as well as de-escalation preferences.
Finally, caregivers need to ENGAGE with them. In every interaction and in every conversation, talk with the person, not to them. Assume, in all cases, that they can hear every word said, catch every facial expression, and feel every nuance of communication. It is in this way that caregivers can fight the Furies that assail the people in our care.
Healing our pain
Maria Yellow Horse Brave Heart is a Ph.D. level clinical social worker, specializing in historical trauma and the transgenerational transmission of trauma. She has developed an approach that is easily
transferable to individuals as well as groups (Brave Heart, 2011).
The first thing caregivers have to do as they support people with histories of trauma is to increase the safety of the “house” in which they live. Chapter One introduced the concept of the Four Walls of the House from Maori culture.
When people can say In this place and with these people, I feel safe™, then they will be able to take the first step to confront their trauma and embrace who they are. Understanding the effects of the trauma is a necessary aspect of healing in order to know the “why” of their own behavior.
The second step in the process is to understand the neurological effects of trauma. The models presented by Dr. Bruce Perry,
a child psychiatrist and senior fellow of the Child Trauma Academy, are helpful in this understanding.
Releasing the pain is the third step in this process. If you hold on to the pain, the pain will hold on to you. Many indigenous peoples have a healing ceremony to release the pain. A common word to describe this process is forgiveness. How one forgives, or chooses to let go, is an
individualized process, and there are many resources available to support this process.
When people let go of the pain, they can take the final step in this process and transcend the trauma. In her book My Name is Shield Woman, Ruth Scalp Lock from the Blackfoot First Nations people writes about the death of her sister and a niece in the residential schools and other traumatic experiences which led to alcoholism. She established the first women’s shelter, Awo Taan, which means “shield woman,” in order to protect others from the pain she suffered. It is in letting
go of the pain and moving past it that people can prevent the trans- generational transmission
of trauma and shield others as they also shield themselves.
The neurobiological effects of trauma and the models presented by Dr. Bruce Perry, a child psychiatrist and senior fellow of the Child Trauma Academy, are helpful in this understanding. Releasing the pain, forgiving the people who committed the traumatic acts, is the next step and in this way people can recover and transcend their own trauma histories. This is crucial so people do not pass on the pain to the next generation.
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Te taha tinana
Physical health Te taha whirua
Spiritual health Te taha whánau
Family health Te taha hinengaro
Psychological health
Healing Pain, Neurobiology Of Trauma
Tonier Cain is a woman who was able to confront her trauma when her hero looked at her and instead of seeing who she was, saw who she could have been if she had not been raped, beaten, and exposed to multiple adverse childhood experiences. When caregivers support people who have been deeply wounded, they need to do more than look at them—they need to see who they could have been, because that is where hope lives. When someone looks at the child who could have been instead of the child or adult who is, and creates a place where that person can say In this place and with these people, I feel safe™, then at that point, healing and hope begin.
Understand the effects of trauma
The ACE pyramid was developed by Dr. Rob Anda with the CDC
It will be explained using the story of a man, called Bart, who is living in Canada.
Adverse Childhood Experiences:
Bart was born to a mother and father who were both alcoholics and abused illegal drugs. Bart is the second of three children born to these parents. When his mother discovered she was pregnant, at approximately three months gestation, she dropped drinking and using drugs. All three children, at various points in their lives, were permanently removed from the custody of the mother, who separated from Bart’s father. Bart was three years old when he was removed from the family’s care and
placed in foster care.
Bart was physically, sexually, and verbally abused from the time he was two years old until he was four years old, according to Bart’s mother, who was an informant for the record review, along with Bart’s court-appointed probation officer. He was neglected until he was approximately six years old. During his childhood and adolescence he had multiple foster care placements. He had brain cancer which was treated successfully with surgery and chemotherapy at age 12.
Disrupted Neurodevelopment:
As a result of his adverse childhood experiences, his neurological development was disrupted. The parts of his brain
behavior, and the ability to form relationships with others at more than superficial levels.
Adoption of Health Risk Behaviors: Bart’s health risk behaviors include morbid
obesity and a history of multiple substance abuse. His disabilities were manifested as described with frequent hospitalizations and arrests. At the time of the assessment and planning process, he was 22 years old.
Disease, Disability, and Social Problems: His social, emotional, and cognitive impairments can be seen as byproducts or results of the differences in his neurosensory system from the ways in which it might have developed had he not experienced abuse and neglect.
Bart has diagnoses of reactive attachment disorder, ADHD, mild intellectual disability, and conduct disorder. Bart is hypervigilant and has difficulty forming relationships with others unless they have something he wants, or he has something they want. His sexual behaviors can be characterized as
“aberrant” in that he photoshops pictures of clothed children into pornographic images. He overreacts to many situations.
Prior to a company working with him that used The Mandt System®, he was hospitalized three times monthly, on probation, arrested frequently for threatening to commit
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supports he is receiving now will begin to alleviate some of the health risks he faces. On average, people with significant histories of trauma lose approximately 20 years from their expected lifespan (Anda, 2006).
Note: There are scientific gaps about the effect of adverse childhood experiences on the neurobiological impact of these traumatic events and how they become part of the behavioral repertoire of individuals. Every year there are hundreds of articles, dozens of books, and numerous national and international conferences addressing the aftereffects of trauma. The gaps in knowledge are lessened every year and The Mandt System® strives to stay current with this information to support organizations to create environments where safety and security are realities, not just words.
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Early Death
Death
Conception
Adverse Childhood Experiences Disrupted Neurodevelopment
Adoption of Health-Risk Behaviors
Disease, Disability and Social Problems
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Complex
neurological system
The brain and the human neurosensory system are amazingly complex. This
information is presented to give caregivers an understanding of the disruptive effects of trauma.
In learning this information, focus on the “big picture.” The trauma people experience not only wounds, it disrupts, changes, and redirects the ways in which the neurological and sensory systems develop.
The brain is organized from bottom to top in a way that uses fewer neurons and fewer neural connections in the lower
with a major 12-lane highway going up through the spinal column into the brainstem, and branching out into a complex set of highways, roads, streets, and alleys as in any major city.
Many people have driven in large cities where the highways were under construction. The delays, detours, and disruptions in traffic flow are a good analogy for the disruptions and differences in behavior that occurs as a result of trauma.
The neurological system is designed to be “wired together”
for the most part after birth.
Basic functions necessary to sustain life such as cardiovascular and temperature regulation
external senses, the process of behavioral output is what “wires”
neurosensory systems.
Neurologists have a saying:
“What fires together, wires together.” In other words, when sensory input and behavioral output are firing, the emotional state occurring at the time is
“wired” into the neurosensory
“web” that is being formed. This wiring forms “neural networks,”
and every human behavior uses these networks.
As an example, imagine a six- month-old child lying in a crib or basinet. She looks up and sees an interesting object hanging from the mobile above her head. She
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When she reaches her hand out to touch it, there is a complex set of actions that work together to tell her muscles how to move so her shoulder, arm, elbow, wrist, and hand work in unison.
As this happens, a “neurological road” is built. But it is the wrong road, so she tries again. All of the materials used to build that temporary road are reabsorbed back into her body, and she tries again.
Finally, she touches it! Like almost all children, she will repeat the behavior, practicing the movements so she can use
this road again the next time she wants to touch something.
It is the process of practicing these movements that result in a special type of glial cell to wrap myelin sheathing around the axon of every neuron involved in this behavioral pattern.
Almost all human behaviors use roads built in this way.
When children live in homes, go to schools, when they are with family members and can say this important phrase:
In this place and with these people, I feel safe™, the roads built in their brains and their
bodies work smoothly. When they are not able to say these words, when they experience abuse and neglect, their roads sometimes are bumpy or have dead-ends in them. Their roads may go in circles and never get them where they want to go.
Trauma disrupts the neurological pathways people need to use to keep themselves and others safe.
Neurological development is the result of sensory input interacting with the genetic factors of the individual in the context of the environment.
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Understanding the neurobiological impact of trauma
To explain how the neurobiological impact of trauma can be assessed using the Neurosequential Model of Therapeutics, the story of Bart will be reviewed here.
Using Bart as an example, his traumatic
experiences during his early childhood are a large part of the causative factors in the behaviors that challenge him and others around him. A box has been placed around the time of his traumatic experience to show this. His morbid obesity (appetite, satiety), hypervigilance (arousal), reactive attachment disorder (emotional reactivity, attachment), and his deviant sexual behaviors are all “within the box.” His difficulties in forming relationship (attachment) and in being used by people (affiliation) as well as using others are within this box.
Had Bart not experienced the traumatic life events
now. By developing a program of supports that focused on safety, predictability, and self-control the team supporting Bart was able to support him in the community in ways that increased his safety and that of those around him.
This approach is called the Neurosequential Model of Therapeutics (Perry, 2011) and provides a programmatic approach that empowers Bart to more easily learn as caregivers teach to his strengths, using his neurology to change his behavior. No single factor can ever be responsible for success. The partnership between the
organization, the local police, the provincial ministry of health, the probation department, and the
behavioral consultant, and the ability of caregivers to follow the plans and maintain fidelity all interact to increase Bart’s quality of life. When quality of life improves, quality of behavior follows.
As a result of this partnership, Bart has had far fewer hospitalizations, police involvements, and aggressive incidents. He started his own business
• Abstract thought
• Concrete thought
• Affiliation
• “Attachment”
• Sexual Behavior
• Emotional Reactivity
• Motor Regulation
• “Arousal”
• Appetite / Satiety
• Sleep
• Blood Pressure
• Heart Rate
• Body Temperature Ages 12 - 18
Ages 8 - 12
Ages 4 - 8
Ages 1 - 4
First Year
3rd Trimester 2nd Trimester
NeoCortex
Limbic
Diencephalon
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with pe
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Understand the trauma
Much of the work done in behavioral approaches to working with people with behavioral challenges has focused on what are called
“top down” interventions.
Positive behavior interventions and supports (PBIS), cognitive behavior therapy, behavior management or modification, and operant conditioning are all examples of a top down approach. These interventions use the “thinking part of the brain,” or the neocortical systems, to help people make a different choice the next
time they experience the same antecedents which resulted in behavioral challenges in the past.
A bottom up approach seeks to provide safety to the person through their bodies. Repetitive motions such as rocking, swaying, or more complex rhythms such as drumming, can produce a sense of safety within the individual at a neurological level.
Bruce Perry has coined the term “Neurosequential Model of Therapeutics” and uses this specific approach in his work. Occupational therapists also use this model, calling it
sensory reintegration. Having an awareness of trauma history is critical to understanding how to integrate PBIS and trauma informed services.
The Mandt System, Inc. offers one-day workshops that go into more depth and provide a deeper understanding of the neurobiological processes central to this.
For maximum effectiveness, bottom up regulation should be used first, and when the person stabilizes or returns to their baseline, then top down interventions can be used with more effectiveness.
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Bottom up activities
Top down activities PBIS, CBT.
NeoCortex
Limbic
Diencephalon
Brain - stem Used w
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Release the pain
In order to take the third step in Maria Yellow Horse Brave Heart’s model, people must have resilience. Resilience is the ability to thrive, mature, and increase competence in the face of adverse circumstances. To do so people must draw on their biological, psychological, and environmental resources.
With resilience, people who have been wounded are able to thrive, mature, and increase competence in the face of adverse circumstances (Gordon, 1995). Using the resilience inside each person requires using all the resources available.
Earlier in this chapter, the external and internal factors
that supported resilience were discussed. They are:
Internal: Hope,
Empowerment, Connections External: Commitment to Human Rights, Positive Culture of Healing, Recovery Oriented Systems of Care
The people served in organizations using The Mandt System® are part of the resources available to people.
Any and every person within the organization can be a hero to someone. The connections caregivers offer to people who have been deeply wounded starts with the relationships between caregivers. If caregivers trust each other, the people served can trust them.
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Transcend the trauma
In Chapter One, the concept of the Four Walls of the House from the Maori culture was introduced. Once their house is built with and for them, people can feel safe and say In this place and with these people, I feel safe™. When people can say these words, then they will be able to confront their own trauma and embrace who they are.
The question is often asked of survivors of trauma: “Have you gotten over it?” The answer is that survivors of traumatic experiences do not get “over”
trauma, they get through it.
They get through it the way Tonier Cain did as she explains her history. She tells of the story of a therapist, who after her last arrest, sat down on the floor with her as she rocked. Tonier Cain had someone who could walk through the experience with her.
Martin Pistorius writes of the people in his life, especially his father and a caregiver, who went through his life with him. These were people who walked with him listened to him, protected him when necessary, and engaged with him to improve the quality of his life.
For Martin and Tonier, their heroes were a father, a direct support professional, and a therapist. Every person who has written or talked about their experience of getting through their trauma has a hero they point to. It is the hero who gives that first connection, that first hope, and provides the initial empowerment needed to start on the journey of recovery.
Te taha tinana
Physical health Te taha whirua
Spiritual health Te taha whánau
Family health Te taha hinengaro
Psychological health
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Secondary Trauma
Secondary trauma is the cumulative effect of listening to the stories of the people receiving services. It can occur when caregivers are emotionally wounded as they serve people who engage in behavior that looks aggressive and angry, but really comes from a place of woundedness and fear.
Studies have found that the primary predictor of secondary trauma is time spent with traumatized people. The more caregivers interact with people who have been wounded, the
more wounded they may become themselves.
Secondary trauma can also be experienced by individuals receiving services who witness restraint and seclusion happening to others. Pat Risser shares that while lying on the bed restrained, he heard the cries of the person in the next room,
“Oh no! Please let me go. Please don’t do this to me. You’re hurting me, please stop. Please let me out of here!”
Pat said these cries went on through the night.
He lay there in fear from those who could care so little; who could be so emotionally scabbed over and so distant from their humanity that they were not moved by these pleas. He asked himself,
“What cold and callous beasts must these people be? How could anyone care so little?”
The answer to the question Pat Risser posed is not that people don’t care. Most likely, they were so wounded as a result of repeated exposure to trauma that they became calloused
or “hard hearted.” Others may use what is called “dark
humor” to make fun of the pain that is present.
Either response must be seen as a defensive response, used to keep the person safe.
In order for caregivers
“You can only give what you have” as a caregiver.
It is the responsibility of supervisors to give caregivers the support they need to in turn support others. The debriefing skills taught in Chapter Two may be helpful here. If needed, a referral through the employment assistance process may be called for.
Putting it all together
The only reason to use any type of restraint—
manual, mechanical, or chemical—is for the safety of the person and/or others. There is no other reason to use restraint! The Mandt System® does not recognize protection of property, no matter how valuable, as a reason to use restraint. It is much
cheaper to replace things than people!
Restraint can be a safety response when there is an immediate threat to safety.
Restraint is not a teaching tool. There are
situations where people have been restrained as a response to their behavior in order to “teach them a lesson.” As will be presented in Chapter Six, courts have ruled that in the absence of an immediate need for safety, the use of restraint
is punishment.
If an organization were to contract with one of the faculty of The Mandt System, Inc.,
to conduct a behavioral assessment and write a positive behavior interventions and
supports (PBIS) plan, the use of restraint would be an indicator that something in the plan may not have worked. The purpose of a PBIS plan is to not have to use a restraint.
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The Power Of Relationships
In working with older children, adolescents, and adults,
emphasize that their brains can also rewire. It will take longer and there will be a greater need for long-term consistency and predictability in their environments.
David Willis is a neurologist in Portland, Oregon, who followed approximately 1,000 children who were removed from their homes by Child Protective Services. He found that when they were placed in settings that were safer, the majority were put back on track for normal neurodevelopment (Willis, 2007).
This research is supported by years of research in adoption literature.
The brain can and will adapt to environments. Unhealthy
environments, traumatic environments, produce neurological systems that are characterized by words such as
“dysfunctional” and “chaotic.”
When children, especially younger children, are placed in environments that are predictably safe and secure, their brains can “rewire”
because the brain is amazingly adaptable.
This process is called
“plasticity” (Child Welfare Information Gateway, 2015).
People can transcend trauma when they experience physical, psychological, and emotional safety. That is why the Relational Skills Section is so important in
supporting organizations to create healthy relationships that in turn create healthy cultures.
When those cultures are also trauma informed, healing can more easily take place.
Notes:
Mr. Rakestraw
Transcending the trauma is the last step in the model created by Dr. Maria Yellow Horse Brave Heart. To be able to do this, people must first recognize that the trauma occurred and then understand the effects of that trauma, especially at a neurobiological level. They must then
confront the trauma, and that can be, for many people, very difficult.
In order to confront trauma, people must have a connection with someone they trust to keep them safe. That person we have called a hero. It is the hero who gives hope. It is the hero that empowers. The internal factors of resilience are often given to people by a hero.
There is a Native American First Nations story that says inside every child are two wolves, a good wolf and a bad wolf. They are equally matched, equally strong, and they are fighting each other to determine who will be in charge of
the child’s behavior as she or he grows into adulthood. The one that wins is the one who is fed the most.
We feed the wolves through our choices of who our friends are, what we watch on television, read, and see in the movies, and by experience. Most of all, as children the wolves are fed by the grown-ups and how they treat children.
In Chapter One, research from Albert
Bandura and Glenn Latham discussed the concept that interactions between people in our society are generally negative. It is the incivility that is present in many workplaces that ends up feeding the bad wolf. “Affirm your feelings and choose your behaviors” is how caregivers can choose to feed the good wolf and in doing so, become a hero to the children and adults with whom
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Self–Study Questions
These self–study questions are provided to give you an opportunity to gauge your understanding of these chapters. These questions will be used on the final exam.
Circle the letter beside the correct response(s) to the following questions:
1. Trauma Informed Cultures: {Ch 4, Pg 103}
a. Focuses on creating services that are hospitable.
b. Minimizes re-victimization.
c. Incorporates knowledge about the neurobiological impact of trauma.
d. Places people in charge of their own process of recovery by being engaging.
2. Which of the following experiences lead to betrayal trauma, the personal experience of interpersonal violence? (Ch 4, Pg 93)
a. Sandy was sexually abused by a psychologist.
b. Ben saw his cousin get beaten up by neighborhood bullies.
c. Jennifer and her family survived a tornado.
d. Adam often went hungry at home due to severe neglect.
3. Internal factors that support people to recover from trauma are: (Ch 4, Pg 104)
a. Hope.
b. Humility.
c. Empowerment.
d. Loneliness.
e. Connections.
4. Secondary trauma: (Ch 4, Pg 115)
a. Can occur when we listen to the stories of others.
b. Can happen when we are emotionally wounded by the behavior of others.
c. Can be the results of seeing or hearing traumatic events being experienced by others.
d. Is not relevant to discussions about trauma.
5. When people are at their own Baseline Phase:
{Ch 4, Pg 105}
a. It is a good time to prepare a de-escalation preference tool.
b. We should leave people alone when they are at baseline and not bother them.
c. The Baseline Phase is relatively unimportant in The Crisis Cycle.
Complete the following statements using a word from the word bank.
6. Caregivers should support individuals in their recovery effort by providing services that are
and . (Ch 4, Pg 103) 7. Acute Episodic Trauma occurs when a person
experiences a life threatening event over which they have no . (Ch 4, Pg 93)
8. trauma is when caregivers abuse or neglect the people for whom they are responsible. (Ch 4, Pg 93)
9. The use of any restraint or seclusion must
Word Bank
betrayal control
engaging natural
safety hospitable
SSG
Notes:
SSG
