Psychosocial Impact of Trauma: SAMHSA TIP 57

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you. Hi everybody, I'm Dr. Donnelly Snipes and today we're going to be talking about the psychosocial impact of trauma. There's a lot of different impacts of trauma, but we really want to look today at how people experience trauma or people who have experienced trauma, how it impacts their relationships and their worldview and all that kind of stuff. We're going to learn about the effects of trauma on the person and the family, explore how these effects impact mood, behavior and relationships, hence the psycho part of the psychosocial and identify tools to help people navigate life while adjusting to what we're going to call their new reality. What are the traumas you see? And we see a lot of different traumas. We see adverse childhood experiences. We see house fires, we see people who are trying to adjust after a loved one dies. We see domestic violence, child neglect, mothers who have or parents who have miscarriaged or mis. Miscarried. And miscarriage can be really traumatic if it's for AD miscarriages, it tends to be more traumatic for them if their third trimester and actually have to deliver the baby as opposed to earlier on. But it still can be traumatic to people. Forcible felonies obviously. And also I want to consider chronic exposure to people who've experienced any of the above. So counselors, we hear about this stuff on a day to day basis. So we are primed for secondary traumatization. Law enforcement, emergency room docs, emergency medical service personnel, any of those people. And Renee raises a good point that when there's a miscarriage, the children in the family who are already in the family may also experience a trauma from it. So that's a really good point. Remember that what is traumatic to one person may not be traumatic to another. And you can be the same age, you can be the same in a lot of different ways, but it may not be traumatic to somebody else. And what is traumatic to a child may not seem traumatic to adults. And we've talked about this a little bit before because you know, I have teenagers and some of y' all have teenagers. And what is traumatic to a teenager, what seems like the end of the world? We see it and we're like, oh honey, you have no idea. That's nothing compared to. But it's traumatic for that person at that point in time based on their history, which is they have far fewer experiences than we do. They have a far smaller frame of reference than we do. We're conscious of the things that can be traumatic. What's traumatic to a 4 year old may not be traumatic to an 8 year old. I remember one time my son was in the house. He was probably 4, 3, 4. And we were out back washing the car and he was inside. He had just woke up from his nap and he looked out his window and we were out there washing the car and he's like, okay, whatever. Hi mommy. And you know, we waved. And then I was finished washing the car. So I got in the car and I turned it on and I backed it out, started backing it out of the backyard and his eyes got all big and he lost his stuffing because he thought I was leaving him and leaving him alone, which I would never do. And I saw him just like, just hit, start to become hysterical and I'm like, oh my gosh. So obviously I turned off the car and ran inside and tended to my child. But that was traumatic to him because he thought he was going to be alone and that was terrifying. Now, was it a, an enduring trauma? No. But we do need to be cognizant of how things can be interpreted by different people. Trauma, triage, and this isn't 100%, but it does kind of give you an understanding in some circumstances, especially with adults, why some people may perceive something as more stressful or more traumatic than somebody else being the victim or similarity to the victim. Obviously, if you're the victim, then it's going to be more traumatic than if, if you're not or if you're similar to the victim. And I work with law enforcement a lot and when they go, for example, to drownings and there's a toddler who's drowned in a pool, there are officers who respond, who, I mean, it's traumatic, it's awful for them to see, but they're able to compartmentalize it. And it doesn't hit them as hard as officers who have a similarly aged child at home or, you know, a younger child at home. And they can visualize, you know, in their mind. Their mind's like, oh my gosh, this could be your kid. So being the victim or similarity to the victim. And the same thing is true when we look at, if you're working with, with rape victims, if you are working with somebody who is just like you, then it can seem more traumatic because it's not an us them thing. There's that safety, isn't there Proximity to a safe zone. And this is not necessarily just home. If you feel safe at work and something happens right outside your work or at your work, then you may experience more traumatic reactions or more stronger traumatic reaction than something that occurred across the city or in another country. How many stressors you've experienced in the prior six months? When we experience stressors, we need time to regroup and reground. And if somebody is just getting pummeled by stressor after stressor after stressor, they don't have to be big things. You know, little things can add up and they add up exponentially. Prior mental health, trauma or substance abuse issues, those have been correlated with having more difficult time dealing with traumas. Access to social support within four hours. Four hours is our primary window here because after four hours people start compartmentalizing it a little bit. So they found that within four hours getting social support is the best. Within 24 hours is still really good. Once you past that 72 hour window, the person has gotten to some stage of numbness, if you will, or some stage of compartmentalization where it's going to be hard to tap into that a little bit more. So it is really important to talk to people. And if they say no, nobody was there for me, oh my gosh, then it is probably more likely that they're experiencing more difficulty with the trauma because they weren't able to process it. They just, they were sitting there with this thing and they're like, what do I do with this? And I see some comments in here about trauma impacting wives of soldiers when another, another spouse's significant other is wounded or killed in action. Very true. And we see the same thing in law enforcement when one of our teammates is killed. And the families, not just the wives, but the families may be sent reeling with this because they're like, oh my gosh, that could have been us. We do need to be aware of this and how secondary traumatization can occur for those things. And Nicole brings out miscarriages are difficult and major medical incidents can be traumatic. So see, we're coming up with all of these traumas that people experience on a regular basis. And my former boss, for example, has diabetes and he ended up not being able to control it very well. And he had his leg amputated. Amputated. And when I look at him, you know, it was like one day he was doing fine and the next day he's in the hospital getting his leg amputated. And I'm like, oh my gosh. And while I don't have diabetes, My aunt does, and they're having a hard time controlling her diabetes. So that was more poignant for me when that happened to him. So there are a lot of things to think about. So fact checker, how did I get there? Okay. Effects of trauma on the person. Chronic stress or repeated trauma can result in a number of biological reactions, including a persistent fear state, which shapes the perception of the environment, especially if this happens in children, but not always. If you're exposed to chronic stress, think about people who are in domestically violent relationships. It alters your perception of safety, it alters your perception in the environment, and it alters your perception of yourself. Some interventions that we can work with, once the person is in a place where they're safe, obviously if they are in a dangerous place, it's going to be hard to alter their perception because their perception may be spot on. Where they're at is not safe. Once they're in a safe place, then we can help them with positive journaling. And there were several articles that I read that had people engage in journaling 20 to 30 minutes a day, which sounds like a lot. They would write down all the positive things that happened that day. That's all they were supposed to write down. It wasn't one of those journaling, let's write about our whole day just writing about the positive things. And after 30 days of doing that, they found that people had an improved mood and seemed to respond better on measures of resilience, depression, anxiety, all that kind of stuff. And those results seem to stay, you know, continue months after the trial. Now, you know, once you get past six months or so, if they're not continuing to do positive journaling, I don't know how long that would. That that change would stick around. But it is interesting to note one of the caveats with positive journaling is I don't want to minimize people and their negative experiences. I don't want to say, well, just ignore those, you know, those kind of sucked. But let's focus on the positive. There's a time and a place to focus on everything, but encouraging them to set aside 30 minutes a day to get into a positive frame of mind. Mindfulness has also been shown to be helpful to encourage people to become aware of their persistent fear state and how it's affecting their perception of the environment and cognitive behavioral interventions. When people endure chronic stress, it seems like they're always in danger. It seems like everybody's out to get them. It seems like all those catastrophic thoughts and all or nothing thinking can be Very detrimental to the person because then they're walking into a bank, for example, and going, this isn't safe, I could be victimized. Or they're getting on a plane and the first thing they think of is all the things that could go wrong. We want to help them do that. And we'll get to the fact checker in a minute. A single trauma can alter a person's sense of safety and worldview. It doesn't need to be chronic. One single trauma can alter a person's sense of safety. One single trauma to a child who relies on mom and dad for sustenance and everything else can have lasting impacts on their development. We do want to pay attention to that. And the trauma is as defined by the person. Not if I look at it and go, well, that wasn't that big of a deal. You know, if the person goes through it. Remember, people experience trauma differently. If the person goes through it and they're like, you know, it was not that big of a deal, then it's probably not going to have the same impact than if the person went through it and they're like, I don't know what you're thinking, but that was pretty horrible. People with a persistent fear response may lose their ability to differentiate between danger and safety because it always feels dangerous and they may identify a threat in a non threatening situation, hence the hypervigilance. So the fact checker that I use, and I encourage clients to keep this on a notepad or on their phone or whatever, what is the situation that is causing me to feel anxious or angry? What are the facts supporting this feeling? And that is to encourage people to look at, you know, what is the logical information here? Am I confusing high and low probability events? You go into a bank, is there a chance that the bank could get robbed? Yeah. Is that a high or a low probability event? Are you unsafe going into a bank? You know, probably not. 99.99999. However many nines percent of the time, you're probably going to be fine. How does this situation remind me of other times when I've been angry or afraid? Encouraging people to look from a psychodynamic perspective, maybe they were at some other place when it was robbed or whatever and going into this place reminds them of that and it was traumatic or taking the medical procedures, Maybe they went into the hospital for something and it was a very traumatic event. And then they have to go back to the hospital even to visit somebody and they walk in there and they're like, oh, this is not Good. Encouraging them to understand the impact of their past on their present and what is different in this situation. Encouraging them. We'll take the medical example. The person who's there now is visiting someone, you know, they're not injured, so they're fine. As opposed to before, when they had some catastrophic thing happen, or even if they're having surgery again and it was something catastrophic before, reminding themselves that this is not the same situation, not the same doctors, whatever it is, so they can focus on the differences and the hope for a positive outcome. Walking to your car at night is another one of those that, you know, some of us feel really uneasy walking to our car at night, especially if it's not like right outside the door. If you're having to walk through this dark parking lot or a parking structure where you can hear footsteps echo and it's kind of eerie. Okay, you know, what are the. What is in the situation is causing me to feel anxious or angry? It's eerie. Am I confusing high and low probability events? Yeah, I'm probably going to be fine walking to my car. Does this situation remind me of other times when I've been angry or afraid? Now, here's one. How many times have we seen somebody get attacked in a parking lot or walking to their car on a television show? Our brain doesn't differentiate sometimes between real life and television. So if we saw that on television multiple times, it seems like it's a lot more likely to happen. Trauma's impact on the person. And remember, in this presentation, we're really just talking about the psychosocial impacts, not all of the biological, neurological impacts. Emotions. People experience emotional numbing when they go through trauma. Not everybody. Everybody experiences trauma differently. But some people experience emotional numbing and they take all their feelings and I call it Pandora's box, and they stuff that event into this box. They lock it up tight and they put it on a shelf somewhere in the recesses of their mind, or they hope it's on the recesses of their mind. And they are terrified to explore that event because exploring it means having to open Pandora's box. And we know what happens when that happens. Some people experience depression, hopeless, helpless sense of loss. Kind of makes sense when you experience a trauma, generally you feel victimized or a sense of loss in some way. Where you do experience horror, hopelessness and helplessness. One of the criteria for ptsd, anxiety. You may have anxiety that will happen again that you're broken or unlovable now that this has happened. You know, maybe I'm not lovable. After miscarriages, I often hear women say, you know, I had a miscarriage, and that's like, supposed to be the most natural thing for somebody to do. And I've had three of them in a row. I can't seem to carry a baby to terminate. I must be broken in some way. I'm not a good female. Or if they have to have an emergency hysterectomy, a lot of women, that's very traumatic for them to not be able to even have the option to have children anymore. And they feel less feminine, if you will. Aside from the concerns about all the health impacts of having a complete hysterectomy. But there are a lot of things that can happen and it affects the way people feel about themselves. And they may feel like they won't recover from this. You know, I can't go on like this after this experience. I can't see being myself again. And yes, trauma changes people. Everything changes people. It is, how are you going to find your new normal? People can be angry at their higher power for letting it happen to them. They can be angry at their higher power for not protecting them. They can blame other people for what happened to them. It's like, if you would have picked me up from work, then I wouldn't have had to walk to my car in the parking garage and this wouldn't have happened. Or if you would have remembered to check the doors, then the person would have wouldn't have broken in or whatever the case is. And they can be angry at themselves. If I would have been paying more attention, this wouldn't have happened. So anger can go a lot of different places and we need to work through it. Part of the grieving process. Denial, anger, bargaining, depression and acceptance. Anger is right in there when we get angry. What is anger? Anger is the fight part of the fight or flight response. When there's a trauma, you know, that's not good. So it triggers our fight or flight response. So it makes sense that people are angry. We need to help them figure out what they're angry at and who they're angry with and really go through that fact checker again. And maybe they're angry at their spouse for not picking them up after work and they blame their spouse for what happened, for example. Okay, well, then that may be something that they need to work through and deal with in order to prevent that marriage or that from dissolving. Grief. People experience grief. When you experience a trauma, a lot of times it represents a loss of some sort of, what do we do with Losses, we've got to grieve them. Guilt now guilt. I probably should have put up with anger because guilt is anger towards ourselves either for what we did. You know, I'm angry at myself for going on a run at 2 o' clock in the morning with my headphones on or what we didn't do, you know, and you know, I should have been more careful at, you know, and turning the oven off so, you know, so the house didn't catch fire. And some people may feel I should have fought harder. Guilt is another thing I should have. And we hear those guilt when we hear those shoulds, they're natural, people are going to feel them and I remind them that that's that anger at themselves, that's their brain going, how can I prevent this from happening again? What do I need to do differently next time? It's that fight or flight response, but it's kind of turned towards the self going, alright, what do you need to do? And some people feel guilty because they survived. That's really important to recognize. If they were in a car crash and three other people were in the car and got killed, that's traumatic. And they may not feel like they deserve to live. And even if they weren't the one driving, they may feel guilty for surviving. We see survivor guilt in soldiers. We see survivor guilt in a lot of different situations. Ptsd, you know, it's not really an emotion, but it's a traumatic impact on the person. It is important to evaluate people who have experienced a trauma, no matter how big or how small, if they identify it as a trauma, evaluate them for relapse of prior conditions. Maybe, you know, they're experiencing a trauma that they're not identifying as 10. On a 1 to 10 scale, it's a 3 or a 4. It's traumatic but you know, they can, they can still breathe, they don't feel like they got the wind knocked out of them, okay, that's fine. But if that person had a prior history of depression or anxiety or substance abuse or something, or a prior history of other traumas, some of those things can be additive or it could trigger a relapse into a major depressive episode or even something like bipolar or a psychotic episode. If the stress is sufficient to get the neurotransmitters that far out of whack. Trauma's impact on the brain. We're going to talk about it just a wee bit. Neuronal pathways that are developed and strengthened under negative conditions prepare children or people to cope in that negative environment and their Ability to respond to nurturing and kindness may be impaired. Now, it's easier to understand this in children, but let's think about adults who are undergoing or in the middle of a domestically violent relationship. Or soldiers, for example, who are fighting and they're in a situation that is virtually never safe. So they are constantly on high alert. Every time we activate those neural pathways, a negative neural pathway or whatever, memory pathway, think about it as like laying down a layer of concrete as you're paving that pathway, and every time you do it, you're laying down another layer. So those pathways get strengthened a lot. But the good pathways, if you're not triggering those, you're not going down there. You're not laying that concrete. So those pathways become weaker and start to crumble. Kind of like, you know, bad city planning, if you will. It makes it harder for people to respond to nurturing and kindness because they don't have the memories of it anymore. Or those memories are so far gone, the brain is still forming these pathways until about 25 years of age. Soldiers, just as a side note, a lot of people enlist in the military when they're 18, so their prefrontal cortex is still actively developing, and they're undergoing this trauma, which can make it more. Even more impactful in terms of the neurological changes that happen. Children and adolescents who experience neglect often have decreased electrical activity in their brains, decreased brain metabolism, poorer connections between areas of the brain that are key to integrating complex information. So learning is impaired and abnormal patterns of adrenaline activity. We've talked a little bit about hypocortisolism before. When your cortisol levels are low for whatever reason, and a lot of times when you're exposed to extreme stress for a long time, your body goes, this is not something I can win. So I can't stay this hyped up for this long. So I'm going to dial down the sensitivity of my stress monitor, which means I'm going to hold on to those excitatory neurotransmitters until there's a problem. And when there's a problem, I'm not going to let just a little bit out. I'm going to open the floodgates. So people who have hypocortisolism often experience a lot of emotional dysregulation. They go from 0 to 250 in 2.3 seconds flat. If this happens in childhood, you know, if the brain is actually altered in childhood and the person's levels of cortisol are abnormal, then it's going to impact how they react to their peers. It's going to impact how they deal with stress. And being a teenager is hard enough without having problems with hypocortisolism. So you can see how problems could develop. The hippocampus. There's reduced volume in the hippocampus, which is central to learning and memory. Now this. Some of these changes are more common and more pronounced in children and obviously less common and less pronounced in adults over the age of 25 who experience trauma. But they have found that in soldiers doing MRIs, they found that trauma actually does cause changes in the adult brain. So we don't want to say that, you know, once somebody's brain is finished growing, then they're fine. No, it ain't the case. Because of the reduced volume in the hippocampus, people may have reduced ability to bring cortisol levels back to normal after a stressful event has occurred. It's kind of the definition of emotional dysregulation. You go from zero to 250, and then you can't slow down, or it takes two or three times as long to slow down. And that's not the person malingering. It just takes that much longer for their system to spin back down again. The corpus callosum. There's a decreased volume in the corpus callosum, which is responsible in part for arousal, emotion, and higher cognitive abilities. Think about how this impacts people's moods and their relationships. If they have difficulty winding down, if they have difficulty returning to baseline after they get upset, and if they emotionally dysregulate. We know that people who have issues like that are often in environments that are extremely invalidating. People are telling them, you just need to get over it, or, why are you making such a big deal out of this? Or whatever they're hearing, they're not getting the tools they need to figure out how to tolerate the distress. They're just being told that they're overreacting for some reason. This causes a lot of people to push others away. It's like, okay, you don't understand. And if you don't understand, I don't know how to explain it to you. So I'm just gonna, you know, withdraw a little bit. It also can cause aggression because people get so frustrated. Like, you're not listening to me. I can't. If I could, I would. So they may get even more upset. I'm not saying they're going to act out and be physically aggressive, but it can cause aggressive verbal behavior. Depending on the person, the prefrontal cortex My favorite part of the brain. It's critical to behavior, cognition, emotion regulation, and impulse control. When the prefrontal cortex is reduced in size, then we have difficulty with these, which impacts learning. Okay, so think about children who have problems in their primary attachment relationship. They have early childhood trauma, adverse childhood experiences, whatever you want to call it. They're entering school and they already have brain changes that are making it hard to regulate their emotions, to learn, and to restrict or moderate their impulsive behavior. It makes sense from a neurological perspective. And yes, in some cases, prior trauma can be a precipitating factor for intermittent explosive disorder. Now, there's not a one to one correlation, but yeah, we certainly want to look for that. One of the things that and her name escapes me right now, Sandra L. Bloom talks about in her book on restoring Sanctuary, is changing the verbiage from why are you doing that? To oh my gosh, what happened to you? That would precipitate this reaction, because everything we do has a reason and generally it's survival. So what happened to you and that made you feel like you had to react in that way helps us understand trauma a little bit better and helps us understand some of these behaviors so we can better redirect them. If we understand what happened to them, then we can help them figure out how to make themselves feel safe so they don't have the need to enact that behavior anymore. And cortisol levels are often lower than normal in the morning, coupled with flatter release levels throughout the day. Cortisol for most people, spikes in the morning. And that's when your body says, wake up, it's time for another day, or wake up, we need a whole pot of coffee, whatever your brain says. But then throughout the day, it gradually goes down. About four or five o' clock, it's starting to get low, which is when we start getting sleepy, and a few hours later we're going to bed. That's what it's supposed to do in people who've experienced trauma. A lot of times their cortisol levels will not spike that way in the morning. And then it will kind of remain flat throughout the day, not declining. So instead of not going up much, but then declining, it won't go up much, but then it may stay flat, which sometimes we call hyper vigilance. But lower cortisol levels can lead to decreased energy, which can affect learning and socialization. Think about it. When your cortisol levels are low, you're tired, you're fatigued, you may have difficulty concentrating. Do these sound like Symptoms of depression to you? Hmm. So again, we want to look at what are some of the reasons, what are the precipitating factors for the depressive symptoms that this patient is presenting with? If they're presenting with those, it may increase externalizing disorders, your intermittent explosive disorder and your oppositional defiant disorder, and it may increase vulnerability to autoimmune disorders. Cortisol helps us respond to stress. I mean, it's our main stress response neurochemical. And if those levels are wonky, then for lack of a better term, it can contribute to increased inflammation and other autoimmune conditions. When people have autoimmune conditions, most of them, some of them are not painful, but they could be, you know, problematic in other ways. But a lot of autoimmune disorders have pain associated and severe fatigue associated. So again, let's think about how does that affect a person's relationships, their ability to get social support, their mood, and their sense of hope and empowerment? It can really have some pretty significant negative effects. And I agree with Renee and Nicole both talking about how ADHD can often get misdiagnosed because somebody has trauma and they're reacting, they have difficulty sitting seated. How many clients have you worked with that had a trauma and they have such. They have difficulty sitting still because they can't be quiet with their thoughts. If they're quiet with their thoughts, it starts to get ugly. So they need to move and they need to stay in order to stay safe in their own head. They need to keep themselves distracted. That makes sense. So again, look at all the all symptoms, whether it's ADHD or depression or anxiety or intermittent explosive disorder or borderline personality disorder, and ask yourself, in what way is this behavior protective and functional? Or has this behavior at some point in the person's life been protective or functional for this person? That'll give you a clue to trying to understand what interventions might be helpful. All of these brain changes can lead to difficulties with concentrating and thinking clearly. Some things that can help, it's not going to resolve the problem, but intermediate interventions encourage people to eliminate extra noise or distractions. So if they're having trouble concentrating or thinking clearly, especially after a trauma. I worked after Hurricane Katrina in the shelters with people, and, you know, there's a lot of noise and chaos and, you know, it just happens when you get that many people on cots and people were having difficulty thinking clearly and getting frustrated and all that kind of stuff. Encourage people to try to eliminate extra noise and distractions if they can. So if they can, go to A corner of the room. Or if they can walk outside and sit at a picnic bench, put on headphones and listen to whatever music they want to. Instrumental is really good because it lets the brain relax a little bit more. If it's not having to pay attention to words, what can they do in their environment to eliminate extra noise and distractions? Encourage people to stay hydrated. 1% dehydration actually leads to difficulties with concentration and higher order reasoning. Who knew? And you don't really even feel thirsty when you're 1% dehydrated. So encourage people to stay hydrated and write it down. If people are having difficulty concentrating, whether it's an acute trauma or it's been chronic trauma or whatever, have them write it down. Instead of saying, I should be able to remember this. No, just write it down. You know, for me, I know I have to write things down. My daughter wanted me to do something today and I, you know, I haven't. Well, I guess I did a few weeks ago, experienced a trauma, but I told her, I'm like, I am not going to remember that between now and when I get to the office. So can you send me a text? Simple as that. Encourage people to just be assertive and be aware of what their limits are at this particular point in time. Short term memory problems here, write it down again and use a calendar with reminders, Outlook, Gmail, whatever calendar you have. If you have something that sends you reminders to do things, and it can be things like take your medicine, they actually have apps. If the only thing you need to do is remember to take your medicine or something, they have apps that will remind you. You can schedule it in and they bug you. I'm bad about remembering to take antibiotics three times a day. I'm like, who remembers that Middle dose. But so I installed one of those apps and it bugged the heck out of me until I would silence it and take the lunchtime dose. But you can use it for different things. Difficulty planning or making decisions. Delay making any major decisions after a trauma. You know, no matter how big or how small. If you feel like it was a trauma or if the client feels like it was a trauma, encourage them not to make any major decisions. Maybe there was some sort of aggressive incident at work and the person's like, I can't take it, I'm quitting. See if you can delay making any major decisions. Or somebody's house got broken into three doors down. Well, that's it, we're moving. Take a breath. Take a breath. And delay making Any major decisions as long as safety isn't compromised, delegate. Sometimes there's just, there's too much to do and you know, the trauma's there. You're still trying to get your, what I call your land legs again and you can't think clearly. To plan stuff, even to plan. Plan out the meals for the week. Delegate, you know, ask somebody in your household. Make a list of what you want to have for dinner each night this week. And I'll go to the grocery store and get the stuff. I've done that before. And try not to overthink. Sometimes you start trying to make decisions and plan and it just, it seems like you can't get all the information. Encourage people to just not overthink things right now. Think about staying in the moment, be mindful. What is it you need to do right now in order to keep moving towards your goals and put one foot in front of the other. And yes, Rene raises a good point that a lot of times after a trauma, people will bring meals to the person who was traumatized. People were bringing casseroles and meals and stuff like crazy to my stepfather last month after my mother passed away, and he was like, I don't know what I'm going to do with all this food. But they were trying to be helpful so he didn't have to think because certainly he was not remembering to eat. But those are things that we need to remind people to do. Thinking about this, if you have short term memory problems, you know, if maybe people don't realize you went through a trauma, something happened at home, or you had a miscarriage, and you don't want to go tell everybody at work because it's none of their business. Okay, that's fine. How is that going to impact? Not saying that you should necessarily tell them, but recognizing. If Sally goes to work and she had this trauma over the weekend and she's not going to tell anybody at work, how does that impact her interactions throughout the day? If Sally was carjacked over the weekend and, you know, goes to work, how does that impact her relationships with other people? What kind of transference reactions might she have with similar people? So there are a lot of things that you need to pay attention to. People who've experienced trauma may have difficulty learning new information. The brain is trying to survive right now. This is not the time to try to figure out EMC2. This is the time to figure out how you're not going to get in a dangerous situation again. Cognition, conceptualization, and Caring are the three Cs of adult learning. People take in information differently. And, you know, some people take it in visually, some people take it in by listening, and some people just have to work with it. And I ask people to figure out their learning style. If you get a new piece of equipment, a new vcr, DVD player, whatever it's called now, that's how old I am. How do you figure out how to work it? Do you read the manual? Do you have somebody tell you how to do it? Or do you just start pushing buttons until you figure out what works? I'm the button pusher, so that's cognition. You got to get the information into your short term memory. Conceptualization is what you relate it to in order to figure out where are you going to file this if it's going to get filed. Which brings us to caring. If people don't care about something, they're probably not going to file it anywhere because they don't want to clutter up the file cabinet. When you're trying to get people to learn something, encourage them to relate it back to themselves. So how does this relate? Which is why I'm regularly asking you, have you had a client who's experienced this? Or you know, have you had similar experiences so you can theoretically care and understand. Okay, you know, now I see how this point she's talking about actually relates to something that might be useful to me in the future when we're overwhelmed. Sitting and listening to an hour lecture is just too much, or doing anything for an hour, maybe too much. So chunk it, do 10 minutes and then give yourself a break and then do 10 more minutes or whatever the case may be. If you're reading a book or studying for something, maybe set that you're going to read two sections or maybe a whole chapter if you're feeling really good. But keep it to small manageable pieces so you get something out of it and then you can come back later. Use all the senses. If you're reading something, try to highlight. If you're allowed to highlight in whatever it is, obviously you're probably not going to smell it, but talk it out, tell somebody about it, that if you paraphrase it, you're using kinesthetic learning in a way because you're manipulating the information to paraphrase it and then you're also hearing yourself say it, record it on a device and listen to your notes. There are a lot of different ways. Draw a pie chart, tons of different ways to take in the information and just apply it, apply it, apply it. How does this relate to me? How can I see where this would be meaningful? And if it's not, if you're in History of the World, Part 101, you know, apply it to something else that you know. So. So you have some memory pathway that's already a little bit laid that you're going to relate it to, so it's easier to access it later. After these brain changes, people can have recurring thoughts of the traumatic event or other traumas. So teach them grounding techniques whenever they start having that thought, whether, you know, happens a lot when people are watching TV and criminal minds come, advertisement comes on or CSI or one of those others, and people are triggered and have a reminder of what they went through or the news, even encouraging them to learn grounding techniques. My favorite is the five. Four, three, two, one. Identify five things that you see, four things that you hear, three things that you smell, two things that you can touch, and one thing that you taste or however you want to do it. But using all five senses, identifying 5, 4, 3, 2, 1 helps people get grounded in the moment. Pessimistic thoughts, you know, it comes with the territory. If those pathways have been strengthened, your brain goes, well, it seems like more. More often than not, this is the. The bad part of the neighborhood that we're living in. So those streets are the strongest. Encourage them to learn. Oh, sorry. I did skip over emergency plans. If they're having recurrent thoughts of the trauma or traumas or if they are afraid they're going to be triggered, have them have an emergency plan. I worked with one law enforcement officer who experienced a really bad trauma with a car wreck and semi ended up bursting into flames. So the smell of exhaust fumes was very triggering for his traumatic memories. Well, that's a problem when you're a patrol officer, because you're gonna smell exhaust fumes. So when he felt like he was gonna be in a situation that he would smell exhaust fumes, he was stuck on the interstate or something. He had a plan for what he would do. People need to have a plan for what they're gonna do when they are in a situation where they might be triggered, because this gives them a sense of empowerment. It's like, okay, you know, if I start feeling this way, I got a plan. We're good with pessimistic thoughts. Learned optimism is super helpful, and you can Google it. Martin Seligman's work is all over the place, encouraging people to practice learned optimism. And they can learn it. They can strengthen those pathways like I talked about with the positivity. Journaling but it takes time. What happened in over the past 20, 30 years isn't going to be undone in 20 or 30 days. And encouraging them to embrace the dialectics. And there's a lot written out there by, especially by Linehan on helping people embrace the dialectics, the fact that good and bad can simultaneously occur. Trauma can impact behaviors. People may have a drop in work or school performance. So we want to know why instead of going, you're not pulling your weight. What's prompting this behavior? What happened to you? What's going on? They may be exhausted after a trauma. Sometimes people have night terrors. Sometimes they're not sleeping as well. Even if they're not waking up because they're hypervigilant, they may be experiencing depression, anxiety, ptsd, or their motivation may just not be there. Some things just don't seem all that gosh darn important after you've experienced a trauma. Before the trauma, it may have been a big deal. Now it's just like in retrospect or in perspective, it just doesn't seem that important to me right now. I'm barely getting along. Encouraging people to pay attention. And Renee points out a good thing when children have a drop in school performance or they become oppositional at school. We want to look and say, what's going on here? What is causing what? What is happening to you? What is causing this to happen? Not why are you doing this, but what is causing it? What's prompting it? And it may be they're just, they're not motivated to do their times tables right now because their dog died this weekend and they're not focused. Change eating patterns again, look at the cause. Sometimes when you're, when you're not sleeping and getting good quality sleep, your circadian rhythms get out of whack. Your ghrelin and leptin hormones, your hunger and satiation hormones get out of whack. So you're not eating. Or sometimes people eat to self soothe. They could be eating differently because of their mood. You know, they're depressed so they're, you know, binging on Ben and Jerry's. Or they may just not have the motivation to eat. They're like, yeah, there's food in the fridge, but that would require getting up and walking across the room and nah, let's take a look at that lack of quality sleep. Well, again, what's causing it could be the trauma itself. It could be substances people are using to self medicate the trauma. It could be mood issues if they've got depression. We know that people with Major depressive disorder often have difficulty sleeping. And people who have anxiety disorders often have difficulty sleeping. And they may just not be motivated to sleep. You know, it's whatever. Most of us, when we go to sleep, we're going to get a good night's sleep so we can get up and face the next day. And if people are reeling from a trauma, they may not be that eager to get up and face the next day. We want to understand what's prompting this. Using drugs or alcohol. Now this one. Generally, people use drugs and alcohol to help numb or deal with overwhelming distress. So we want to look at what are the benefits and drawbacks of using right now. This is a coping skill you're using. However, it may not be the most effective. So what are the benefits and the drawbacks? And what are the benefits and the drawbacks to the alternative? Some people just can't even imagine not drinking, not having their wine or whatever. Okay, I'm not telling you you got to quit. We're just making a benefits and drawbacks list. And help the person evaluate what's going on. And encourage people who have used drugs and alcohol in the past or currently are to return to meetings or counseling or whatever. That way they can get some additional support. We talked earlier about being unable to rest or keep still. Look at the function of the agitation. Are there mood symptoms? So if the person is anxious, they may be revved up. If they're hypervigilant, they may have difficulty keeping still. Are they having difficulty being still because they don't want to be alone with their thoughts? Or if they're not still, they're going to fall asleep. And they're terrified of falling asleep because when they do, they have night terrors. Let's take a look at the function. If they have a lack of motivation when we're exhausted, when we're not getting good quality sleep, our motivation typically goes down. Go figure. The brain says, okay, we only have half a gallon of energy today instead of a full gallon, so we're just going to conserve that energy. For the basics. You're not motivated to do much. And there may be increased aggressiveness or engaging in self destructive or self harming activities. If people are angry because of the trauma, they may be outwardly aggressive. Well, why? If they were traumatized, then they may feel unsafe. And what does anger do? Anger tries to get. It's a power move. It's trying to get power back in some way. So there may be some increased aggressiveness. If they blame their parents or their spouse or somebody for not doing something that led to them being traumatized, then they may be angry and aggressive because they don't know they're trying to deal with that, that sense of frustration. And people may become increasingly aggressive or engage in self destructive or self harming activities in order to get flashbacks to stop. If flashbacks start, sometimes they feel like they're back in the moment. And self harming activities can actually help people dissociate or get regrounded because it's like, okay, I can feel this in the moment, this is what I'm focusing on. And the flashback dissipates something to some extent. Family members may become short tempered or irritable. And children or teens may become clingy, demanding, argumentative or naughty or rebellious. It happens. We see this when there's stress in the family. People tend to become more agitated in one way, shape or form. Clingy. I want my parent close to me because that makes me feel safe. Demanding or argumentative, they're trying to get their control back. Naughty or rebellious, they're trying again to get their control back or to get somebody to pay attention to how much they're struggling. Encourage family mindfulness practice. Have the family sit down at breakfast and at dinner and go around and everybody talks, states how they're feeling, what they're needing, how they slept, whatever. Family gratitude practice. Same thing. You can go around the dinner table or the breakfast table and everybody says something that they're grateful for, either that happened that day or just in general to strengthen those gratitude pathways. Encourage assertive communication. Have people say, I am feeling, you know, overwhelmed because of this. Or if we see this a lot in families where parents start to get really irritable and just like really Junior, I can't do one more thing. I'm glad that you're involved in so many extracurricular activities, but I just can't take you tonight because I'm exhausted, I haven't slept well in four days. Or whatever the case may be. Helping Junior understand. I'm not mad at you. I'm not punishing you. I, I just don't have it in me right now. Can help a lot and then you can start problem solving for okay, now, who's going to be taking Junior from now on? So parent can have a break. Plan for requests ahead of time, have calendars out so you know when you've got to take somebody to softball or soccer or gymnastics or even go grocery shopping. That way you can delegate as much as possible. Encourage people to make shopping lists. We have one of the dry erase boards on our refrigerator I take a picture of before I go to the grocery store. That way I know what everybody needs and I don't have somebody telling me as soon as I can come home, oh, we needed butter too. I've got to go back to the store. That may be too much so keeping shopping lists can also help encourage adults in the family to remember to examine the function of everyone's behavior instead of again thinking it's to be oppositional or obnoxious. What is this person needing that they're trying to get met? With this behavior, people may lose interest in activities or perform less well at work or school. Try 15 is another example of chunking. Whatever it is, start doing it. Do it for 15 minutes. If you're still hating it, do something else. Most of the time, it's getting started that's the hardest part. Set morning goals before you go to work. You get up, you're sitting there eating your breakfast in the morning, okay, these are the seven things I've got to get done today. Add rewards for school or work and even for adults, we can add rewards if we're having a hard time getting motivated to go to work. We can give ourself a reward at the end of the day where we can leave the dishes in the sink overnight or go to a movie or whatever it is. Individuals may feel neglected and misunderstood, so encourage mindfulness and assertiveness. If they are feeling anxious about something, remind people about the five love languages, touch gifts, quality time, affirmation, and acts of service. When in a trauma or after a trauma, sometimes the family becomes so chaotic, people may not feel like they're being paid attention to. Remembering each person's primary love language and trying to communicate with them in that way once a day can be helpful to encourage communication and a sense of understoodness. Some family members may work so hard to help loved ones that they neglect to look after themselves. Parents give so much trying to help the children get settled again that they forget to take care of themselves. Self care is so important because you're no good to anybody if you're completely worn down. Individual family members may feel less attached or involved with one another, so encourage family activities as appropriate. Maybe going out on Saturday, if that's possible. Parents may experience emotional or sexual problems in their relationship, so educate about how the stress of the trauma may be magnifying issues in their relationship and reducing stress. Sex Drive when we are hypervigilant after a trauma, our body is not concerned with reproduction, so our libido actually kind of Gets turned down when our HPA axis is turned up. Everyone feels exhausted and wants support but can't give much in return. Encourage people, families to ask for help from family, from friends, from clergy, from counselors. What do you need? Because generally people are wanting to help, they just don't know what to do. Parents may feel unsure about how to help their children after the crisis, so educate them about common childhood reactions to trauma. Provide resources to find tools as problems arise. We can't guess what problem will arise in any particular family, so encourage parents and provide them resources like United Way information referral and particular books and websites that you think are particularly helpful after a trauma so parents can go there if they need to. Encourage support groups for parents for children, people who've been in that situation. Encourage them to get support from others so they can hear how others are getting through. Parents may feel guilty or helpless if a child is traumatized, so again, encourage support groups. It happens. You can't always protect your children. You want to, but you can't. Encouraging them to get out and use cognitive processing therapy. Household schedules are often disrupted and recreation is often neglected because people are exhausted and they're just barely getting by. So encourage them to get help when possible. If they can get somebody to come in and clean, great. If they can get somebody to bring them groceries, you know, have groceries delivered instead of having to go to the grocery store, great. Bring in dinner. You know, pizza won't kill people even if they have it two or three times in a week. I'm proof. I think I lived on it my first year in college. Simplify. You don't have to make a six course meal. You know, you can order in pizza schedule. In recreation, it's not optional. You need to have some fun and try to create a new, albeit temporary, normal. People who are in shelters, this is not their permanent normal, but they may be stuck there for four, five, six weeks. So what is this new normal going to look like? The usual. Responsibilities and boundaries change. Children may cook meals and tend to siblings if parents feel unable to do the tasks or they have to be gone. For example, at the hospital when my son was born, he was a micro preemie and either myself or his father was there with him pretty much 24 hours a day. We didn't have any other children, but if we did, you know, obviously there would be issues to contend with. Enlist help when possible so children don't feel overburdened. If mom and dad are both at the hospital with Big Brother, you don't want to have middle child feeling like they've got to do everything and help parents be emotionally available to children. Sometimes parents get so caught up in trying to fix things and make them right that they have difficulty just sitting that down and being emotionally available. Changes to family life that occurred in the days, weeks or months after the event may become permanent habits. Encourage narrative therapy. Encourage them to write their story. Write what happened, okay, that's the closing of a chapter or the ending of a season. Now what is the next chapter or next season going to look like so they can see how they want this to settle out. Encourage family members to identify what their roles were pre trauma and describe what they want to go back to. The experience may be relived when faced with a new crisis. So make sure to educate the family ahead of time about the possibility. After Hurricane Katrina, this was so true. Every time there was a forecasted hurricane, people got exceptionally, you know, devastated. And I'm sure it was the same after Harvey and all the other big ones. I just happened to be in Katrina. When families face a crisis, inquire about previous traumas to better understand their reactions. Problems may seem worse than they are and be more difficult to handle in the midst of a trauma. So you're driving down the car and the transmission goes out. Well, normally that's a big deal, but after a trauma when you're already drained, that may just, you know, be the straw that broke the camel's back. So encourage proper self care, teach distress tolerance and problem solving skills, and make sure people have a support system or a third party they can get help from or bounce ideas off of. Family members may cope differently with reminders of the event. And this is really important. Some may want to commemorate the anniversary or revisit the scene of the event, while others may want to forget about it. This is true after a death too. Some people really want to go to the funeral and the wake and all that stuff. And other people, they can't deal with it. It's just, you know, it's over, they don't want to think about it. And the people who are at the funeral can sometimes feel abandoned if somebody doesn't come. But we need to respect people have different ways of coping. Conflict and coping styles can lead to arguments and misunderstandings if the family members aren't sensitive to each other's needs. So trauma can happen to individuals, families or communities and can have a lasting effect on people, including actual changes to the structure of the brain. Even in adults, these changes, coupled with the disruption of the person's life can contribute to a host of issues, including anxiety, anger, depression, guilt, grief, difficulty with memory and decision making, loss of motivation, sleeping and eating changes, withdrawal from or enmeshment in relationships, all of which can compound each other. After a trauma, people need time to regroup and find their new normal. So to assist survivors, educate them about the impact of trauma and traumatic reactions so they're not surprised, provide hope that what they're feeling is a normal reaction to abnormal events, provide resources and tools to help them navigate life until they start feeling more grounded, help them figure out how to mitigate the negative effects of trauma and encourage them to think about how they want the next chapter of their life to play out. 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