Trauma Informed Care Trauma Awareness: SAMHSA TIP

Welcome everybody to today's presentation on trauma informed care, trauma awareness. So we talked yesterday about kind of what is trauma, and we're going to talk a little bit more today about the different types of trauma. So we're going to define and differentiate between the different types of trauma, individual, group, mass, natural or human caused. Explore how trauma impacts communities and cultures, not just the individual. Identify staff and agency issues that could cause retraumatization and ways to maybe prevent them. Explore objective and subjective characteristics of trauma and their biopsychosocial impact and identify characteristics that nurture resilience among individuals from diverse groups. Attention therapists all. CEUS is grateful to our new sponsor, the Diversion Center. They offer workbooks that are 100% editable and delivered to you in a word document on topics including anger management, substance use disorders, domestic violence, parenting and shoplifting addiction. Each workbook can be used for individual or group sessions and is over 120 pages. You have the option to add or remove content, insert your name as the author and reprint and resell the workbooks to your clients. Go to privatelabelworkbooks.com and take advantage of their buy one, get one free bundle offers. Remember, that's privatelabelworkbooks. Com. So individual trauma, we're going to start there. An individual trauma occurs to one person. So it can be an assault, it can be a rape, it can be a purse snatching, a death, you know, just. But one person is involved. It can be a single event or multiple prolonged events such as a life threatening illness, multiple sexual assaults, continued child abuse, domestic violence, first responders, or people who are in a war zone or are in war. And so what's happening to the individual is what we're looking at, not what's happening to the group. Although the trauma directly affects just one individual, others who know the person and are aware of the trauma will likely experience emotional repercussions. So think about it. I mean, if your child is is assaulted, that's going to have an impact on you. If your spouse suffers a trauma of some sort, you know, maybe a bad car accident, that's going to impact them, but it's also going to impact you. Not just because, you know, you're afraid that that person could have passed away or been severely hurt. But it will also kind of shake up your sense as a supporter, as a care person. It'll shake up your sense of how safe is the world. Exactly. So a lot of things that a person who directly experiences trauma are very similar for those who love and support that person, not exactly the same, don't get me wrong. But they are similar. So we want to look at that and we want to look at talking with support people, the people that care about the person who experience the trauma and help them deal with their own issues, as well as help them prevent any further issues that may come out of it. So if they start, if it triggers a past trauma of theirs, we need to deal with that. If it makes them feel unsafe, we need to help them deal with that. And we also want to help them recognize that the person who's been traumatized is going to possibly react differently for a while. They're going to be working through their trauma stuff and how can they be supportive and how can they take care of themselves so they don't get burned out? So those are all the things we need to consider when we're talking about caregivers. The survivor of an individual trauma may not receive the environmental support and concern that members of collectively traumatized groups and communities receive. If one person is raped or if there is a home invasion, robbery or something that affects that one person, you're not going to have FEMA mobilized for that. So the types of support services and the rally cry, I mean, if one person is traumatized, unless the media gets a hold of it or they make it known, nobody else is going to know about it. If you're in a bank robbery or in a 15 car pileup or something that's going to get on the news and other people will know. So the community may be more mobilized, the church pastors and things. Instead of you having to go to them and say, you know, my loved one who is a member of your church experienced this trauma, they're probably going to know about it and they're going to be reaching out to you, going, hey, I heard about this, can I help? Sometimes that's helpful. Sometimes it can be overwhelming. But we do need to be aware that survivors of individual trauma often don't have people reaching in. So they have to reach out. They're less likely to reveal their traumas or receive validation of their experiences. How many rapes go unreported? How much domestic violence goes unreported? You know, think about some of these individual traumas. Think about some of the things that we talked about yesterday that, you know, you might look at it like a car accident and somebody may see, yeah, that was a really bad car accident. But they don't think about it as a trauma. Because in general, the community thinks about a trauma as being a crime victim or being a Victim in some way. So we need to expand people's conceptualization of what trauma, what is traumatic? What does trauma look like? So if you go through an experience and it kind of shakes the way you see the world or, you know, makes you feel unsafe, takes away your power, it potentially could be traumatic to you. And these are some of the symptoms that could happen. Instead of getting stuck in trying to define, well, this is a trauma or this isn't like we talked about yesterday, what may be a trauma for one person may not be for another. So we just. We need to be a little bit fluid with it, but we need to encourage other people, the community, to be more fluid with it. So people who are traumatized are able to get help. And somebody says, you know what? That sounds like you're dealing with a traumatic reaction there. And the person might say, oh, you know, you're right. I didn't really think of it as a trauma. So we want to encourage people to identify things that are traumatic as traumatic. We want to encourage them to be able to reach out. And as an organization, you know, I want you to think about things your organization can do to reach out and let trauma survivors and let people who haven't experienced a trauma yet know what trauma is, know what trauma reactions are, and know where they can find resources. You know, not everybody needs to go to therapy. You know, some people just need a little bit of, you know, a victim advocate can help them navigate the process, or a case manager of some sort. And, you know, if you're dealing with your fire, your fire, your house burning down in a fire, you know, you may have somebody at the Red Cross who works with you sort of as a case manager to make sure you get what you need. You know, I would encourage you to work with local churches, since, again, it just really bothers me, but there's nothing I can do about it that we can't bill as clinicians. Most of the time, even LCSWs cannot bill for a lot of case management services that we do, and insurance won't cover it. So trying to find an organization that provides those services that unless somebody has a severe and persistent mental illness, we can't get reimbursed is challenging. So I encourage you, work with your community, work with local church groups, work with local community organizations that are willing to form a group of people who are educated about resources, provide them a little training on what case management is to help people. So if you have someone who's undergone some sort of a trauma, and, you know, they may need three or four different community resources or whatever, there's somebody that can help them navigate the process. Because after a trauma, people are not concentrating as well as usual. People are not thinking as clearly as they might. They're not problem solving quite as well. That HPA axis is on high alert. Fight or flee, protect yourself. It's not on, you know, case management stuff, you know, it's worried about survival. So it's important that we have people in the community to help fill that gap. And for pastors, that's another thing. Involve pastors in this. If you're involving church groups, you know, synagogues, churches, whatever, get the members involved. But also a lot of pastors feel very ill equipped to handle a lot of the issues that we deal with on a day to day basis. And I'm not saying that they should provide counseling, you know, or provide social work services. They have their own pastoral counseling that they do and they know when they need to refer. But sometimes they're not even, they don't feel like they're even equipped to handle the stuff that just lands smack in front of them. So providing occasional trainings for pastors on or inviting them to your CEU lunch and learns and stuff so they can learn a little bit about what does trauma look like, what do these trauma reactions look like? So when they're talking to a parishioner, they might be able to identify that, oh, you know what, you know, I hear that this is affecting you spiritually and totally. I'm there for you to help you work through that. But have you considered that this might be, you might be having a traumatic reaction and educating the person so the pastor can educate the person about traumatic reactions and resources that are available in addition to his or her services. So, you know, look broadly, be creative. And we're going to talk later about trauma informed peer support because a lot of people, especially people that go through individual traumas, may feel broken, they may feel isolated, they may feel like nobody can understand or what I have to say is too powerful for anybody to be able to handle. So trauma informed peer support basically links people up with others who've gone through similar things. They've survived a suicide, they've survived a rape or a bank robbery or whatever. And it helps them start opening up and realizing that there are other people and they're not broken. And this is not. Their reaction, is not pathological. It's actually quite an adaptive survival mechanism. And yes, when you're. Somebody pointed out, if you're involving churches, not all, not all referrals are Going to be appropriate. And it's important to look at, again, what caused the trauma. So if the church caused the trauma, then referring somebody to the church might not be the best place to go. If the trauma was caused by. I have a friend who was molested by his pediatrician. So going to the doctor every time he goes is still somewhat of a traumatic experience. So we do want to pay attention to where. Where was the trauma initiated? But I encourage you, you know, if you involve churches, for example, because they generally have a lot of people who are willing to volunteer, you may not have it at the church or, and. Or you may want. You want to have it in a neutral location and make sure it's separate. The services you're providing are separate from the church. It's not pastoral counseling. It's not just church case management. It is case management. Individuals who are traumatized may feel shame, which distorts their perception of responsibility and trauma. Sometimes they'll look at whatever happened and blame themselves. If I wouldn't have. Or if I would have, only if I would have checked the burner one more time. My stepfather's family lost their lives on Christmas Eve because of a fire in the Christmas lights. And he and his wife were. Yeah, he and his wife were at a party three doors down, and the children were asleep when they noticed the house was on fire. She ran in to try to get the baby out of the crib, never made it out, and his whole family perished at that point. So, yeah, he has a lot of what ifs. You know, am I to blame because I went to the party? Am I to blame because this happened? And, you know, if he would have been home asleep, it may not have turned out any differently. But he has to work through that in order to figure out where his responsibility lies and how to deal with that. They struggle with the issues of causation. You know, what caused this to happen? What, why, especially. And this is where the spirituality comes in. If they believe in a power greater than themselves, why did my higher power let this happen? Why is this happening to me right now? Why am I having to go through this where, you know, Jim Bob down the street is a mean old son of a gun, and he just won the lottery. I don't understand. And they may feel isolated by the trauma, like we've talked about. So individuals are unique, so we want to be able to reach out. If there's a group trauma, then there's at least more likely that somebody's going to go, this was traumatic. You know, we may need to seek help or people may come in and provide help. If it's an individual trauma, it may not ever get mentioned again. So we want to make sure that we are educating every single person about what trauma looks like, and we want to make sure that we're educating parents about what children's trauma reactions look like. If they start suddenly wetting the bed or having a lot more somatic complaints or acting out, does it mean they've been traumatized? Not necessarily. Well, wetting the bed probably does, but we want to look at what changed in the environment and what's going on. So, you know, we want to make sure that parents are aware that, you know, it may not be junior acting out or being oppositional. What's motivating this behavior? In working with clients who have histories of individual trauma, we as counselors should consider that empathy or putting oneself in the shoes of another is more potent than sympathy. And I've shared this analogy with you before. It was one that one of my mentors shared with me. Sympathy is having somebody stuck in a well and looking down from the top of the well into that dark, damp, cold well where that person is stuck and in pain and scared to death and going, wow, it sucks to be you. You know, it must be really cold and dark down there. I, I feel bad for you. Well, you know, that's providing a little bit of connection. But if you strap on the rappelling gear and you go down into that well with them, so you're experiencing the cold darkness, you're not in the kind of pain they are, and you, you can get back out. That's the thing with the rappelling gear. You don't just do a header into the well and go, hey, let me join you. As clinicians, we need to be able to get ourselves out, but we want to be able to get into the well with that person and empathize with what's going on. So we need to be able to be emotionally available. Some clients need to briefly describe traumas they've experienced, particularly in the early stages of recovery. But remember, intensive exploration needs to wait until the client is more prepared. So if they want to tell you briefly about the experience that they had when they were a child, or last week for that matter, that's okay, you know, that's cool. Try to have them keep it to high level stuff. We don't want to get into a cognitive interview of, you know, what were you smelling? What were you seeing? Do you remember the taste in your mouth? What did you feel that's way too much, not now, but they may want to give you an overview and that's kind of important. I mean, if they were carjacked when they were driving home from work, you know, last Tuesday by, you know, a person that, with a certain description or something, that's a high level overview. So you get a sort of an idea, you know, driving at night and maybe seeing a pedestrian that is of similar characteristics to the person that carjacked. You could, could all be triggers for traumatic reactions. I get that you don't want to start asking and you want to keep them from getting into too much detail about what exactly they were thinking, what exactly they were feeling. Don't want them to go back there until they have the tools to be able to manage those really powerful emotions. Understanding the trauma should begin with educating the client about and normalizing trauma related symptoms. We start talking about those symptoms we talked about yesterday and say, you know what? Hyper vigilance perfectly makes perfect sense, you know, and I usually, instead of telling them why it makes perfect sense, I say hyper vigilance is when you're constantly scanning the environment and it's hard to relax because you're waiting, you know, you don't feel safe. How is that a perfectly normal reaction to what you had had happened to you and how does that protect you and help you survive right now? And you know, we talk through it and then I say, okay, you know, what are some ways that you can help yourself feel more safe so you can relax and you know, pulling down the blinds at night, for example, making sure the doors are locked, getting a dog if they can, whatever it is that they think is going to help them, it's not going to take it away completely. They're still going to have some apprehension. But if they can start identifying the function of that behavior, the hypervigilance, and find ways to mitigate it, you know, hyper vigilance helps them feel safe and prevents them from being taken unawares. So what can they do? So they feel safer and they feel more in control of their environment so they don't need to be as hyper vigilant. My husband to this very day was when we go into a restaurant, I know that he has to sit with his. So he's facing as many of the entrances as possible. He was a cop for 20 years. That doesn't go away. And he prefers to sit with his back to a wall if he can. And that's just one of those things that I know ahead of time, helping people figure out what's Going to help you feel more safe at home, in your car, at the store and at work. Those are usually the big four where people are, you know, what can help them feel more comfortable. We want to help them create a sense of safety within the treatment environment and address how trauma symptoms may interfere with their life in the present. So we're going to talk about hyper vigilance and, you know, the nightmares and maybe emotional numbing, whatever they've got going on. And we're going to talk about how it totally makes sense as an adaptive reaction, how they can adapt differently, what other tools they could use so they don't have to be on guard all the time. And then we're going to talk about how these symptoms may be interfering with their life because it may be impairing their relationships, it can be impairing their sleep, it may be upsetting their entire schedule because maybe they used to go to the gym first thing in the morning when it was dark outside and then go to work and then come home when it was dark outside. And now they're afraid to be out by themselves when it's dark outside. Or maybe they're withdrawing from family and friends because of that emotional detachment. So we want to talk about how these symptoms are impacting their life and then start addressing the symptoms. You know, how can we help you feel less disconnected? It's helpful to examine how the trauma affects opportunities to recover. So in addition to how is it impacting your life, how are these symptoms and how is the trauma impacting your willingness to be vulnerable, impacting your willingness to engage with other people? Because you might not. If a victim of a date rape, for example, may not, you know, want to go out and start trying to date again and get back on with their life, so to speak. So we want to talk about those things. We want to talk, identify and explore strengths in the client's history that can help the client apply those strengths to his or her ability to function in the present. So when you've been scared before, how have you dealt with it? When you've done something new like you moved, you know, when I moved out of my parents house and moved into the dorms, you know, that was a new situation that wasn't nearly as scary as moving from the dorms into my own apartment. And that was a little bit scarier, ground floor apartment, you know, and that was also, you know, after like three years after the, the Gainesville murders. So I'm still remembering the Gainesville murders and going, you know, I'm not crazy about Living on the, on the ground floor here and, you know, whatever, but helping people identify, you know, so for me, I would look back and go, that was a scary time. How did I survive it? During the murders was a scary time. How did I survive it? And use those strengths and build upon those. Encouraging people to recognize that they are resilient, they've made it until now. They figured out. And not all the ways they're coping or responding are necessarily the most helpful for them, but it did help them survive. So it's been helpful in some way. So let's figure out what we could do differently to help them improve their quality of life. Now, a group trauma is a little bit different. It refers to a traumatic experience that affects a particular group of people. Groups often share common identity and history, as well as similar activities and concerns. So like a family would be considered a group. Each person in that family is probably at a different developmental stage. Different perceptions, different needs, different coping skills. So that's how they're different than maybe an individual. So you're going to be navigating all those things. And in a group, you know, if a group suffers a trauma, if a family suffers a trauma, then everybody is a little bit off their game for a little while, most likely. So we need to help the family figure out how to support each other when they're just barely staying afloat themselves. So we want to help them figure out how to work that. Vocational groups who specialize in managing traumas, trauma counselors, outreach counselors, or who routinely place themselves in harm's way, like law enforcement or even emergency doctors and nurses, they see some pretty intense stuff and they are routinely handling people's lives and, you know, there's a lot of stress and stuff on them and a sense of loss of control sometimes. So we want to recognize, you know, if you're working with an ER doctor, how could what he or she does be considered traumatic? You know, you know, seems pretty obvious to me, but they may not see it that way because that's what they've trained to do. But helping them remember that most people don't see this on a day to day basis. And most people don't have 20 people's lives in their hands on a daily basis. That's a lot of pressure and that can be traumatic. Examples of group trauma include crews and their families who lose members from a commercial fishing accident or a. We regularly hear of mines collapsing and the miners are trapped in the mines. A gang whose members experience multiple deaths and injuries. Yeah, gangs are not, you know, Vocational groups. But it is a unique group and they do have strong bonds. So if there's a bunch of deaths that happen, it's going to impact the gang teams of firefighters who lose members in a roof collapse, responders, just people who attempt to save flood victims. A lot of times law enforcement officers will jump right in to try to save flood victims, military service members in a specific theater of operation. So they're sharing a similar traumatic experience. And we want to look at this group trauma and say, how is it impacting every member? And before the trauma, how did all of these members interact and interface and support each other? And what was that dynamic like? And what has changed in that dynamic or since the trauma? And how might that dynamic be influencing how people recover and perceive the trauma? Group members who've had traumatic experiences in the past may not actively support traumatized colleagues. They may just say suck it up, but buttercup, for fear that acknowledging the trauma will increase the risk of repressed trauma related emotions of theirs surfacing. And I don't say suck it up, buttercup, to be sarcastic. I've worked, one of my specializations is working with law enforcement. And the F word feelings is very uncomfortable for a lot of them and firefighters to an extent too. Although I haven't worked with them as much as, you know, the idea with both of them, both of those professions is often espousing very macho type values, not being overly emotional. And they don't want to be talking about vulnerabilities. They don't want to admit that they felt vulnerable at any point in time. Survivors of group trauma can have individual experiences and responses that are different than survivors of individual or mass traumas. So this is important. You know, if you have Jim Bob, who is a sergeant on your local pd, he is part of a group. And if there's a group trauma, you know, maybe there's a shooting or something and it can be one of the people in their agency gets shot. It may, he may not have even been on scene. But they're a family, it's a group. So when that person gets shot, it impacts ripples go through the entire agency. So we have to remember that group groups as we're defining them here, are often likely to experience repeated traumas. They're in some sort of dangerous type occupation. They tend to keep the trauma experiences within the group, feeling that others outside the group will not understand. And in law enforcement, we refer to it as a blue wall. And one of you points out that you're a firefighter and you have to Go through group counseling if there's any sort of traumatic incident. And that is true. And most agencies, if there's a critical incident, require their people to go through a critical incident debriefing. But at least with law enforcement, my experience has been, most officers that go to that debriefing don't take it seriously. They're like, no, we're not. I'm not going to be. No, that's not going to happen. So while the services may be there, a lot of times they're not accepted by the group. The administration kind of forces that down on people. And yes, in some of these occupations, military law enforcement, if there's an admission of some sort of mental health issue like PTSD or depression, there's a risk that it could hijack your career. Even though they say it won't, it can. And that's just practical experience. And, you know, I wish it weren't that way. And many people who experience, even if it's not ptsd, if it's just clinical depression, I hate to say just. But if it's clinical depression or ptsd, a lot of people feel weak, like they should be able to handle it more. And you know what? Nobody should be able to handle whatever that person went through, most likely. So, you know, I don't want to tell them that they're wrong because they believe they should. But we want to look. And that's where cognitive processing therapy comes in super handy to help people evaluate their cognitions and their beliefs about the event and their beliefs about life since the event. But yes, a lot of times people don't participate in group counseling or services that are immediately offered to the group right after a trauma because they don't want to appear weak. Members may also see group members may not want to seek help and may discourage others from doing so out of fear that it may shame the entire group. You know, we don't want to bring shame here. We don't want people to think that we're weak or that we've got a problem. Members may also see it as a violation of group confidentiality when a member seeks assistance outside the group, such as going to a counselor. So it's like, why didn't you talk about it? And the firefighter here can correct me if I'm wrong, But with the firefighters that I've talked to and been friends with and had in my family, the idea is, if we have a stressor, if we have a bad call, we will work it out among ourselves. And they generally go back to the firehouse after the call and, you know, sometimes talk about it, there may be a mandatory debriefing that they do or don't take seriously. That's up to the agency and to the individual. But a lot of the stuff and social support is handled back at the firehouse after the trauma. And when a group member, when group members keep their trauma within the group, there really hasn't been much research that's indicated whether it's positive or negative at dealing with the trauma. Part of it depends on how healthy the group is. I mean, if you've got people with good coping skills and good mentoring skills that can help others get through the trauma and educate, then it's probably going to be just grand. But if you've got a bunch of people who are, you know, afraid of being seen as weak or don't want to admit the full extent of the problem or whatever, then keeping it inside is just like a dysfunctional family trying to make everything look good on the outside, when inside it's kind of falling apart. So my guess would be the research would indicate it depends on the health of the group. Community and cultural Trauma Trauma that affects communities and cultures covers a broad range of violence and atrocities. Atrocities that erode the sense of safety within a given community, including neighborhoods, schools, towns and reservations. So mass murders, other traumas can be, you know, acts of God. If there's a huge tornado that tends to be more localized than a hurricane that comes through and tears up an entire city, that is a community trauma and it erodes their safety. Obviously, nobody could have prevented the tornado. It's not like they're feeling unsafe from other people, but they may feel unsafe the next time a thunderstorm comes in, the next time they have to go to sleep, if it happened at night. So community traumas have a bit of a different flavor to them, if you will. They may involve violence in the form of physical or sexual assaults, hate crimes, robberies, workplace or gang related violence, threats, shootings or stabbings. So if there's widespread violence in the community, it's going to affect the community. If there's a string of bank robberies or a serial rapist out there, it's going to affect the community. It also includes actions that attempt to dismantle systemic cultural practices, resources and identities, such as making school attendance mandatory for Native American children. And this was boarding school attendance. So they would take Native American children away from their homes and make mandatory boarding school attendance. And, you know, that disrupts in so many different ways the family system of many Native Americans. Cultural and community trauma can also occur via indifference or limited responsiveness to specific communities or cultures that are facing potential catastrophe. So if there's something going on, when you're looking at a particular culture or community that could result in disaster, if there's a community that's struggling because of low employment and high violence, that community needs help. And so they may feel forgotten about if they don't receive resources from the outside. Cultural traumas are events that, whether intentionally or not, erode the heritage of the culture, as with prejudice, disenfranchisement and health inequities. So we want to be aware of what things impact each person's culture. Historical trauma, we're not going to spend a lot of time on this, but there are volumes of information to learn about. Historical trauma is also known as generational trauma and refers to events that are so widespread that they influence generations of the culture beyond those who experience them directly. So thinking about enslavement, torture and lynching of African Americans, forced assimilation and relocation of American Indians onto reservations, exterminations of millions of Jews and others in Europe during World War II, or genocide policies in Rwanda and Cambodia. So it's important to kind of think about where does this person come from? What's their culture? You know, what has happened in their culture that has kind of shaped who they are? Because going back to when this happened, you know, you know, when the original trauma happened, they had family, they had friends that didn't experience necessarily that trauma directly. You know, they had family who used to be slaves, or they had people who were in concentration camps that are in their family. But it impacts everybody, not just the person necessarily being directly victimized, which impacts the culture at that point. And everybody in the culture's perception of safety that gets passed on to the next generation and that sense of caution may get passed on to the next generation and so on and so on and so on. So we need to pay attention to things that are that broad. And look at how did, how did this event impact the entire culture and how is it still potentially being communicated through the generations? Mass trauma includes large scale intentional and unintentional natural and human caused disasters. So hurricanes. And, you know, this is, you know, larger than just a community. We're talking, you know, a county, a state, you know, you know, huge traumas involve significant loss of property and lives, as well as the widespread disruption of normal routines and services, require extensive resources that exceed community capacity. So this is when FEMA starts coming in and, you know, we start bringing in the feds and other resources. Maybe the National Guard initial event causes considerable destruction and spawns additional traumas and other stressful events that lead to more difficulties among survivors, first responders, and relief agencies. After Katrina, you know, we had considerable destruction. People had to get uprooted. Some of them were shipped to entirely different states because, you know, Louisiana, for example, was just uninhabitable. So they lost connection with their families. You know, they didn't know if family members were still alive or dead or where they were. They lost their stuff. They lost their sense of safety. They lost a lot. Then they go to this new place and, you know, the shelters were somewhat chaotic even after it had been going on for a while, at least in Florida. And so then they have, you know, they're living in a shelter with 150 other people, they have no privacy, and that starts to wear on their nerves, and that starts to be traumatic. And they experience other losses, and they start becoming irritable and feeling like everybody forgot about them. You see how this can cascade, and one trauma leads to another trauma. And the first responders and relief agencies are out there trying to help. And, you know, sometimes they're getting the job done, and other times, despite their best efforts, they're falling short and they feel guilty because, you know, they really want to be helping people, and they're seeing this suffering all around them. You know, it gets pretty ugly. Mass traumas create an immediate sense of commonality and rally of support, though, which removes much of the isolation. I mean, people have something to talk about now. And one of the challenges in the shelters is to try to keep the tone positive. Focusing on, okay, this stuff that happened is unfortunate. You're safe now. Know is not ideal, but you're safe. People acknowledge their difficulties and receive support from strangers. After 9, 11 and the snowstorm they had up in the northeast a few years back and hurricanes, we see neighbors reaching out to help neighbors. People acknowledge their difficulties and receive support. And it's easier to ask for help because blame is often externalized. One person generally isn't going to say, I caused the tornado or I caused the hurricane. We don't do that. Blame is externalized to contractors that didn't build strong enough houses, to legislators that did not make strong enough regulations to keep buildings from blowing over, to FEMA for not responding appropriately. The anger gets pushed out. And there's also generally anger at, for those who believe in a higher power, at their higher power for letting this happen. But that's not personalized, so people have something to talk about and they have general generalized enemies to rally against, so to speak. And again, as a shelter worker and going in there to try to do some debriefing and stress management, one of the things is to try to encourage people to focus less what people aren't doing for them and what they can do for themselves and what is being done. Because when you get that group think going and they start really focusing in on they're not meeting our needs, it starts to snowball on itself and people can get very angry very quickly. Survivors often encounter an initial rally of support followed by quickly diminishing services and dwindling care. And if you've been through any of these, you know, natural disasters, fires, hurricanes, snowstorms, you see it happen the first month or so. The news, that's all they can talk about. And then all of a sudden you don't hear about it anymore and the resources quit coming in. So while they get immediate help, you know, they start to feel like they're getting back on their feet, and then the support stops. So we need to make sure that there's an ongoing network in each community in order to support the survivors after FEMA leaves, after the immediate rush of help has left. Natural traumatic experiences are often referred to as acts of God and are typically unavoidable. Survivors of natural trauma, their response to the experience depends on the degree of devastation. After Andrew, you couldn't even figure out which way to turn because even the street sides were gone. The extent of individual and community losses, you know, loss of life, loss of property, loss of jobs, loss of, you know, when schools are closed, you know, if the community's flattened, that's going to be a lot more devastating than, you know, if there's some flooding. And the amount of time it takes to re establish daily routines and services. The faster people can get back to normal, the less likely they're going to experience an extended traumatic reaction. The amount, accessibility and duration of relief services can significantly influence the duration of the recovery process. Alongside disruption of daily routines. The presence of community members or outsiders in affected areas may also add significant stress. If you see the National Guard walking around outside, for me, it gives me an uneasy feeling. You know, I'm like, I don't like feeling like I'm in a police state for having strangers in people who couldn't stay in a shelter in their local area and they're in your shelter, it can add to overcrowding, it can create problems. From a behavioral health standpoint, when people come in from other areas, they may not have insurance for that area. So you need to get Medicaid waivers and try to communicate with their provider, who may or may not have access to their electronic medical health records, in order to ensure continuity of care for Jane, who was relocated here after the hurricane in Texas. And you're going, okay, trying to do this, but there's a lot of stress that goes along with it. So we need to try to figure out how to make it as stress free as possible. Examples. Other examples of stress include threat of others stealing from them while they're in the shelter, restriction to access to property or living quarters, you know, if they can't get to their house. This happens a lot with the fires. You know, they're told you can't go back into that area yet. Lack of privacy in shelters, media attention and subsequent exposure to repetitive images reflecting the devastation. So if you're constantly seeing your house get burned down, you're constantly seeing images of the twin towers. It can be traumatic. Human caused traumas are caused by human failure, such as technological catastrophes, you know, bridges collapsing or accidents such as an airplane going down. Survivors that have an unintentionally caused human traumatic event may feel angry and frustrated because of the lack of protection or care offered by the responsible party or government, particularly if there was a perceived act of omission. So if the stuff that was used to make the bridge was substandard and you find that out later, then people may be very angry that the person who was supposed to do that inspection either got bought off or didn't do their job correctly, or if they feel like the government is keeping something from them. Human design and intentional traumas. Traumas perceived as intentionally harmful often make the event more traumatic for people and communities. You're looking around going, I thought everybody was good. Why are you doing this? After intentionally caused human acts, survivors often struggle to understand the motives for performing the act, the calculated or random nature of the act, and the psychological makeup of the perpetrators. They're trying to figure out how to stay safe. They're trying to understand how it happened, what caused this, did I cause it? So there are a lot of questions that people have that they do need to answer for themselves. Retraumatization, Challenging or discounting reports of abuse or other traumatic events using isolation or physical restraints. And that can even be putting somebody in a room. And, you know, my doctor and my vet do this all the time. They put you in a room and you're sitting there for, you know, 30, 45 minutes, you're like, did they forget about me? But so not only using isolation to calm somebody down, but just using isolation where people feel like they've been forgotten about. Using experiential exercises that humiliate the individual. You may be going, I can't even think of one. I can. I worked with a therapist who used to get frustrated with clients who she perceived as, quote, sitting on their pity pot. So she took an old Folgers can and decorated it and labeled it Pitty pot. And when a client in group would start, in her perception, sitting on their own pity pot, she would give them that can and she would make them sit on it for the rest of the group. So, yeah, retraumatization, not okay. Endorsing a confrontational approach in counseling may not be appropriate for everybody. So we want to be cognizant of what their experiences have been. If they've been abused, we want to make sure we don't make them feel like they are going to be reabused. Allowing abusive behavior of one client towards another to continue labeling behavior or feelings as pathological. They are what they are. They're not necessarily right. Failing to provide adequate security and safety within the program. Somebody gets mugged in the, in the parking lot or if they're doing drug deals in the hallway, you know, that can re traumatize clients. Limiting participation of the client in treatment decisions and planning processes. Minimizing, discrediting, or ignoring client responses. When they say, you know, something's wrong, or I don't like this. Disrupting counselor client relationships by changing counselor schedules and assignments. It's really hard once you've become vulnerable with one person to back up and go, okay, let's start over again. Inconsistency with enforcing the rules and imposing agency policies without exceptions or opportunities for clients to question them. To address retraumatization, we need to anticipate and be sensitive to the needs of clients who've experienced trauma. Attend to their behavioral and emotional reactions to decrease them when they start getting agitated. We need to help them de escalate. Develop an individual coping plan in anticipation of triggers. So talk with clients about what their triggers are and what works for them to help them de escalate and what they don't want to have happen. Routinely rehearse the coping strategies highlighted in the coping plan. Recognize that clinical and programmatic efforts to control or contain the behavior in treatment can cause traumatic stress. So again, restraints, isolation, moving somebody out of group, all of these can re traumatize them. Listen for specific trigger that seems to be driving a client's reaction. To understand the behavior and normalize the traumatic stress reaction. So if somebody all of a sudden they're in group and there's a tense conversation going on, and one of the other clients just gets very boisterous and says, why don't you just shut up and quit bothering us with all of this? Okay? That's not an appropriate response. But as a clinician, we want to say what just triggered that. And it could be that, you know, they were mimicking what they saw when they were growing up. If their siblings were fighting, that's what their parent used to do, or they used to see bickering like this or feel this kind of tension, and then it exploded into violence. So they wanted to make sure to stop it before the violence erupted. Don't shame the trauma survivor for his or her behavior. We want to look at it as adaptive, although maybe not the best choice. It's helped them survive until now and respond with consistency. Single, repeated or sustained trauma or cascading trauma occurs when multiple traumas happen in a pattern that does not allow the individual to heal from one traumatic event before another occurs. Think about if people who've had loved one die, and then another loved one die, and then another loved one die, and then they lose their job or something, you know, before they can catch their breath, another trauma happens. So they just keep getting less and less or more and more drained, if you will. The number of losses caused by the trauma impacts the trauma. So if they lose interpersonal relationships, if they lose status, if they lose self esteem, financial standing, tangible things like houses and pets, occupational, you know, if they lose their job because of it or because of whatever happened to them, they have to move to a different city in order to stay safe. So then they have to find a new job. Maybe they didn't get fired, but they had to quit because they were forced to move. Any physical losses, including a sense of safety but also physical abilities. It's helpful to access and discuss the losses associated with the initial trauma. The number of losses greatly influences the individual's ability to bounce back from the tragedy. Doesn't mean it's impossible, but if there's more losses, it's going to take more work. We want to look at were the trauma's effects on the person's life. Isolated, pervasive. People who remain in the vicinity of the trauma may encounter greater challenges to recovery because the traumatic event intertwines with various aspects of the person's daily activities, increasing the possibility of being triggered by surrounding cues. So if you were raped while you were out jogging in your neighborhood, you know that's more pervasive because every time you come home, you're going to go by that jogging path and you're going to feel unsafe versus if you were, you know, you had your purse taken from you when you were on a cruise in Hawaii or something. Another way to view this potential dilemma is to reframe it as an opportunity. Because the repetitive exposure to trauma related cues may allow them to sort of desensitize to it. If the trauma was expected, it's probably going to have less of an impact than if it was unexpected. Most traumas are not expected, but some are like hurricanes. If you move to Florida, you know it's likely you're going to experience a hurricane at some point and you have warning before the hurricane happens. Tornadoes, not so much. Although if you live in tornado alley, you know there's a good likelihood that you will experience tornadoes. So it's a little bit expected there. Being in a car accident, that's unexpected. Who was responsible for the trauma and was the act intentional? When terrible things happen, it's human nature to assign blame. So if people can assign blame to somebody else, then they may not trust other people, but they're not feeling necessarily as guilty. And if it was unintentional, people tend to feel do less blaming than if it was intentional. If it's intentional, they're going, that makes no sense. How could you hurt another person? Trauma survivors can become heavily invested in assigning blame to finding out who is at fault in order to make sense of give meaning to the trauma or or re establish a sense of predictability, control and safety. It's far easier to accept that someone, including oneself, is at fault than to accept that the fact that you were just in the wrong place at the wrong time, so it's easier to say if I would have done this differently, so if I never do it this way again, I will be safe. Versus It's a crapshoot. Wrong place, wrong time. For some trauma survivors, needing to find out why a trauma occurred or who is at fault can become a significant block to growth. When the individual would be better served by asking, what do I need to do to heal? I may never understand why this happened, but what do I need to do to heal? Was the trauma experienced directly or indirectly? Obviously, if it happens directly to you, there's going to be a different impact than than if it happened to your friend down the street. What has happened since the trauma? What does the trauma mean to you psychologically? Does it mean that you're weak, does it mean that you're a failure? Should you feel guilty? Does it mean that you're a survivor? What does it mean? How much did it disrupt your core assumptions and beliefs about predictability, safety, the goodness of people, and maybe your higher power? What's the cultural meaning of the trauma? How do cultural interpretations and cultural responses affect the experience of the trauma? If the culture says this happened to you because you're a sinner or because you're a bad person, then it's going to impact somebody differently than if they don't get that response. What's the prior history of trauma, stressors and mental illness in the person? You know, if they were already worn down, already at risk, this could impact the stress reaction. What's their history of resilience? When they've experienced bad things before, how have they bounced back? Obviously they have bounced back or they wouldn't be there. So how have they bounced back? But how well have they bounced back? They may just be holding on by a thread or they may be as resilient as I'll get out. So resilient people are obviously going to fare better. And look at socio, demographic, income variables such as income, occupation, ethnicity and gender. People react differently to different traumas. And you know, based on your occupation, you may react somewhat differently. You may have different supporters based on your income. Some people can. If a bad thing happens, then they can, you know, they have a home invasion, robbery, they may be able to sell their house and move, whereas other people may not have that luxury. People with more income may have access to more resources. So we want to figure out resilience among individuals from diverse cultural, racial or ethnic groups can be really strong because of strong kinship bonds. And so we want to look at the culture. Is there an extended family? Is there an extended support? How does this culture generally deal with illness, sickness, problems in the family? If there's a respect for elders and an importance of extended family, then there's a network there, hopefully a functional one. What are their spiritual and religious practices? If their spirituality allows them to make meaning out of what happened, it will help them become more resilient. If they have friendships and warm personal relationships, that's going to help them be resilient. And remember, culture is not necessarily ethnicity. Culture is much more broadly defined. How do they express humor and creativity? Can they use that in order to be resilient and recover from the trauma? Culture can instill a sense of history, heritage and historical traditions. So maybe the house was taken away from this person, it burned down or whatever. But that doesn't take away everything that they are because the culture still exists, community orientation, activities and socialization. So if the community is out there and can help them, is willing to respond and provides that social support, even if it's, you know, just being there for them, then they're going to be more resilient. If the person has a strong work ethic, yeah. Recovering from trauma takes work. So it means somebody has to be dedicated to recovering and moving forward, and they have to believe that they have the ability to do so. And their philosophies and beliefs about life, suffering and perseverance are going to be shaped by, by their culture and their ethnicity. So we want to find out what exactly does this trauma mean to you? You know, I don't know what meaning you ascribe to it. Just like when we're doing counseling for people with mental health issues from other cultures, we want to say, or physical health issues, we want to say, what does this illness mean to you? What do you think causes it? What do you think could help you recover from it? So trauma can impact individuals, groups or communities, or even masses of people. Each type of trauma presents different issues with garnering support and achieving recovery. Sometimes the support you have to reach out and ask for it because nobody knows about the trauma. Other times you've got support forthcoming, but then it quickly goes away. So we want to pay attention and make sure support is available from the beginning through the end of when the person needs it. Traumas can be caused intentionally or unintentionally and by man or by nature. And the way an individual responds to trauma depends on their culture, gender, age, socio, demographic characteristics, whether it was expected and how pervasive the trauma is and the number of losses associated with it.