Trauma Sensitive Work

with
Domestic Violence
Survivors
 PTSD (Post-Traumatic Stress
Disorder)
►Apotentially disabling condition that
many people experience after
enduring a traumatic event in which
they:
 are threatened with serious injury or
death and
 feel a sense of intense fear, helplessness,
or horror
PTSD SYMPTOMS
1. Intrusive Re-experiencing
 Repeatedly re-experiencing the trauma
in the form of flashbacks, memories,
nightmares, or frightening thoughts.
 Experiences occur unexpectedly and may
be so intense that the person feels as
though the trauma is occurring again.
► This may cause the person to react in ways
they did when the trauma originally occurred.
PTSD SYMPTOMS (cont)
2. Avoidance - Also referred to as
“dissociation”.
 Individual has numbed their
emotions to avoid painful,
overwhelming feelings.
 May attempt to:
► avoid all reminders of the traumatic
event,
► feel emotionally detached,
► withdraw from friends, family, and
everyday activities.
PTSD SYMPTOMS (cont)
Hyperarousal
 Being constantly on guard,
easily startled or “jumpy”
 Difficulty to concentrating or
remembering information
 May have sleep disturbances or
panic attacks.
COMPLEX PTSD
Dr. Judith Herman of Harvard

University
1. The individual experienced a prolonged
period (months to years) of total control by
another.
2. Symptoms that tend to result from chronic
victimization. Those symptoms include:
 Alterations in emotional regulation, which may
include symptoms such as persistent sadness,
suicidal thoughts, explosive anger, or inhibited
anger
 Alterations in consciousness, such as forgetting
traumatic events, reliving traumatic events, or
having episodes in which one feels detached
from one's mental processes or body
COMPLEX PTSD (cont)
 Alterations in self-perception, which may include a
sense of helplessness, shame, guilt, stigma, and a
sense of being completely different than other
human beings
 Alterations in the perception of the perpetrator,
such as attributing total power to the perpetrator or
becoming preoccupied with the relationship to the
perpetrator, including a preoccupation with revenge
 Alterations in relations with others, including
isolation, distrust, or a repeated search for a rescuer
 Alterations in one's system of meanings, which may
include a loss of sustaining faith or a sense of
hopelessness and despair
COMPLEX PTSD (cont)
3. Other difficulties of complex PTSD
survivors:
 May avoid thinking and talking about
trauma-related topics because the feelings
associated with the trauma are often
overwhelming.
 May use alcohol and substance abuse as a
way to avoid and numb feelings and
thoughts related to the trauma.
 Survivors may also engage in self-
mutilation and other forms of self-harm
TRAUMATIC MEMORIES

► Traumatic events are remembered

by some individuals while in
other individuals the memories
are dissociated.
Factors influencing a
continuous memory
include:
 experiencing a single traumatic
event naturally or accidentally
caused,
 being an adult at the time of
the trauma, and
 receiving validation and
support.
Factors influencing
dissociation or amnesia:
 experiencing the trauma repetitively
 trauma deliberately caused by
another person
 trauma related to betrayal of trust by
a significant person in one’s life
 being a child at the time of the
trauma
 living in an atmosphere of secrecy
and denial
WHO IS AT RISK?
People who are at the greatest risk for
developing PTSD are:
 Survivors of violent assaults (domestic
violence, rape, sexual assault/or abuse,
physical assault such as a mugging or
carjacking)
 Children who have been neglected, or
sexually, physically or verbally abused,
and adults who were abused as children)
 HELPING TRAUMA SURVIVORS
HEAL
Trauma Theory:
► Sickness/Badness vs. Injury Model
 Changing the fundamental question
from:

“What's wrong with you?"

to
"What's happened to you?"
 MOVING FROM
SICKNESS/BADNESS to INJURED
Our understanding of the impact of trauma alters our
fundamental explanations for human dysfunction.
At present, there are basically three widely accepted
reasons for why people do deviant things:
The person is “sick”.
The person is “bad”.
The person is both “sick and bad”

Trauma theory implies that it is far more useful

to assume that a person has been “injured”
Sickness:
► Thecause of the problem lies within
the sufferer, unconnected in any
meaningful way with the outside world.
► Impliesa basic weakness, malfunction
or defect that medical science can hope
to stabilize or cure.
► Holds an expectation of passivity on
the part of the sufferer
► Denies both personal and social
accountability for the course of the
sickness. 
Badness:
► Connected to the concept of sin.
► Implies a basic defect and little hope
that anyone can correct
 But we can, and should, punish it.
► Requires self- corrective action -
totally on the part of the bad person
► The bad person is wholly responsible
for their deviant actions
 should stop the misbehavior- regardless
of its origin or
 accept the consequences (punishment).
Injury:
► Implies a cause that is obvious
or discoverable
 connects the sufferer to the social
environment that allowed or failed
to prevent the injury.
► Implies a process of recovery
and rehabilitation
 the sufferer must learn how to cope
with a semi-permanent or even
permanent disability.
Injury (cont):
► Implies a cause that is obvious or
discoverable
 connects the sufferer to the social
environment that allowed or failed to
prevent the injury.

► Implies a process of recovery and

rehabilitation
 the sufferer must learn how to cope with
a semi-permanent or even permanent
disability.
Injury (cont):
► Requires active participation by the
sufferer in the process of recovery
 helpers are more consultants and
catalyzing agents of change than healers.

► Requires assumption of both

 individual responsibility on the part of the
sufferer, and
 social responsibility on the part of the
larger social group.
Injury (cont):
► The injured individual must look at the ways
he or she contributed to the injury in order
to
 ensure proper risk management in
the future, and
 must take necessary steps to ensure
recovery and future risk prevention.

► The larger social group – represented by

family, school, workplace, or the community
as a whole  - must come to terms with the
role the society played in
 failing to prevent the injury
 providing the contexts within which
individual healing can occur.
TRAUMA INFORMED ADDICTION
TREATMENT
Maxine Harris, Roger Fallot

CORE TREATMENT ELEMENTS:

1. Teach integrative and contextual
explanations
 NOT “EXCUSES”

1. Place substance use in the

context of client’s life,
relationships and trauma history
CORE TREATMENT ELEMENTS (cont)

3. INCLUDE ACCESS TO
ANCILLARY SERVICES:

VOCATIONAL PARENTING SAFE HOUSING

EDUCATIONAL LIFE SKILLS LEGAL SERVICES

HEALTHCARE
CORE TREATMENT ELEMENTS (cont)
4. TEACH CROSSOVER SKILLS FOR
RECOVERY FROM TRAUMA AND
ADDICTION:

► SELF-KNOWLEDGE ► HONEST LABELING

► CLEAR COMMUNICATION ► SELF TRUST
► SELF-REGULATION ► APPRECIATING MUTUALITY
AND RECEPROCITY
► ACCURATE PERCEPTION OF
OTHERS AND ► LIMIT SETTING
► SELF-SOOTHING ► CLEAR EXPRESSION OF
  NEEDS AND DESIRES
KEY COMPONENTS OF TRAUMA
SENSITIVE SERVICES
Most trauma informed interventions
cover three primary areas:
1. Identifying the nature and extent of
the trauma, including:
► symptom development;
► strengths used for survival;
► distortion of feelings and behavior due
to trauma;
► how ongoing symptom experiences
(dissociation, substance abuse) may
function to numb the pain of abuse
history.
KEY COMPONENTS OF
TRAUMA SENSITIVE SERVICES (cont)

2. The creation of a safe haven.

Certain basic rules help to
establish this environment,
including:
► confidentiality;
► opportunity to speak or “pass”;
► a group norm disallowing advice-
giving, criticism, or confrontation
Safe Haven (cont)

Common responses among victims

experiencing such an
environment include:
 increased self esteem at knowing
what they have to say is heard
and valued,
 relief at finding they are not
alone or “crazy” or “bad”
because of their experiences
 increased empowerment
KEY COMPONENTS OF
TRAUMA SENSITIVE SERVICES (cont)

3. Survivors are encouraged to develop

skills needed to recover from traumatic
experiences and build healthy lives.
These include learning:
 cognitive- behavioral “re-thinking”
strategies,
 problem-solving skills,
 relaxation techniques,
 stress coping,
 relapse prevention and
 short- and long-term safety planning skills.
How Trauma Affects People’s
Lives:
Trauma interferes with
 Knowing how to feel safe and how to keep self/family
safe
 Feeling understood by and able to connect emotionally
with other persons
 Knowing how to feel in control and how to be organized
and goal-directed
 Feeling like a person worthy of respect, support, and
compassion (versus damaged/bad)
 Knowing how (and when, and whom) to trust
 Knowing how to help and show caring to others without
being exploited or controlling
 Knowing how to contain intense emotions and
impulses, and how to soothe/calm oneself
What Intervention Can Do:
Provide modeling/guided experience in:
 Identifying life experiences that may have
been traumatic and feelings, problems, and
coping styles that may result from trauma
 Identifying dangers/problems and taking
practical steps to be safe and feel safe
 Identifying intense emotions/impulses,
understanding how they make sense, and
how to self-soothe, problem solve, and be
soothed and guided by trustworthy others
 Recognizing the worth and value of one's
own actions and intentions
What Intervention Can Do (cont):

Provide modeling/guided experience in:

 Organizing complicated problems into small
practical steps toward solutions
 Engaging in a non-coercive, non-abandoning
relationship based on mutual respect,
responsibility, and learning
 Recognizing attempts to maintain and repair
relationships despite despair/fear/anger
 Recognizing attempts to deal with intense
emotions and impulses despite lapses
 Recognizing attempts to maintain or regain
personal control/autonomy and safety
What Intervention can achieve
Trauma sensitivity adds value to all
types of services by:
 Enhancing the client’s safety (including ability to
identify and practically manage dangers)
 Enhancing the client’s autonomous self-control
(including identifying and making choices)
 Directly demonstrating respect, compassion, and
confidence in the client as an adult/parent
 Showing the client how relationships can be
personal without violating her personal space and
boundaries, trustworthy without being perfect, and
satisfying without any exploitation
 Helping the client directly face problems without
avoidance, blame, secrecy, or dishonesty
What Intervention can achieve
(cont):

Trauma sensitivity adds value to all

types of services by:
 Enhancing the client’s understanding in
non-stigmatizing terms of how she learned
to cope with trauma and why these types of
coping made sense for dealing with her
trauma
 Enhancing the client’s understanding of
how post-traumatic symptoms are an
attempt to regain a sense of safety, self-
respect, and empowerment
 Integrated Treatment: Seeking
Safety
THE FOUR KEY PRINCIPLES OF SEEKING SAFETY TREATMENT
1. Safety as the priority of this “first stage” of treatment
The basic philosophy of the treatment is that, when a person has
both active substance abuse and PTSD, the most urgent clinical
need is to establish safety. "Safety" is an umbrella term that
signifies various elements including:
► discontinuing substance use,
► reducing suicidality,
► minimizing exposure to HIV risk,
► letting go of dangerous relationships (such as
domestic abuse and drug-using "friends"),
► gaining control over extreme symptoms (such as
dissociation), and
► stopping self-harm behaviors (such as cutting).
 Safety as the priority of this “first stage” treatment
(cont)

► "Seeking safety" refers to helping clients free

themselves from such negative behaviors and, in so
doing, to move toward freeing themselves from
trauma at a deep emotional level.
► This treatment attempts to teach life-
enhancing skills that promote safety:
► learning to ask for help from safe people,
utilizing community resources,
► exploring "recovery thinking”,
► taking good care of one's body,
► rehearsing honesty and compassion,

► increasing self-nurturing activities, and so on.

THE FOUR KEY PRINCIPLES OF SEEKING SAFETY TREATMENT
2. Integrated Treatment Of PTSD And Substance Abuse
“attention to both disorders at the same time in the present”
 Each topic can be applied to both PTSD and substance abuse.
 Integration is goal for clients: to "own" both disorders.
 Treatment content is focused on helping clients to:
 learn what the two disorders are and why they co-occur;
 exploring their interrelationship in the present (e.g.,
using crack last week to cope with PTSD flashbacks);
 understanding the course of the disorders in recovery
(e.g., with absti­nence, PTSD may feel worse before it
feels better);
 increasing compassion by viewing sub­stance abuse as
an attempt to cope with the pain of trauma; and
 teaching safe coping skills that apply to both.
THE FIVE KEY PRINCIPLES OF SEEKING SAFETY
TREATMENT
3. A Focus on Ideals
Addiction and trauma (individually, and especially in
combination,) lead to demoralization and loss of ideals

 Trauma - "shattered assumptions": Many clients report

feeling more upset about a loss of ideals, such as trust, than
about par­ticular external conditions, such as poverty or lack
of a job.
 Addiction – loss of ideals: Life has become narrowed in
focus, one is living "at the bottom”-surrounded by people who
cannot cope, pushing away reality, losing connections to
normal life (job, home, relationships), lying about substance
abuse, unable to face emotional pain.
 Recovery from both: The treatment explicitly seeks to
restore ideals that have been lost.
► The title of each topic is framed as a positive ideal-
one that is the opposite of some pathological
characteristic of PTSD and substance abuse.
► The AA goal of living a life of moral integrity is an
anti­dote to the deterioration of ideals inherent in
substance abuse and PTSD.
 THE FOUR KEY PRINCIPLES OF SEEKING SAFETY
TREATMENT
4. Three Content Areas; Cognitive, Behavioral
and Interpersonal
 Cognitive - Present- and problem-
oriented, to reduce current
symptoms.
► Brief, time-­limited, and structured, with
the goal of strong treatment gains over a
short time frame.
► It is educational, with emphasis on
rehearsal of new skills.
► It is directive and collaborative, guid­ing
clients (much as a good parent would)
while emphasizing their mature
contribution to their own treatment.
4. Three Content Areas; Cognitive, Behavioral and
Interpersonal (cont)
 Behavioral - The "behavioral bottom line"
is taught: that it is not sufficient to talk
about action, but real action, however
small, is essential.
► Each session – Clients make a
commitment to one concrete step to
promote healing
► Counselors are encouraged to listen to
Clients’ behavior more than their words
► Clients guided to "own" their actions-
no matter what happens in their lives.
 THE FOUR KEY PRINCIPLES OF SEEKING SAFETY
TREATMENT
4. Three Content Areas; Cognitive, Behavioral and
Interpersonal (cont)
 Interpersonal - most PTSD arises from trauma
inflicted by others (in contrast to natural
disasters or accidents
► PTSD survivors: distrust of others, confusion
over what can be expected in relationships,
and concern over re­enactments of abusive
power both as victims and as perpetrators
► Substance abusers: substance abuse is often
precipitated and perpetuated by relationship
issues (substance-abusing family members,
substance use as an attempt to gain
acceptance by others, substance use to
manage interper­sonal conflict)