Module 3: Trauma Awareness and Healing

Module Purpose

The purpose of this module is to:

  • Learn about different types of trauma that people experience.
  • Understand the impact of trauma on development.
  • Learn about the Adverse Childhood Experiences Study.
  • Support trauma healing and promote resilience.
 

What is Trauma?

The word “trauma” is used to describe people’s experiences when their capacity to respond is overwhelmed. These experiences can be emotionally painful and distressing and impact people’s ability to cope, often leaving them feeling powerless.

“Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.”  — Judith Herman, Trauma and Recovery

  Normal Responses to Trauma/Toxic Stress

Normal Responses to Trauma/Toxic Stress

 Is it stress or is it trauma?

Trauma differs from stress in that trauma is stress run amuck. Normal levels of stress generally disrupt our nervous system for a relatively short period of time. At that point, our nervous systems calm down and we return to a normal state of stability. This return to our body’s normal routine is not often the case when we have experienced toxic stress or trauma.

Definition of stress

Stress is internal or external influences that disrupt an individual’s normal state of wellbeing. These influences are capable of affecting health by causing emotional distress and leading to a variety of physiological changes. These changes include increased heart rate, elevated blood pressure, and a dramatic rise in hormone levels.

Positive stress  <<<<<<<>>>>>>>toxic stress

Positive stress is an important part of a child’s developmental process and helps a child learn how to cope and overcome stress in their lives.

Toxic stress results from adverse experiences that may be sustained for a long period of time. This type of stress can disrupt early brain development, compromise the functioning of important biological systems, and may lead to long term health problems.

When children are very young, their brains are the most vulnerable to stress. Not all stress is bad for a developing brain, but when it lasts a long time or is extreme, it can impact how the a child’s brain develops. Toxic stress (like abuse and neglect) can interfere with the healthy development of the connections in the brain.

Click here to download InBrief: The Impact of Early Adversity on Children’s Development which outlines basic concepts from research on the biology of stress which shows that major adversity can weaken developing brain architecture and set the body’s stress response system on high alert.

Effect of early toxic stress and trauma on development

Early toxic stress and trauma in early childhood can:

  • influence a prolonged stress response,

  • impair childhood brain development, and
  • effect health and quality of life throughout the lifespan.

One way to tell the difference between stress and trauma is by looking at how much residual effect these events and circumstances are having on our lives, relationships, and overall functioning.

To learn more about toxic stress go, to the Center on the Developing Child at Harvard University:  www.developingchild.net.

Various responses to trauma

Not all people who experience the same event respond in the same ways. It is important to recognize that trauma is experienced differently in all individuals. The impact of trauma and the related effects, such as triggers and symptoms, may vary from person to person.

What determines whether individuals and groups are traumatized to the degree to which they are traumatized?

  • The event itself
  • The content of the person/group’s life at the time of the event
  • Individual and emotional characteristics

It is important to remember that a traumatic reaction is valid regardless of how the event that induced it appears to anyone else.

Forms of Trauma

An individual person’s experience of trauma and the impact it has on them varies from person to person. A person can also experience multiple forms trauma. For example, a young person who is growing up in a community in which they may be experiencing racism and may also be exposed to ongoing violence in their neighborhood or family.  

Improving awareness of trauma

The first step to healing trauma is increasing our awareness of the various forms of trauma that people experience and its effects on yourself and others.

The following questions may be useful to reflect on as you read the following descriptions of different forms of trauma that people may experience. 

  1. What types of trauma do you see with the people you work with?
  2. Are any of the types of trauma surprising?
  3. Are there other types or causes of trauma that you would add?
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Single event or ongoing trauma

Trauma can be experienced from a single event. It also can be influenced by ongoing or continuous events or conditions. For example, exposure to violence in one’s family or community may be an ongoing and repeated experience.

Individual or societal/collective trauma

Individual trauma results from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being (1).

Societal or collective trauma can result when a traumatic event/series of events affects a large number of people. It can be directly experienced, witnessed (on TV) or heard about. The traumatic experience can bring forth fear, horror, helplessness, or anger (2). Examples of societal or collective trauma include terrorist attacks, natural disasters, wars, genocide, oppression and racism experienced by certain ethnic group or culture, murder/fires in a community.

Dignity violations

Dignity plays an important role in the breakdown and restoration of relationships. Dignity violations contribute to a breakdown in relationships. We may react to a threat to our dignity in ways that escalate negative interactions and maintain cycles of conflict and/or violence. In order to break the cycle, it is important to acknowledge and address violations of dignity. When we extend ways that honor each others' dignity we promote healthy relationships (3).

Microaggressions

Microaggressions are statements or actions that are often subtle, unintentional, and ambiguous about socially constructed identities that embody privilege in different ways - including sexuality, class, religion, education level. Recognizing microaggressions can help to make visible the ways in which social difference, marginalization, and identify consciousness are formed from structures of power and privilege and produced and maintained in everyday lives through people's comments (5).

"Racial microaggressions are the brief and everyday slights, insults, indignities and denigrating messages sent to people of color by well-intentioned [people] who are unaware of the hidden messages being communicated." - Derald Wing Sue, Columbia University

Click here for examples of racial microaggressions. 

Structural or historical trauma

Structural trauma can be individual or collective like structural racism, inequality or oppression. Youth voices from the RYSE Listening Campaign identified the following factors that contributed to their experiences of trauma: economic disempowerment, histories of oppression, mass incarceration, immigration & legal status, environmental racism (4).

This video gives an example of historical trauma experienced by indigenous peoples in the United States.

Historical trauma is the “cumulative emotional and psychological wounding over the lifespan and across generations emanating from massive group trauma” (2). 

Examples of historical trauma include slavery, genocide, colonialism.

 

 

Vicarious or secondary trauma

Vicarious or secondary trauma refers to the cumulative physical, emotional, and psychological toll that can occur when we are exposed to the suffering, hardship, crisis, or trauma of others. It is the impact from exposure to traumatic stories or events when working in a helping capacity, combined with the strain and stress of everyday life. There is a toll individually, individually, organizationally, and societally. Other terms used include trauma exposure response, compassion fatigue, empathic strain, or trauma stewardship.

See Module Ten and Eleven for more information on secondary trauma. 

Participation-induced trauma

Participation or participatory-induced trauma is a form of trauma that occurs when a single person or group of people are active participants in causing harm or trauma to others. Participation-induced trauma can be voluntary or involuntary, intentional or unintentional. Examples of participation-induced trauma include soldiers in war, police officers, people who have participated in gang activity, someone who has committed a crime such as murder.

Socioecological model and trauma

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Trauma can be an individual, family, group or societal experience. To learn more about the social-ecological model as a framework for violence prevention please see www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html.

Sources

  1. SAMHSA-HRSA Center for Integrated Health Solutions - https://www.integration.samhsa.gov/clinical-practice/trauma
  2. Yoder, 2015. Little Book of Trauma Healing: When Violence Strikes And Community Security Is Threatened. Little Books of Justice & Peacebuilding. Skyhorse Publishing, Inc.
  3. Hicks, D., & Tutu, D. (2011). Dignity: The essential role it plays in resolving conflict. New Haven: Yale University Press.
  4. The RYSE Center’s Listening Campaign: Community-engaged inquiry of young people’s experiences and articulations of trauma, violence, coping, and healing (2016). http://rysecenter.electricembers.net/wp-content/uploads/2016/06/LC-Report-May-2016.pdf
  5. Microaggressions. Power, privilege, and everyday life. http://www.microaggressions.com/
 

Impact of Adverse Childhood Experiences (ACEs)

Many have recognized the connection between childhood adversity and health. The Adverse Childhood Experiences study illuminates the powerful link between childhood stressors and a persons increased risk of medical, psychological, and social issues as an adult (1).

What are ACEs?

  • Childhood abuse
    • Emotional
    • Physical
    • Sexual
  • Neglect
    • Emotional
    • Physical
  • Growing up in a seriously dysfunctional household
    • Witnessing domestic violence
    • Alcohol or other substance abuse in the home
    • Mentally ill or suicidal household members
    • Parental marital discord (separation or divorce)
    • Crime in the home (household member imprisoned)

The ACE score is the total number of ACE that people experiences during childhood. For example, experiencing physical neglect would be an ACE score of one. Experiencing physical neglect and witnessing a parent being treated violently would be an ACE score of two. Compared with people who have none, people with four types of ACE’s are twice as likely to be smokers, 12 times more likely to attempt suicide, seven times more likely to be alcoholic, and 10 times more likely to inject street drugs.

However, Dr. Elena Quintana from Adler School of Professional Psychology reminds us: “It is important to remember an ACE score is not destiny, but is wind in your face…rather than at your back.”

Click here to calculate your ACE (and resilience) score (https://acestoohigh.com/got-your-ace-score/).

The ACEs pyramid

 ACE Pyramid

ACE Pyramid

During the time period of the 1980s and early 1990s, information about risk factors for disease had been widely researched and merged into public education and prevention programs. However, it was also clear that risk factors, such as smoking, alcohol abuse, and sexual behaviors for many common diseases were not randomly distributed in the population. In fact, it was known that risk factors for many chronic diseases tended to cluster, that is, persons who had one risk factor tended to have one or more other risk factors too.

Because of this knowledge, the ACE Study was designed to assess what we considered to be “scientific gaps” about the origins of risk factors. These gaps are depicted as the two arrows linking Adverse Childhood Experiences to risk factors that lead to the health and social consequences higher up the pyramid. Specifically, the study was designed to provide data that would help answer the question: “If risk factors for disease, disability, and early mortality are not randomly distributed, what influences precede the adoption or development of them?” By providing information to answer this question, researchers hoped to provide scientific information that would be useful for developing new and more effective prevention programs.

The ACE Study takes a whole life perspective, as indicated on the orange arrow leading from conception to death. By working within this framework, the ACE Study began to progressively uncover how adverse childhood experiences (ACE) are strongly related to development and prevalence of risk factors for disease and health and social well-being throughout the lifespan. For example, people with six ACEs die on average 20 years sooner than those with no ACEs.

Social emotional and cognitive adaptations refer to the adjustments people have been shown to make in their lives when faced with adversity that may lead to adoption of health risk behaviors, that lead to disease and possibly early death.

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“We saw that things like intractable smoking, things like promiscuity, use of street drugs, heavy alcohol consumption, etc., these were fairly common in the backgrounds of many of the patients…These were merely techniques they were using, these were merely coping mechanisms that had gone into place.” Vincent Felitti, MD

Expanding our understanding about ACEs

The Philadelphia ACE study explored ACEs in context of an urban city with a socially and racially diverse population. They added five new definitions of trauma to the original ten: 1) Experiencing racism, 2) witnessing violence, 3) living in an unsafe neighborhood, 4) being placed in foster care, and 5) experiencing bullying. "The study found that 40.5% of Philadelphia adults witnessed violence while growing up, which includes seeing or hearing someone being beaten, stabbed or shot. Over one-third (34.5%) of adults reported experiencing discrimination based on their race or ethnicity, while almost three in ten adults (27.3%) reported having felt unsafe in their neighborhoods or not trusting their neighbors during childhood. In all, over 37% of Philadelphia respondents reported four or more ACEs. The findings from this study suggest the need for services that address the unique environmental stressors experienced in urban neighborhoods to mitigate their impact on individuals and prevent ACEs (2). 

The RYSE Center in Richmond, California knew that there was more to a person’s trauma than just her or his experiences and that youth come “into this world in structures and conditions already established” (3). The following expanded pyramid reflects the additional experiences and conditions that people reinforce systems of marginalization and oppression and contributes to people's experiences of ongoing trauma and adversity.  

RYSE ACE Pyramid

It is important to recognize that:

  • ACEs are common.
  • ACEs tend to occur in clusters, rather than single experiences.
  • The cumulative impact of multiple exposures can be captured in an ACE score.
  • The ACE score likely captures the cumulative neurodevelopmental consequences of adversity and traumatic stress.
  • The ACE score has a strong, graded relationship to numerous health, social, and behavioral problems throughout a person’s lifespan.
  • ACE-related problems tend to be co-morbid or co-occurring.

As a person's ACE score increases; the risk for the following health outcomes also increases

  • Alcoholism and alcohol abuse

  • Chronic obstructive pulmonary disease
  • Depression
  • Fetal death
  • Illicit drug use
  • Ischemic heart disease
  • Liver disease
  • Risk for intimate partner violence
  • Multiple sexual partners
  • Sexually transmitted diseases
  • Smoking
  • Suicide attempts
  • Unintended pregnancies

The cumulative stress of ACEs are the most powerful determinate of the public’s health and the strongest common driver of mental, physical and behavioral health costs. The gray area across the pie chart below represents the portion of risk attributable to ACEs. Like an oil spill, it defies predetermined boundaries and shows the interconnectedness between adverse childhood experiences and presenting public health issues (4).  

ACEs Oil Spill Image
 

What Trauma Looks Like

Too often the normal response of trauma in children and adolescents is viewed as negative behavior, for example physical aggression or substance abuse. When it is viewed and treated as such, the traumatic experience itself remains unaddressed and the child’s development is impacted. In fact, Post-Traumatic Stress Disorder is often misdiagnosed in children because symptoms present as behavioral issues (1). According to Yoder, an individual can present trauma through “acting in” behaviors in which the person turns the trauma in on oneself, or “acting out” behaviors, in which the person turns the trauma outward towards others (2).

"A lot of these kids get labeled as being bad, difficult, defiant. This is a very natural response to their circumstances. What the child is doing is a survival strategy for them, but it creates behaviors that are very difficult in the classroom, and when they  are in a crisis mode, they can't learn." Linda Chamberlain, First Impressions - Exposure to Violence and a Child's Developing Brain (3)

 

It is important to recognize this cycle of “acting in” and “acting out” in a non-linear process and is a natural response to experiencing trauma. Yoder provides the following examples of these behaviors (2).

Acting in

  • Substance abuse
  • Overeating or not eating
  • Self-mutilation
  • Depression
  • Anxiety
  • Physical ailments (somatic complaints)
  • Suicidal ideation

Acting out

  • Physical or verbal aggression
  • Gang activity
  • Criminal activity
  • Running away
  • High risk sexual behavior
  • Repetitive conflict

A short video by Dr. Peter Levine, PhD reviews the physical signs and behaviors of children experiencing trauma. He discusses what the behaviors actually mean and how addressing the behaviors can help a child heal from their trauma (3).

Click here to see how Head Start-Trauma Smart, designed by the Crittenton Children’s Center, shows their trauma informed response to the acting in and acting out behaviors (4).

Sources

  1. Rennison, C., & Taylor, L.A. (2013). Recognition and treatment of posttraumatic stress disorder.  Journal of the American Academy of Physician Assistants, 26(3), 64-66.
  2. Yoder, C. (2005). The little book of healing trauma: When violence strikes and community security is threatened. Intercourse, PA: Good Books.
  3. First Impressions - - Exposure to Violence and a Child's Developing Brainhttps://www.youtube.com/watch?time_continue=432&v=GuWkqF-WfOM
  4. Kids in the House (2013). Signs of Trauma in Kids – Peter A. Levine, PhD. Retrieved from http://youtu.be/pWSOEhJMCfk
  5. Robert Wood Johnson Foundation (2014). Head Start- Trauma Smart. Retrieved from http://youtu.be/bXzKVpiSzH8

Lived Experience: Anna Choi

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Read Anna's Story

I don’t like it when Dad hits Mom. When he hits her I am really scared and my head hurts. My heart pounds so hard in my head I can hardly hear anything else. All I want to do is go into my room and hide my head under the pillows. It’s hard to go to school and listen to what my teacher Ms. Edwards is saying. She keeps asking me what is wrong, but I can’t tell her. Sometimes I go to the office because my stomach hurts. I am afraid my Dad will be angry if Ms. Edwards tells him I am not listening in class.  Why is my Dad always mad? Maybe it is my fault. I love my dad, but he hurts my mom all the time. I love my Mom very much, I love my brother too.  But I don’t like my grandmother because she yells at my Mom. I wish my parents would be friends.  I like to go outside and play with other kids, not just stay inside and help around the house all the time. But I know helping out makes my mom less sad. I just want my family to be happy.

Lived Experience: Brian Carlson

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Read Brian's Story

I’m so mad at my mom; last time she kicked him out and this time she called the police. Now he is in jail. I know it is hard for her when he comes home angry from work. But I just don’t understand why she hates him so much. I think she needs to see his side. My dad says he hates his job and his boss is a total jerk. Some days he would come home from work and say and do mean things, but I know that he loves us.

My dad is my role model. I want to be just like him when I grow up. And when my mom had him arrested I got really angry at my mom. After my dad left, I didn’t want to do anything except sleep. Sometimes I think I don’t even want to be alive. I used to love to be at school. But now I see how my friends don’t have the same problems I have, so I avoid them and don’t really want to hang out with anyone. My teacher is always picking on me. Just yesterday she kicked me out of class because I yelled at her. I always get picked on for no reason. That is why I wish I could be my father, no one picks on him.

Trauma-Informed Approaches

Viewing social issues through a trauma-informed lens

›A trauma-informed lens shifts our question from: “What is wrong with you?” to “What has or is happening to you?” This helps us recognizes the impact of trauma on people’s behavior. A trauma-informed lens also moves from simply a focus on an individual's behavior to ask, "How can we be a better support for people?" and addresses the organizational and systems issues that might get in the way of people's efforts at healing and wellness (1). What changes would need to be made in organizations and communities if social issues were viewed through a trauma-informed lens?

  • Acing out and acting in behaviors are common ways individuals, organizations, communities, and societies re-enact trauma.
  • ›Often families, organizations, communities, and societies react to these behaviors rather than recognizing trauma as a root cause and providing interventions that support trauma healing.
  • For example, it is important to recognize incarceration and substance abuse is strongly related to childhood adversity and trauma. 

Carolyn Yoder in the Little Book of Trauma Healing reminds us that the proof of trauma healing is not only in the ability to carry out basic functions, but importantly in the quality of people’s relationships (2).

Providing safety and support is foundational to trauma healing

What helps create an environment of safety and restores one’s sense of personal control?

Establishing safety begins with control of the body and moves outward toward self-protection and self-care and the organization of a safe environment. Survivors often feel unsafe in their bodies and unsafe relative to other people. Emotions and feelings often feel out of control. Strategies must address people’s safety concerns in all of these areas. Along with these elements of safety there is a progression to safety and control of the environment. Establishing a safe environment requires not only a mobilization of caring people but also a plan for future protection (3) - Judith Herman.

Acknowledgement

Acknowledgement of trauma has been identified as crucial to trauma healing, as it allows the individual (and larger community) to recognize the violence committed. It allows there to be a connection to the reality, and offers a possibility of grieving that is necessary to be able to reconnect to others, re-establish trust and relationships, and reintegrate the trauma into the life and of the individual or community (3).

Reconnection

An important task of trauma healing is “empowerment and reconnection as experiences of recovery” (3). Trauma creates a rupture in relationships that requires reconnection with one’s self and others (4). 

Throughout the process of reconnection it is important to remember that the process of healing is a journey that involves work on multiple dimensions (2). The individual going through the healing process can often loose connection with their own self which can lead to feeling “unsafe in their bodies” (3). There are many tools to assist an individual in reconnecting with their bodies including grounding techniques, meditation, and yoga (5).

Sources

  1. Dhaliwal, Kanwarpal (2017) Going beyond asking what happened: building beloved community. Accessed http://www.acesconnection.com/blog/going-beyond-asking-what-happened-building-beloved-community on April 11, 2018.
  2. Yoder, Carolyn. (2005). The Little Book of Trauma Healing. Intercourse, PA: Good Books.
  3. Herman, Judith (1997). Trauma and Recovery. The aftermath of violence-from domestic abuse   to political terror. New York, NY: Basic Books.
  4. Winslade & Williams (2012). Safe and Peaceful Schools: Addressing Conflict and Eliminating Violence. Sage Publications.

  5. Sparrowe, Linda (2011). Transcending yoga. Yoga International, Fall 2011, 49-53, 89. https://yogainternational.com/article/view/transcending-trauma-how-yoga-heals

Lived Experience: Latanya Johnson

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Read Latanya's Story

I know that I have to stay away from Clinton for my children’s sake. The kids are really upset; they believe that Clinton tried to burn the house down with us in it. I keep trying to reassure them that it was just an accident. I have known Clinton for a very long time and I know that he would never do anything that will harm our children.

I know I am a strong and independent woman, and I know that I do not need a man to define me. It’s just that I have been having a hard time dealing leaving Clinton, we have been together forever. And it gets extremely lonely at times. My kids do not want me to have anything to do with Clinton. I know what I have to do; I have to remain strong for my children. And if that means staying away from Clinton, then that is what I will do.

At church a couple of months ago, my pastor was talking about domestic violence and shared that there was a new group for women. I decided to attend but I wasn’t sure if I would share my story. However, over a couple of weeks, we began to really trust each other. I realized we wouldn’t judge each other. After I shared my story, I was amazed to find out how many other women had similar experiences. We count on each other and provide support during hard times. I don’t know what I would do without my women’s group.

Critical Thinking

This section is intended to allow you to integrate the training content into the “lived experiences” of our case families. Each of our critical thinking questions addresses one or more of the people in the Carlson, Choi, or Johnson families, and examines an aspect of their lives.

Take time to think about your responses to each of these questions, and think about your answers from multiple stakeholders’ points of view. We encourage you to go back and review sections of the curriculum, re-read the lived experiences of each family member you met in this training, and engage in dialogue with community partners and co-workers.

  1. What physical signs and behaviors are Anna and Brian exhibiting of their experience of abuse in the home?
  2. What would a trauma-informed response look like to support Anna and Brian?  
  3. How is LaTanya's experience with the women's group trauma-informed? How might her experience support her path to safety?