 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on trauma-informed care, the impact of trauma. So we started out talking about the sociocultural effect of trauma and impact in kind of a general way, how it impacts cultures, communities, et cetera. We also talked about defining what is trauma. But we've talked sort of vaguely about the impact of trauma. We've talked about those symptoms that are in the DSM as occurring with PTSD, hypervigilance, hyperarousal, emotional detachment, yada yada, those more clinical things. But we're going to look at the breadth of symptoms that trauma may cause and sort of how they may progress, the immediate symptoms as well as the delayed reactions that you may still be seeing a year, two, three, four years later. And we're also going to finish up by talking about the impact of trauma on the family. We're going to learn about the sequence of trauma reactions, explore the common immediate and delayed experiences and explore impact of trauma on family. I already covered that. So delayed or traumatic response. Now, one of the things that we may not realize is that there can be a delay of months or even years before the symptom appears. So if the person goes through a trauma and doesn't develop acute stress disorder, doesn't seem to develop PTSD and then, you know, eight, nine, 10 months later, a couple of years later, all of a sudden there's a trigger. It can happen. We're not saying that it won't happen. And, you know, what I've seen in people who have experienced something like this, a lot of times they're the type of people who compartmentalize and they take whatever it was and they put it in a tidy little box and they put it in the back of their mind and they just refuse to think about it again until something triggers it. Childbirth, for example, can trigger the memory of childhood sexual abuse for some people that they may have completely dissociated, put that in another box. And then when they have a child, all of a sudden their abuse memories start flooding back and they start having problems. You know, we want to be sensitive to the fact that it's not necessarily something that just recently happened and it can catch people unawares. You know, they think they've dealt with it already or they didn't think it was traumatic. So we want to be aware of that. Trauma symptoms can appear suddenly even without conscious memory of the original trauma or without overt provocation. So, for example, somebody who was abused as a child may not have a memory of that, particularly if they were abused as a very young child. And then something happens in their adult life that triggers that memory. It could be watching a movie, it could be seeing another parent strike their child. You know, it could be a variety of things. It doesn't have to be necessarily them getting abused again themselves. Clients who are experiencing a delayed reaction to trauma can benefit if you help them create an environment that allows them to acknowledge the trauma. They start having flashbacks and nightmares and they're like, I don't know where these are coming from. And, you know, we don't want to get too far because there's that whole concept of false memory. So we don't want to get too far into having them detail necessarily everything. You want to be careful. But we do want to talk to them about what are you remembering and, you know, is there, do you think this really happened? Discuss their initial recall or first suspicion that they were having a traumatic response. And what I tell clients a lot of times is sometimes our brains, they want to help us survive. So they block stuff that we're just not able to handle at that particular point in time. When people write their autobiographies for me, you know, they'll write their autobiographies and they may have gaps of, you know, a month or a couple of years where they really don't remember anything. And they find it very frustrating. And my response to them is, you know, for whatever reason, your brain is not allowing you access to that. When you have the coping skills, when you have the resources, when there's a need for it, your brain will let you know. And generally that does happen, you know, as we go through treatment, some of those gaps start to fill in, not necessarily all of them. Sometimes people just keep holes in their memory. And there are ways to address it if they want to explore hypnosis or something like that. But most people, you know, in trauma-informed care, we're going to look at, you know, is how important is it to remember that gap there versus how important is it and what do you need to do right now to help you recover? Sometimes that memory is crucially important and we kind of talked about this yesterday. Sometimes not so much. We want to draw a connection between the trauma and presenting trauma-related symptoms. So if the person has been showing some trauma-related symptoms, but they haven't remembered the trauma, and then all of a sudden they start remembering the trauma, most of the time we can be pretty confident that there was a trauma, that they had just pushed away, they weren't able to look at or willing to look at, and now it's starting to come out. Explore their support systems and fortify them as needed, as people start to recognize a trauma and experience trauma-related symptoms, whether it's delayed or immediate, they need social support. You know, there are going to be nights when they wake up in a terror. There are going to be nights where they can't go to sleep because they're afraid. There are going to be times when they just need a friendly voice on the other end of the line. So it's important to make sure they've got people they can reach out to, and it may be people that are already in their support network. It may be people in support groups that they connect with, and it can be people in crisis hotlines. Last-ditch effort, you want to make sure that if they wake up at 2 in the morning, they can connect to a live person somewhere. So crisis hotlines can be, you know, sort of a last resource. And I say a last resource because most people, you know, it's kind of like starting with a new therapist. They got to rehash the whole thing when they call the crisis hotline. So it's not the ideal situation, but it is a compassionate person. We want to identify the triggers. What do you think may have triggered this? If they're starting to remember what may have happened, what their memory is, what their experience was, then you can start kind of guessing about some of the triggers. But we can ask them, when did you start noticing these symptoms and what was going on? You know, you weren't experiencing them, then what changed that made you start, you know, experiencing them or feeling kind of wonky? Develop strategies to navigate and manage symptoms and triggers. So here we're going to talk about what your symptoms are, how they represent a normal adaptation to help you survive until now. And we're going to talk about triggers. And then we're going to talk about how to deal with triggers, minimize as many as possible and, you know, deal with the ones that you can't minimize, as well as managing symptoms. What are some alternate things you can do when you have, when you feel like you're constantly scanning and constantly on guard? How can you help yourself feel safer? So we're going to talk real briefly about the biology of trauma. And it's a fascinating field to go to look into and to learn about. But there are changes during a trauma for some people, especially an extended trauma or an extreme trauma. And it can be, you know, it's more problematic in adolescents and youth whose brains are still developing. But people who have fully developed brains like soldiers and cops, they're not immune to it. So when there is a trauma, your HPA axis, your threat response system is activated. And so it says there's a threat you need to prepare to fight or flee. So a bunch of things happen and it releases cortisol. Cortisol is your stress hormone. Cortisol causes you to have a release of blood glucose. So you, you know, you've got that immediate energy for fight or flee. But it also causes the suppression of sex hormones and serotonin. Sex hormones, you know, it's a threat. This is not the time to procreate. So those go down and serotonin goes down. Serotonin is our calming chemical. We don't want to be calm right now. We want to be prepared to survive and to fight or flee. So this is what happens. But in a trauma situation, when the person never feels safe afterwards, they are in this persistent state of hypervigilance, if you will, this persistent state of alert in order to prevent themselves from being taken unawares again. And the brain, like, like I explained, I think two sessions ago, if you stay hypervigilant long enough, the brain eventually will say, you know what, I can't keep devoting resources to this. I need to conserve some energy for when there actually is something to fight or flee from. So the person starts to have lower cortisol levels, which is called hypocortisolism. And they start to feel more depressed. They start to feel more apathetic. Things that used to make them happy don't make them happy anymore. Things that used to bother them don't seem to bother them anymore. They feel more numb. You know, there's that numbing thing that we talk about. And hypocortisolism has a lot of other symptoms that go along with it. When cortisol levels are high, when you're on high alert, think about a soldier in a foxhole. He's probably going to sleep at some point. But is he going to get good sleep? No. And people who've been through a trauma may not be able to relax enough to get good sleep. And as sleep quality and quantity diminish, depressive symptoms increase. So we start to see a lot of problems from this persistent activation of the threat response system. So think about sailors on a boat. You know, they have their drills every once in a while. But if the captain is calling a drill every single hour, every single day for three months or four months, or heaven forbid, two years or something, the sailors are going to start to get really worn down. And they're not going to really even pay attention much anymore. They're going to drag their happy self up to where they're supposed to be. But not with the enthusiasm as before. And this is kind of what happens when cortisol levels start to go low. And this is regardless of what kind of trauma it is. If it is traumatic, then the person felt a sense of loss of control for something going on. So it will cause them to be hypervigilant. It will cause them potentially to emotionally dysregulate. And these symptoms will come back. There's hypocortisolism. The interesting thing is when something does trigger the reaction, when something does trigger that symptom to go off again, the stress response is significantly higher than it normally would be for that particular stressor. So it's zero to 120, which is what we think of as emotional dysregulation. So as you start understanding what's going on here, you can start understanding how the brain and chemicals in the brain and changes in the brain might be causing this. And if we can help not dampen the response, but help turn off that HPA axis so it's not constantly firing on alert, let the person get some rest, let the person get some sleep and some relaxation, and get those serotonin levels back up and the estrogen levels back up or testosterone, then they will start feeling a little bit better. So it is definitely a bio-psycho-social approach to treating trauma. Immediate reactions to trauma, numbing and detachment, anger, fear, helplessness, guilt, including survivor guilt, exhilaration as a result of surviving. So that's one we don't usually talk about. We think about, you know, anger, fear, guilt, all those things. But exhilaration, you're like, where's that come from? And it's just that you survived and, you know, you're thankful that you survived. So we don't want to say, well, somebody is, you know, seeming to deal with it really well. They're in a good mood. They're downright giddy. So they're not going to have any problems in the future. You can look at it as, you know, they have this sense of exhilaration and, wow, what a rush. Maybe even a sense of being reborn or life anew. But then as that adrenaline wears off, there can be a opposite sort of reaction where it's like what the heck just happened. And they start thinking about things even more. There can also be sadness, a feeling of depersonalization for a lot of people in that, you know, if you think of the grief process, denial, anger, bargaining, depression and acceptance, the first one is denial. When something like this happens, it's a loss. It's a loss of your personal control, a loss of the way you conceptualize the world. There are a lot of, you know, sort of esoteric losses that happen in addition to potentially tangible ones. So there may be a feeling of depersonalization because your brain does not know how to make sense of this. This does not fit into any schema that you have in there and your brain's like, ah, this isn't supposed to happen. Maybe it was a dream. Maybe it was a television show. Maybe, you know, and you keep trying to think and bargain and maybe it wasn't real. And that can go on for extended periods of time, you know, even, you know, after a trauma, when the person's working with the cops or, you know, trying to put things together, they may have moments where they think maybe it was just a dream. Disorientation, that's pretty common. If something unexpected happens, you're going to be disoriented. Feeling out of control, denial, constriction of feelings, you know, just kind of shutting down. And I've seen it before. Not everybody gets super emotive. Not everybody shuts down. Everybody deals with trauma in their own way. So we don't want to, again, assume that just because somebody's not overly emotive, that they're dealing with it quite well. They may just not be feeling anything right now. And feeling overwhelmed, just kind of looking around going, I have no idea where to begin to fix this. So those are just the immediate reactions. And that's the immediate emotional reactions. There's a whole bunch of other stuff we're going to go to. But as time passes, and it can be three or four days, or it can be, you know, three or four months after the immediate reaction or the immediate sensations, the person may start having irritability and or hostility. You know, their world was turned upside down. What happened to them was likely not fair. Irritability and hostility are also power moves. They keep people away. So I'm going to push people away to stay safer. Depression, as the cortisol levels go down, as serotonin levels go down, as estrogen and testosterone levels go down, people are going to start experiencing depressive symptoms. But not always. You know, there may be some mood swings because, you know, they're not feeling a lot. But when they do feel something, it's zero to 150. Because that HPA axis is holding on. And then when it's finally triggered, it just kind of opens the floodgates. There's no trickle to it at all. It's like turning the water on or off. There's no moderate stream. There can be anxiety and fear of the trauma recurrence. That's totally natural. And it can go on for years. If someone was victimized when they were younger, when they were a child, when their children get to be that age, they may start having flashbacks. They may start having a recurrence of some of those trauma symptoms and fearing that trauma is going to recur to their child. They may fear the trauma after it happens. It's going to recur to them. So, you know, we don't want to negate what might be going on with any of our clients. Grief reactions. As I said, there are a lot of losses. Oh my gosh, when a trauma happens. So we want to be open to how did this change the way you view life? How does this change the way you think? How does this change what makes you happy? What makes you sad? What makes you scared? And all of those can be potential losses for them. So we want to help them frame it in terms of a change or a loss and help them adjust and move to that stage of acceptance. Shame can perpetuate, you know, for many, many years after something happens. A feeling of being fragile or vulnerable can perpetuate and emotional detachment. You know, just not even being able to connect emotions with what happened then, but sometimes not even being able to connect emotions with what's going on now. It's just, I can't feel. And we see emotional detachment a lot in law enforcement and military who see a lot of really traumatic things. And, you know, they start, they shut this down and then they shut that down. And eventually they just, it's too dangerous in some ways to feel. So they start becoming detached and just kind of emotionally flat. Now, somebody asked me to say more about shame. Depending on what happened, you may have a shame that you didn't do something. Shame that you did do something. You dressed a certain way or you said a certain thing. Or somehow you feel like you brought it on yourself. Or some, you may have shame because you feel like you didn't protect somebody else. You can have shame about how things turned out. You know, after going through, for example, a rape exam, you know, that's pretty humiliating. And you've already been humiliated once after a rape. Then you have to go through a rape exam, which is humiliating again. And you just keep being humiliated. So there's shame associated with or can be associated with the whole process. And then having to tell the detectives and the lawyers and the court, you know, exactly what happened and kind of bear your soul to everybody can be humiliating and people can be shameful. And people can look in retrospect, like you said, and say, you know what? I should have done this and I would have gotten away. I should have done that and I would have gotten away. And other people may say that too. And it can be very, very triggering. I'll share with you when I was younger, I was the victim of a home invasion robbery. And I was 11, you know, I was home by myself. I was homesick from school that day and, you know, home invasion robbery. And I was paralyzed. I remember not being able to make a sound, not being able to move. And we'll be watching TV now and we'll be watching law and order or one of those shows or something. And my husband who's a cop and has been trained to act in, you know, stressful situations is always like, well, why doesn't that person just run or scream or do this? And every time it just, you know, I just want to go, maybe they can't. You don't understand that not everybody reacts the way that you do to a trauma. And, you know, I quit saying that a long time ago, but it's important to understand that sometimes well-meaning people, even, you know, 20, 30 years later, will say things that trigger that shame reaction again. And they go, well, why didn't I? They may not have been able to. They did what they did and they survived. And let's get through that. Cognitive reactions to trauma, difficulty concentrating, ruminating or racing thoughts, distortion of time and space, memory problems and strong identification with victims. So let's kind of go through those real quick. Obviously, after a trauma of any sort or a stressor of any sort, we're not going to concentrate so well. The brain devotes those resources to fight or flee, not learn and concentrate. So the energy and the neurochemicals we need aren't there for concentration. So writing things down can help, encouraging people to be kind to themselves because they're not going to concentrate as well. Ruminating or racing thoughts. Obviously, you can ruminate over with survivor guilt. You can ruminate over what you should have done. You can ruminate over how bad the world is or unsafe it is. There are a lot of things that you can dwell on. A lot of times rumination serves the purpose of trying to help the person sort through things and figure out how to regain control. But sometimes they can get stuck in it. Racing thoughts are just kind of the opposite. I mean, they're just going all over the place because they don't want to sit still. They don't want to think about it. So they're thinking about this and that and the other thing over here. Distortion of time and space. After something happens, sometimes it'll feel like you can't remember when it happened. Was it yesterday or was it a week ago? Because so much is happening, your schedule gets turned upside down. Whether you're a victim of a crime and you had to have physical exams and talk to cops and all that kind of stuff. Or whether your house burned down and you had to go stay at a hotel and are involved with the Red Cross. After a trauma for 99.9% of people, their life is disrupted in some way. And so they may have a distortion of time and space because they don't have those normal anchors of going to work and coming home. Think about when you're on vacation. If you have like a two week vacation, oh my gosh, wouldn't that be nice? Sometimes it's hard to remember. Is it Saturday or is it garbage day? Because you're not doing your normal things. Memory problems. When we're traumatized, our ability to consolidate memories. There's a lot of chemical reactions that happen that keeps you from consolidating some of those memories, which is cool in a way. Because your brain is going, you know what? We really don't need to remember that. That was pretty horrid. So it keeps those memories from consolidating. Well, that may continue to go on because you're having difficulty concentrating. But sometimes those memory problems, the person can't remember what happened during the trauma. When you're being interviewed by the cop right after it happens, you're like, you know what? I can't remember. And people look at you quizzically and accuse the victims, I guess, of either lying or not paying attention or not wanting to help or whatever. But we need to remember that even right after the trauma, if all of those neurochemicals were going and the person wasn't able to consolidate those memories, they weren't able to do it. We can't squeeze blood out of a turnip. And they may identify strongly with other victims of similar crimes, if they were the victim themselves, or if they're observing a crime. If they're a bystander and they see the crime happen, they may have a super strong identification with the victims and sort of an over empathetic response. Delayed, cognitively, you know, we don't just suddenly turn a switch and all of a sudden we're back and thinking in our happy, hunky, dory way. They may have intrusive memories or flashbacks. So we talk to people about what's the purpose of this and how is it protective. Reactivation of previous traumatic events. So things can happen in the future. Like I said, when women have start having children or even men, I would assume it can happen with them to when they bring home their first child. If they were abused as a child, they may start having flashbacks to what that was like and wondering if they're going to be an abusive parent or wondering if they're going to be able to protect their child. They may start bringing back floods of feelings and memories. They're self blame, you know, still that's emotional and physical or emotional and cognitive. So thinking about your cognitive distortions and a lot of times cognitive distortions are all or nothing. And, you know, I should have been able to get away. There's no way this should have happened. So we want to look at self blame through the lens of two things. Emotional versus factual reasoning. Well, three things. Emotional versus factual reasoning because if they are reasoning using emotions, not facts, it's probably faulty reasoning. Right now, when they're doing this reasoning, they're calm so they can see all these opportunities. When you're not calm, you're not seeing all those opportunities. So you need to remember what kind of state you were in when this was happening. Emotional versus factual, you want to look at the big picture. Is the person focusing on one aspect of the situation or the whole thing? Who else was there? What else was going on? What else was going through your mind at that particular point in time? And what cognitive distortions are you using? You know, are you using all or none thinking or personalization when it's not helpful? There can be a preoccupation with the event, you know, wanting to get their power back, difficulty making decisions. Magical thinking or a belief that certain behaviors including avoidant behavior will protect against future trauma. So, you know, this is especially true for example for parents whose children who were abused as children, especially if they were abused by, you know, somebody outside of the family. They may be way overprotective of their children because they don't want their children to be exposed at all. So they're avoiding even the slightest risk that this could happen again. And you can see changes in the person's own behavior, how they may be avoiding situations that put them in similar positions. Now the other caveat that you see with magical thinking sometimes is people thinking lightning won't strike twice or I'm going to master this. So there is a subset of people who survive traumas who kind of put themselves in that situation again to try to get it right this time. Try to master the trauma instead of feeling victimized. So we want to talk about that. If someone who was date raped continues to put themselves in risky situations, you know, we want to talk about, you know, how they can stay safe when they're dating. Belief that feelings or memories are dangerous. Yeah, it can be really overwhelming so it can feel dangerous to the person because they don't know what to do with these feelings and emotions. And they can generalize triggers. So if, you know, one of my clients watched his best friend commit suicide in front of him with a gun, the sound was a very loud bang. Well that very loud bang became generalized to just about anything that was a very loud bang. If it's a car backfiring, if it's a door slamming and that can trigger a very strong emotional reaction in him. So we want to kind of look at those things. Magical thinking could lead to OCD like behaviors. Yes, because if they believe that they do, if they do this, that and the other thing, then they'll be safe. I would tend to look at it more as superstitious behaviors than wanting to label it as OCD because it's generally not going to progress to obsessive compulsive disorder, but they will have a certain ritual that they do, which is, you know, somewhat superstitious in order to try to stay safe. Behaviorally, immediately people may have an exaggerated startle reaction and even later they can have an exaggerated startle reaction. So it's important to help them understand that you can work with that. You can start learning to be okay with loud noises, but it takes time. It doesn't happen overnight. They may be restless. You know, when your world's turned upside down, you want to get back to some sense of normalcy. And if you're hypervigilant, if you're worried that, you know, you got to stay on guard all the time. You've got norepinephrine and cortisol in your system and it's keeping you kind of awake and agitated. So it makes sense that they may be restless. Sleep and appetite disturbances. Well, that's that old HPA axis again. We're not going to be able to rest enough to get sleep. Good quality, deep restorative sleep. So people are going to start getting a little more tired. It also means that hormones like grailin and leptin, which are responsible for telling you when you're hungry and when you're satiated, they're going to get out of whack too. So this is when we start to see physiological reactions. So sleep, just so important. Difficulty expressing oneself. How do you express yourself when you can't even make sense of what happened? So they may feel challenged in expressing how they're feeling, what they're needing. They may feel numb so they don't know and it's frustrating to them that they don't know what they need, but they don't know how to kind of articulate that. We can help by paraphrasing that if we ask them what they need and they're like, I don't know. We can talk with them about how frustrating that must be to deal with. They can be argumentative. You know, this is the way it's going to be. They're trying to take control of their situation again. I'm not going to testify or I am going to testify or I'm not going to go to that shelter or I am. And they can start getting very rigid in their opinions and remembering that most of the time this is the way they're trying to get their world back into control. Try to get that box back together again. Increased use of alcohol, drugs and tobacco for calming kind of purposes or just to help them forget for just a minute to make those flashbacks go away to just numb it out. Does it mean they're going to become an alcoholic or a drug addict? No, but we may see an increased use of these drugs. Withdrawal and apathy, cortisol levels go down, serotonin levels go down. The person just starts feeling depressed, hopeless, helpless. Yeah, makes sense. And we can see avoidant behaviors, not wanting to be around other people. Well, after you've been traumatized, there's a lot of reasons like we've already talked about. You either can't trust them or you can't take the input or you don't think they can handle your emotional stuff right now. So a lot of times people start avoiding other people and they may start avoiding places that remind them of the trauma. All of this, you know, works its way through, but people may continue to avoid event reminders. You know, my stepfather, they don't ever put up a Christmas tree because the Christmas lights are triggering for him. Now, you know, he has learned to deal with the Christmas lights at his daughter's house and everything, but he doesn't want to be surrounded by it at his house. There may be social relationship disturbances, just still lingering distrust or frustration with other people or just irritability, you know, not wanting to deal with other people's crap because you're barely dealing with your own stuff on a day to day basis. Decreased activity level as exhaustion sets in, increased engagement and high-risk behaviors. If people are emotionally numb, especially, they may do this just so they can feel something. They may do it in order to also forget to have, you know, different things going on. Increase use of alcohol or drugs can continue. You know, this is one of the most common symptoms that continues on. So if we look at what's the function of your substance use when you started using it, you know, once people start using substances, the neurochemicals in their brain get messed up because the brain starts or the body and the brain start expecting those chemicals to be coming in. So the neurochemistry in the brain changes and that will precipitate or perpetuate the need for alcohol and drugs. You know, if the brain chemicals get messed up, then there's the withdrawal syndrome people start using just to feel normal again. So we can see problems develop, but it's not necessarily going to happen. Attachments in relationships. Trauma can impact people's ability to develop strong, healthy attachment to caregivers. And this is for children especially, but also for adults. When something happens, you know, people may kind of break their attachments with other people. They don't want to love anybody because they don't want to get hurt like that again. If they, you know, had a loved one murdered, you know, I can't do it. It may break their attachment or keep them from developing attachments with other people. Again, because they either don't want to trust, don't want to love or can't trust other people. People who do not have healthy attachments in relationships have been shown to be more vulnerable to stress, have trouble controlling and expressing emotions and may react violently or inappropriately to situations. Well, let's kind of take all these together. It sounds like emotional dysregulation going from zero to 250 in 1.2 seconds. Relationships are one of our greatest buffers against stress. So when somebody is like at their peak completely stressed out all the time and they don't have anywhere to put it. They don't have anybody to help them deal with it. It makes sense that every little thing could kind of send them over the proverbial stress edge. So we want to talk about, you know, you're reacting to this with a 10 when it probably deserved a two. So what's fueling that reaction? You know, let's look at what's contributing to it and generally it's the trauma stuff. So if somebody, for example, doesn't call your kid doesn't call and they're going to be late for curfew. And yeah, you deserve to be angry about that, of course, because they're breaking the rules. But if you react to it like as if they had gotten into a car accident and they're on death's doorstep in the ICU, that's probably an overreaction. So where's that coming from? And you may look back to prior traumas when, you know, maybe the person's best friend was killed in a car accident. And so now whenever their kids late, they just assume the worst. There are people who have been sexually abused, who say they will never be able to trust somebody of the same gender as their abuser again and may never be able to trust anybody sexually again. So even if their abuser was a man and they want to be in a relationship with a woman, making themselves vulnerable or interacting in that way may be too overwhelming. So they need help dealing with those issues and compartmentalizing. Yes, that was a horrible experience. But they need hopefully to figure out how to be able to separate the sex between two loving people and the traumatic experience and separate them, even though some of the physiological reactions are the same. Some of the feelings are the same. There's a lot of stuff that goes into recovering from sexual abuse or rape. I mean, it doesn't have to be an ongoing thing. Physical health, the body and brain. When a child grows up afraid or under constant or extreme stress, and this is true all the way up through 25, especially, but it can be true later in life if somebody is in a domestically violent marriage for 20 years, for example. It can change the brain. The immune system and the body stress response systems may not develop normally, or they may start to change as cortisol levels stay high. Your immune system starts to change later on when the person or adult is exposed to even ordinary levels of stress, these systems may automatically respond as if the individual is under extreme stress. So we already talked about that hypocortisolism and then the overreaction after that or dysregulation stress in an environment can impair the development of the brain and nervous system. And it can also cause problems even in a fully developed brain. The absence of mental stimulation in neglectful environments may limit the brain from developing to its full potential. And we've seen with older persons, if the person is in an under stimulating environment, symptoms of cognitive decline come on more quickly. So it's not just for kids. You know, if you've got an elder who is being neglected, if they're homebound and they're being abused by their caregivers, you know, you can see cognitive decline in those people. So, you know, it can go either way, failure to reach potential or rapid decline. People with trauma histories may develop chronic or recurrent physical complaints such as headaches or stomach aches. Well, number one, serotonin is 80% of your serotonin is in your gut. So when your serotonin gets out of whack, generally your GI system gets out of whack. Number two, when you're under stress a lot, you're also retaining a lot of tension in your body, which can contribute to stress headaches. You may be grinding your teeth, which can contribute to headaches. So we do want to pay attention to that. And some people will somaticize their symptoms. You know, they're not going to talk about depression. They're going to talk about fatigue and lethargy and body aches. Okay. You know, let's talk about it however you want to talk about it. Let's label it what it is. But if you look at the diagnostic criteria for depression, for example, fatigue and body aches and stuff are there. And remember that serotonin is responsible for our pain perception. So if the stress is keeping cortisol levels high, then serotonin levels are going to be lower. And estrogen, which makes serotonin more available, is going to be lower. Same thing with testosterone. Which means their people's pain tolerance is also going to be lower. So it makes sense. I mean, all of this stuff is interconnected. Trauma survivors may suffer from body dysregulation, meaning they over-respond or under-respond a sensory stimuli. For example, they may be hypersensitive to sounds. Something that doesn't bother you at all may drive them crazy. I won't call it a trauma, but we had a tornado come through and took down a couple hundred feet of our fencing. And I walked out the next morning and I was just like taking a back from it. And now whenever I hear the wind start to pick up, it doesn't have to even be that loud. I'm kind of on alert because I want to make sure that the fence doesn't fall down again. Not that that was a trauma, but that was a big stressor for me. Stop short of trauma. So imagine what somebody who's traumatized may experience. Smells, something that you don't really even smell that much can be traumatizing to somebody. Especially if it reminds them of their trauma because smell is our greatest memory trigger. Touch or light, some people may be hypersensitive to touch. Or they may suffer from anesthesia and analgesia where none of this, I mean, they can hurt themselves. They can pick it themselves, they can cut themselves and it doesn't even hurt. They just don't feel anything. Emotional responses, they may have difficulty identifying, expressing and managing emotions and may have limited language for feeling states. So we want to use as many tools as we can to help people develop an emotional vocabulary that works for them. Not everybody likes those feeling words like happy, mad, sad, glad and afraid. Whatever terms they're going to use, they feel like they got kicked in the gut. They're feeling drained. They're feeling, you know, really tense right now. Okay, whatever words you want to use. But let's start encouraging people to, when they do their mindfulness scans in the morning and the evening and preferably at lunch too. I usually say do it right before every meal. That they can identify at least one emotion that they're feeling. And I always remind people that emotions are like onions. There's multiple layers to them. So don't, if you can identify multiple emotions, great, but tell me at least one thing you're feeling. They may internalize or externalize stress reactions and as a result may experience significant depression, anxiety or anger. And their emotional responses may be unpredictable or explosive. Since traumas are often interpersonal in nature, even mildly inter stressful interactions with others may serve as trauma reminders and trigger intense emotional responses. So if a child was abused and they told their caregiver and they weren't believed, then that disbelief, you know, hit them really hard. Later on in life, they may be telling their boss something and their boss doesn't believe them or is dismissive of them. And they react very explosively to it or they take it, you know, react with a 10 instead of a two. And we might look at, you know, what did that remind you of when you felt like you were being dismissed? What did that remind you of? So again, it doesn't have to be the same type of situation. You know, those are two very different situations, but they triggered the same response. Having learned that the world is a dangerous place with and people are often vigilant and guarded in their interactions with others and are more likely to perceive situations as stressful or dangerous. They're scanning. They're looking around in the environment for people who remind them in some way of the person or persons that hurt them or the situation that hurt them. Dissociation and going back even some of those, you know, like hurricanes, they may be harboring resentment and anger towards those people they felt did not help them. So maybe it wasn't somebody that directly hurt them, but it was somebody who showed apathy or didn't help them in their time of need. Once people have learned to dissociate as a defense mechanism, they may automatically dissociate during other stressful moments or when faced with trauma reminders, they just space out. Dissociation can affect people's ability to be fully present in activities of daily life and can significantly fracture a person's sense of time and continuity. Sometimes people don't even realize when they're dissociating, they just kind of space out for a minute or a few minutes. It can have adverse effects on learning, classroom or work behavior and social interactions because when they get stressed, they may just kind of, and it's not even going to a happy place. They zone out for a second and they're like, what were you saying again? And they're not trying to be rude, but it may come off to a teacher as daydreaming or to a supervisor as being disrespectful or not paying attention in a meeting. It's not always evident when someone's dissociating and at times it may appear if the person is just simply spacing out or not paying attention. A person with complex trauma histories may be very easily triggered or set off and are more likely to react very intensely. Remember, complex traumas are ongoing, repetitive traumas and they can be, you know, mild in intensity but ongoing or they can be severe in intensity, but it's not one and done. It's a consistent thing. Now think about that. Whether you're an adult or your child or a child, if this bad thing keeps happening, think domestic violence, for example. How is that going to impact the way you think, the way you see the world, the way you see yourself? You know, it starts eroding your self-esteem, your self-confidence, your trust in others, your belief in a just society. People may struggle with self-regulation and may lack impulse control or the ability to think through consequences before acting or may behave in ways that appear unpredictable, oppositional, volatile and extreme. If you're continually having all these stressors, you know, eventually you may just say enough and people are like, whoa, don't know where that came from, sorry, I'll come back later. And a lot of times these behaviors come to light, if you will, because people start having problems either in their relationships or at work and they don't really understand why they are being more volatile. Traumatized people are more likely to engage in high-risk behaviors such as self-harm, unsafe sexual practices, and excessive risk-taking, such as operating a vehicle at high speed. Now, not everybody's going to do this, but this can be a way that either they feel like they're controlling things, they're putting themselves in a risky situation and they're getting out and they're mastering that situation, or it can be an adrenaline rush, so they're trying to feel something. Thinking and learning can be impacted. Traumatized people may have problems thinking clearly, reasoning or problem solving, may be unable to plan ahead, anticipate the future and act accordingly. So if someone has been traumatized, we want to help them figure out how to stop, take a breath, think, you know, before they make a decision, we want to help them get into their wise mind, so to speak. When people live under conditions of constant threat, all of their internal resources go towards survival, so they may struggle with sustaining attention or curiosity or be distracted by reactions to trauma reminders. So they may have difficulty focusing in their own life, in their relationships. People learn their self-worth from reactions of others, particularly those closest to them, such as their caregivers or their spouse. Caregivers have the greatest influence on a child's sense of self-worth and value, and abuse and neglect make a child feel worthless and despondent. Shame, guilt, low self-esteem, and a poor self-image are common among people with trauma histories. So, you know, those are four treatment plan issues you can identify right away. People exposed to violence learn they cannot trust the world is not safe and that they are powerless over their circumstances. Negative expectations interfere with positive problem-solving and the ability to make a difference in their own lives, so they expect that they're going to fail. They expect that bad things are going to happen. A traumatized person may view himself as powerless, damaged, and perceived planning as a positive action and therefore futile. You know, why should I plan? Because, you know, the world's going to dump crap on my head anyway. They have trouble feeling hopeful and have learned to operate in survival mode, living from moment to moment without pausing to think about, plan for, or even dream about the future. So, figuring out what things and people are important in your life and, you know, where do you want to be six months from now? That might not be something they've even pondered because they're just trying to survive the day. So, helping them, you know, be able to plan and think about the future so they can make more effective choices in the present to get them closer to those goals is going to be super helpful. Results demonstrated the connection between trauma exposure, high-risk behaviors, chronic illness such as heart disease, cancer, and early death. A lot of the chronic illnesses are chronic as they would call them stress-related illnesses, which makes sense because a person who's been traumatized repeatedly or hasn't dealt with their trauma is going to continue to have higher stress levels than the average Joe out there. So, let's look briefly at the family. Trauma changes families as they work to survive and adapt to their circumstances and environment. So, whether it's one person in the family who was traumatized or the whole family, it's going to change the family dynamics. Adult relationships can be a source of strength in coping with a traumatic experience and its aftermath, but the adults have to be emotionally present. If it's thrown the adults for a loop two and the children are looking to the adults for guidance and the adults are just kind of spinning out of control, there's going to be problems. When coping resources are stretched too thin and stress is too high, partners can have difficulty communicating, managing emotions, being intimate. All of this stuff can increase the chance for separation or even violence in the relationship. Helping people look at what are the impacts of the stress that's going on and how can we reduce the stress. We're not even talking about the trauma right now. We're talking about stress. Parents protection, nurturance and guidance speeds recovery and supports their child's coping in the face of trauma. When parents are not available or struggling with their own reactions, they have difficulty effectively responding to and parenting their children. So, when junior starts acting out in order to try to get some comfort, if you will, get mom to give them a hug and tell them it's going to be okay, or put some boundaries on them so they feel like mom still got some control over what's going on or dad. And instead, parent reacts by yelling at them and sending them away. Then juniors just like, oh my gosh, I don't know how to deal with all this on my own. So, a lot of times children will become more agitated because they're looking for or they're needing the parent to set some boundaries and to help them develop the skills to cope with this. Because they've never been exposed to anything like this before. So, they need help developing those tools because they don't know what to do with it. It's kind of like if you grabbed a whole handful of earthworms and you're just holding them and you're like, okay, now what do I do with them? You know, they're kind of wiggly and you're trying to keep them from falling out of your hands, but you know. Sibling relationships are important sources of daily support, especially when living under stress or impacted by trauma. But when sibling relationships become overtaxed, just like, you know, marital relationships, developmentally normal rivalries can turn into intense conflict or feelings of rejection, which can also lead to violence and, you know, aggressiveness. Extended family can offer the day-to-day assistance as well as emotional support. They found that families separated from their extended family often develop a new kinship network. So if the extended family was the perpetrator of the abuse, it doesn't mean all is lost. Because a lot of times people will develop their own extended non-blood family. The family as a whole provides resources to meet the basic needs of each family member and support the family's well-being and day-to-day functioning. Traumatic circumstances, though, drain the family's resources such as time, money and energy and interfere with growing, learning and working. You know, if you've got mom and dad and they're exhausted and the kids are, you know, exhausted and they're all trying to struggle with trauma, they may be, you know, not able to go to work as much. So income goes down. They may be going to the doctor more. You know, there may be other expenses. They may have had to move. You know, there are a lot of things that can drain and add additional stressors that drain the energy and effectiveness of the family. So we need to help them again. Not even looking at it so much as the trauma, but how can we help you relieve some of this stress so you can breathe? Burdens often associated with trauma such as costly court proceedings, moving, changing schools can result in cascading effects such as loss of income as well as time with family and friends. When trauma limits access to needed resources and social support, families have difficulty carrying out daily routines and sustaining important traditions that bind them together like family dinners or, you know, whatever it is. So we need to educate our clients. We need to frame re-experiencing the events such as hyperarousal sleep disturbances and other physical symptoms as physiological but adaptive reactions to extreme stress. It totally makes sense. You're not broken. You're not pathological. You're trying to survive. Now let's see if we can help you sleep a little bit better so you're having a higher quality of life. Communicate that treatment and other wellness activities can improve both psychological and physiological symptoms. Discuss traumatic stress syndrome symptoms. Give them a checklist. Have them look over it and check which ones they experience each week. Explain the links between traumatic stress symptoms and substance use disorders if appropriate. And normalize trauma symptoms. Explaining that they're not a sign of weakness, a character flaw, or a sign of being damaged or going crazy. It's just how they manage to survive and adapt in the face of really abnormal circumstances. We want to support clients and provide a message of hope that they're not alone and they're not at fault and recovery is possible and totally expected and anticipated. Resilient responses that we can encourage, including increased bonding with family and community, helping them redefine or increase their sense of purpose and meaning. You know, what does this trauma mean to you? And what's your purpose in life? You know, how can you integrate this into your story? You have this narrative that you're writing and this was a chapter. It was an unpleasant chapter. Now what happens in the next chapter or in the next season of your life if you want to look at it as a television play? Increase commitment to a personal mission. You know, help them use this energy. You know, now's a chance for you to decide what's important in your life. They can revise their priorities and they may have an increase in charitable giving and volunteerism. These are ways people try to reconnect with the good in the community, so to speak. Trauma impacts the person emotionally, cognitively, physically, developmentally, interpersonally, and spiritually. It just hits the whole gamut. So we want to make sure that people understand that and they're not just focusing on the emotional symptom or the flashbacks. We want to help them see that there could be an array of symptoms, but as they start dealing with the trauma, those symptoms will start to remit. And as they start taking care of themselves, you know, sometimes they're not ready to deal with the trauma, but they're willing to work on improving their sleep. You know, start wherever, you know, wherever you start is going to have positive impacts at reducing the stress, increasing their social support, and helping them deal with the trauma. When the entire family system is experienced to trauma, it's difficult to even have a trusting relationship to turn to within that system. Yes, that's very true. After a hurricane, for example, if you lost everything, you know, it may be difficult to turn to somebody else in the family for children to turn to parents or even for parents to turn to each other, because none of them is functioning really well right now. They're all kind of reeling from the trauma. So if I look to my husband for support, and he's not able to even deal with his own stuff, then he's not going to be able to provide me support. So then I may feel let down and betrayed by him. So, you know, helping families understand that, you know, everybody's feeling the effects and everybody's reeling right now. So how can we help you re-stabilize? And when you work with families, you know, if they've got support people, whether they're kin or not, encourage them to bring them into the treatment process. They may not want to come into therapy. They may not want or need to hear the nitty-gritty of what's going on. But it may be helpful to occasionally touch base and talk with those people about how can you help the identified patient or patients? You know, what can you do and provide some education? In community disasters, you can really do a lot of that in the shelters. You can go in there and talk to people because they're kind of a captive audience at that point. And yes, whenever you bring anybody into therapy, you're not bringing them. The client is bringing them. So you're not going to call, you know, their aunt Sally and go, hey, I think it'd be a good idea for you to show up. Always remember that you need releases of information and to talk to anybody. And the client has to be the one to initiate bringing people into treatment. If they don't want other people involved, that's totally cool. We want to make sure that they have a sense of personal power and control over their treatment, especially. Any other questions, comments? I appreciate all the stuff that you gave me to work with today. And I think I got to everything. I'm reviewing just in case I didn't get to everything. Yeah. One of you pointed out that you're in Texas and after Hurricane Harvey, every person that was influenced or impacted by Hurricane Harvey, they may have had very similar losses, but the family itself may react differently. And remember, we want to look back at the family or the individual and say, when we're looking at these two, what's their history of stressors in the past six months? What's their social support like? What's their, how many losses did they experience as a result of it? You know, looking at, and is there a history of mental illness or substance use or abuse within that family? All of those can be factors that are subtle in, you know, helping us figure out who may be more traumatized or experienced trauma symptoms more greatly. Alrighty, everybody, have an amazing weekend and I will see you on Tuesday to finish up this series. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox. This episode has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. Use coupon code, counselor toolbox to get a 20% discount off your order this month.