Trauma and Posttraumatic Stress

What is trauma?

According to the SAMHSA, "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 wellbeing."

Trauma can result from exposure to an event or multiple events that a person experiences as being harmful or life threatening. Exposure to the events results in lasting negative effects on the person’s life. Trauma can affect mental, physical, social, emotional, and spiritual health. Trauma can affect both victims and witnesses of traumatic events.

Common Reactions to and Effects of Trauma

• Inability to cope with normal life stressors
• Lack of trust in other people and systems
• Difficulty building and maintaining relationships
• Problems with memory, attention, or thinking
• Difficulty controlling behavior and emotions
• Hypervigilance, or living in a constant state of heightened sensory sensitivity and intense responsive behaviors (e.g., appearing overly or suspicious of surroundings)
• Lack of emotion (feeling “numb”)
• Avoiding situations that remind the person of the traumatic event
• Loss of faith in spiritual beliefs
• Inability to make meaning of the traumatic experience
• Decrease in overall health and wellbeing

Traumatic Events

A traumatic event includes actual or extreme threats of physical or psychological harm to an individual. Trauma events may occur once or many times over.

Examples of traumatic events include:

• Accident.
• Injury.
• Natural disaster.
• Domestic violence.
• Death of someone close.
• Physical violence.
• Sexual abuse.

Child neglect and abuse can also be traumatic. In fact, adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, increase the risk of substance abuse, mental health disorders, physical diseases, and early death. See Past Abuse and Neglect.

How people interpret, label, and assign meaning to a traumatic event will shape their life experience. Feelings of humiliation, guilt, and shame can result in silence about the event. Survivors of child sexual abuse wherein the perpetrator was a loved one often describe intense feelings of betrayal. War veterans often report “survivor’s guilt.”

Cultural beliefs, availability of social support, and developmental stage can also influence how individuals experience a trauma event.

Trauma involves exposure to situations that overwhelm the body’s “fight, flight, or freeze” system. Exposure to trauma can result in increased arousal and reactivity, re-experiencing the traumatic event after the fact, avoidance behavior, and changes in thoughts, perceptions, and mood. These adverse effects can start immediately after the event or they may be delayed, and they may last for a short time or extended period. When effects of trauma are delayed or last a long time, individuals may not connect understand that their current symptoms are related to a past traumatic event.

Fight, Flight, or Freeze

All human beings have an internal alarm that turns on when we experience dangerous or overwhelming situations. When faced with such a situation, our bodies naturally respond and we either fight, run away (flight), or feel paralyzed or unable to respond (freeze). The human brain and body respond in this manner for survival. The fight, flight, or freeze response is outside of conscious control.

Heightened Arousal and Reactivity

Exposure to traumatic events can result in heightened arousal and reactivity. As a result, people may be more easily “triggered” into a fight, flight, or freeze state of being, even when real danger is not present. Triggers lead to hypervigilance. Hypervigilance may be evidenced by someone appearing to be “on guard” at all times, choosing to sit only where the whole room is in view, or becoming easily startled. A “trigger” is something that brings up the memory of the traumatic event, causing the person’s high alert switch to turn on. Triggers are not always easily linked to the traumatic event. Over time, triggers can generalize to lots of things in a person’s environment.

Re-experiencing the Traumatic Event

When “triggered,” a traumatized person may re-experience thoughts, feelings, emotions, or sensations related to the trauma event as if it were happening in the moment. People who are re-experiencing trauma may report having little control over their mind replaying trauma events. They may keep seeing images from the original events months and years later. This re-experiencing can take place in nightmares, night terrors, and as intense flashbacks wherein a person feels and believes the event is actually reoccurring in the moment. Often, people describe these experiences as disruptive to their current life and ability to function in a healthy manner.

Avoidance

Hypervigilance and re-experiencing of trauma can lead traumatized individuals to avoid anything that might be a trigger. This avoidance can lead to social isolation and depression. Substance abuse commonly co-occurs with trauma and can be considered a form of avoidance because using substances can help people avoid the feelings associated with hypervigilance and re-experiencing of trauma.

Cognition and Mood

Exposure to traumatic events can also lead to changes in a person's cognition (thoughts and perception) and mood. Gaps in memories and negative thoughts and feelings related to the traumatic event are common. A decreased interest in previously enjoyed activities is common, as is feeling isolated from friends, family, and community.

Traumatic Stress Disorders

Categories of traumatic stress disorders include posttraumatic stress disorder (PTSD), developmental trauma, complex trauma, and historical trauma (review the DSM-5 for more information on each condition). As a BHA/P, you are not expected to diagnose these conditions; however, you are likely to work with someone who experiences one or more of them.

Posttraumatic Stress Disorder

PTSD is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event, which may be in their personal lives, community, or other environment. Most of what we know about Posttraumatic Stress Disorder comes from research with war veterans. The diagnosis involves four categories of symptoms that appear after a traumatic event: re-experiencing, avoidance, arousal and reactivity, and cognition and mood.

It is very common for an individual who has a diagnosis of Posttraumatic Stress Disorder to have a co-occurring disorder. See Co-occurring Disorders.

Developmental Trauma

Developmental trauma refers to trauma that happens before the age of 18. Trauma that occurs early in life can change the developing brain. At birth, infants depend on their primary caregiver for survival. By receiving consistent care, infants gradually learn to communicate their needs with caregivers and to regulate their own emotions. By school age, typically developing children are busy making friends and learning in the classroom on their way to developing the skills necessary to becoming a contributing part of their community. For more information about typical patterns of brain development, see Development Across the Lifespan.

Children who are neglected and abused may not learn how to communicate their needs well, especially if their needs have been mostly unmet. They may spend so much time in survival mode that their ability to regulate emotion, develop friendships, pay attention in class, and complete homework is compromised. This sort of chronic stress is sometimes called “toxic stress” because of the changes that can occur in the brain as a result. Toxic stress can result in developmental trauma.

Symptoms of developmental trauma can include:

• Rapid mood swings
• Inattention
• Hyperactivity
• Difficulty transitioning from activity to activity, or place to place
• Difficulty making and keeping friends
• Substance use
• Self-harm
• Suicidality

Youths with developmental trauma often get diagnosed with other mental disorders, such as Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), or Bipolar Disorder. Recognizing trauma as a possible factor that is contributing to a person's symptoms can lead to a more accurate diagnosis and relevant treatment. At the same time, signs and symptoms of trauma are similar to those of other diagnoses, so the presence of these signs and symptoms is a warning sign but not firm predictor that trauma is present. See Introduction to Overlapping Issues.

You may see a child who has been a victim of abuse that was previously reported. The child may have been removed from the home and may be currently living with relatives or a foster family. In these cases, the child may be receiving therapy already. See Foster Care and OCS for more on foster families.

Complex Trauma

Without treatment, developmental trauma can turn into complex trauma once a person reaches adulthood. Complex trauma involves problems with controlling emotions, tolerating painful emotions, and developing and maintaining healthy boundaries and relationships. Substance abuse, self-harm, and suicidality are common symptoms of complex trauma. Supporting parents with complex trauma is important to preventing intergenerational transmission of trauma within families.

Historical Trauma

Historical trauma refers to the combined emotional and psychological wounding that can occur as a result of group traumatic experiences. These traumatic experiences can be transmitted across generations and can impact entire communities.

Historical trauma is common in Alaska Native communities that have been exposed to generations of violent colonization, forced assimilation, intergenerational loss, and attacks on their culture and wellbeing.

Common effects of historical trauma include unresolved grief and anger, a breakdown of traditional Native values, alcohol and substance abuse, depression and anxiety, posttraumatic stress disorder, suicidality, child abuse and neglect, domestic violence, general loss of meaning and hope, internalized oppression, and self-hatred.

It is important to keep historical trauma in mind when intervening with a number of other conditions (e.g., substance abuse, suicidality) commonly seen in Alaska Native and American Indian communities.

Trauma is much more common than previously thought, especially trauma that results from adverse childhood experiences. Because of the overall high rates of trauma among the general population, it is a best practice to adopt a “trauma-informed” approach to care.

Taking a trauma-informed approach to care requires you to:

• Realize the widespread impact of trauma and understand potential paths for recovery.
  • It is important that all people, at all levels of the system of care, understand how trauma can impact individuals, families, and communities. Often problematic behaviors (e.g., substance abuse, aggression) are really coping strategies for traumatized people. Realizing the role of trauma in your client’s life can help you intervene more effectively with many presenting problems.
• Recognize the signs and symptoms of trauma in clients.
  • Recognizing the signs and symptoms of trauma and screening for trauma can help you intervene effectively with your clients. There are many useful screening tools, including the 10-item Adverse Childhood Experiences measure and the PTSD checklist.
  • NOTE: The screening processes should also include efforts to help clients identify their strengths and factors of resiliency. Such an approach can help people to have hope and see that they have the ability to bounce back from any negative experiences they have had.
• Respond by integrating this knowledge into clinic policies, procedures, and practices.
  • Responding to the needs of traumatized clients requires careful consideration of clinic policies, procedures, and practices. Training all clinic staff on the basics of trauma is one way to respond to this need. Creating a safe, secure environment for all clients is another way of responding to this need. The goal of “responding” is to actively resist retraumatization.
• Resist retraumatization of clients.
  • Clinic staff should adapt clinic practices to resist retraumatization of clients. For example, a client with a trauma history may feel trapped if she is put in a room with her back to the door. Simply rearranging a room so that the client can see and have access to an exit is one way to resist retraumatization.

Key principles of a trauma-informed approach to care:

• Safety: Traumatic stress is about feeling very unsafe. Therefore, it is essential to provide a safe environment for the client during the times that you are working together.
• Trustworthiness and transparency: Traumatized people tend to have difficulty trusting others, especially people in power. Be transparent in your decision-making process and actively work to build trust with clients.
• Collaboration and mutuality: Collaborating with clients on treatment decisions can help level power differences. Show your clients that you care through active listening.
• Empowerment, voice, and choice: Build upon clients’ strengths, look for existing resilience, and recognize the potential for healing. Respect your clients’ right to choose their life path. Give them a voice in their treatment process.
• Cultural, historical, and gender issues: Move past biases and stereotypes. Leverage the healing value of cultural connection. Recognize and address historical trauma.

When you are aware that a client has experienced past trauma, ask yourself these questions:

• How is the trauma affecting the client now?
• What does this client need to cope with the trauma?
• What can I do to support and encourage this client?

The client may not have spoken before about the trauma he experienced.

• His presenting problems may be in different areas of his life. He may be in denial or feeling shame; there may be other reasons for not talking about it before.
• If the client has not previously spoken about his experiences, provide him with opportunities to speak and tbe heard by a person he can trust.
• Assure the client that he is a valued human being, just as he is.

Assess how the client is functioning in day-to-day activities, in school, with family members, and in the community. Work with the client to establish a safe social network and to identify ways to feel safe doing daily activities. Help the client to identify and establish healing relationships with mentors who can model positive healthy behaviors. Support the client in the community and in connecting with healthy peers and mentors.

Clients with trauma-related stress may feel particularly vulnerable or threatened. Their symptoms may include exaggerated feelings and responses. It is very important to build their trust.

The client’s perceptions may be influenced by her parents’ or peers’ responses. Sometimes a caregiver is unaware or unwilling to identify the event as abuse or trauma.

The client’s worldview and perceptions of the intensity of the event will strongly influence the intensity of her symptoms. The severity of the event’s impacts can also be influenced by how much support the client receives from her community, family members, elders, and other support systems.

Trauma leaves both physical and emotional scars, and the effects of trauma do not just go away. The client may need ongoing support or therapy. Individuals should not expect to be “cured” of trauma-related stress. They can learn to live with it and manage it so that their symptoms have a smaller impact on their lives.

Trauma can involve and affect the client’s whole family and even extended family.

If you become aware of a past incident of abuse involving a minor, see Mandatory Reporting and Duty to Warn.

If you become aware that the child is being abused or neglected, see Abuse and Neglect.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information (ROIs)that are current or updated before getting information about the client from other sources.

Client history, including past therapy, hospitalizations, out-of-home placements, or current medications. Include any information about his symptoms of traumatic stress and any known triggers.

Treatment Plan, including a history of presenting problem and recommended course of treatment. Review the DSM-5 for criteria on Posttraumatic Stress Disorder.

General concerns

• Unexplained aches and pains
• Irritability or aggression
• New phobias or sources of anxiety
• Difficulty trusting or feeling safe with others
• Regularly withdraws from or avoids contact with others
• Reports nightmares or difficulty sleeping

Child- and youth-specific

• Acts out aspects of the traumatic event through play or art
• Loss of previously acquired skills (e.g., previously potty trained child has begun having accidents)

Intense physical responses when reminded of the event

• Racing thoughts
• Nausea
• Sweating
• Rapid heartbeat
• Shortness of breath
• Fear of being separated from parent
• Sleep problems
• Feeling like he is going to die

Emotional challenges

• Frequently overwhelmed by emotions
• Devoid of emotion
• Reacts strongly to events that would not typically be seen as threatening
• Self-harm behaviors
• Low self-esteem
• Regularly expects bad things to happen

Trauma symptoms

• Patterns of overwhelming memories, nightmares, night terrors, or flashbacks
• Re-experiencing fear and trauma from the event
• Seeing images from the original event months or years after it occurred
• Difficulty focusing and paying attention

Family/home environment

• Witnessed or experienced domestic violence
• Loss, death, or suicide in the family

Daily functioning

• Who do you trust or feel comfortable with?
• Who would you talk to about your problems?
• Have you lost anyone close to you?
• Do you ever worry that bad things are going to happen to you or to someone you care about?

Symptoms of traumatic stress

• Do you experience any of the following?
  • Difficulty sleeping
  • Nausea
  • Sweating
  • Rapid heartbeat
  • Shortness of breath
  • Fear of being separated from your parents or loved ones
  • Feeling like you are going to die
• Have you had any nightmares recently? How are you sleeping?
• Are you bothered by memories of things you have seen or experienced?
  • Do you ever feel overwhelmed by these memories?
  • Do you ever feel like you are experiencing these things over and over again?
• Do you ever have difficulty controlling your thoughts or focusing?
• Would you rather spend a lot of time with other people or be by yourself?

Emotions/mood

• How do you feel about yourself? Do you ever feel angry with yourself?
• Have you stopped talking to your friends or family members?
• Do you ever feel out of control?
  • Do you ever feel that your emotions are too much to handle?
  • Do you ever feel numb?
• Do you ever think about hurting yourself? How often have you acted on those thoughts?
  Note: If the client has engaged in self-harm, see Self-Harm and Self-Injury.
• Do you ever have suicidal thoughts? Have you ever attempted suicide?
  Note: If the client has thoughts of suicide, see Suicidal Thoughts and Plans.

Routinely review BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Consider helping your client develop healthy self-care practices, specifically those that address historical and personal trauma. See Self-Care for the BHA/P and Clients for more information.

When working with clients who have symptoms of Posttraumatic Stress Disorder or have experienced trauma, it is important to help them develop skills to manage their emotions. Sometimes it is helpful for clients to describe their past traumas; however, it is strongly recommended that you do not try to push them to do so. Instead, work with them to develop and practice coping strategies that can help them feel grounded and safe when they are experiencing severe distress related to past traumas. Some strategies that may help include:

• Mindfulness exercises.
• Distraction with pleasurable activities, smells, or cognitive tasks (e.g., counting, making lists, taking a mental vacation).
• Diaphragmatic breathing.
• Stretching.

Clients can also benefit from interventions that are focused on helping them identify and express emotions they are experiencing when they feel "triggered." Some strategies include:

• Teaching them how to identify a range of emotions (e.g., irritated, frustrated, angry, mad, enraged).
• Helping them identify when they are experiencing these different degrees of emotion.
• Helping them understand how their body feels when they are experience different emotions.
• Identifying environmental cues that trigger emotional reactions, as well as behavioral response patterns after they become triggered.

Some clients, particularly children and adolescents, are able to express their emotions and experiencing through art, drawing, journaling, poetry, and free play. It can be very helpful to introduce these exercises to the client; however, be cautious when attempting to "interpret" or analyze what the client has expressed.

If your client appears to experience severe and prolonged symptoms related to the traumatic event, refer her to a master's-level clinician for a mental health assessment and treatment focused on addressing issues related to the traumatic experience.

If your client appears to be significantly affected by physical symptoms related to the traumatic experience, such as difficulty sleeping (perhaps due to nightmares) or an uncontrollable rapid heartbeat, refer him to a medical professional or local CHA/P for evaluation.

Be sure you are familiar with the information in Mandatory Reporting and Duty to Warn and Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.