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Trauma-Informed Medical Care

My blog post focuses on trauma-informed care, its benefits, and ways trauma-informed practices can be implemented in other areas and fields that often interact with justice-involved people. Here, I focus on trauma-informed medical care. It is important to note that trauma-informed practices can help both offenders and victims of crimes in countless ways.  

Trauma-Informed Medical Care:  In a small study of sexual assault survivors, all participants report avoiding routine medical care after their sexual assaults. The details of each person's experiences differ significantly. However, none of the participants experienced sexual assault in a medical setting- an important distinction as we discuss why this population avoids care. Medical care often consists of exams with varying degrees of invasiveness, and there is usually a perceived power imbalance between provider and patient. Mary Farley (2022) writes about survivors avoiding medical care, "Avoiding these appointments, screenings, and tests comprise long-term care. For SA assault survivors, annual gynecological physicals have similarities to the details of their assault." (Farley, 2022, p.4). Farley (2022) suggests that trauma-informed care in primary care settings might have a significant impact on survivors and their willingness to consent to routine medical procedures and screenings.  Farley (2022) notes one key barrier to more providers embracing a trauma-informed approach: time.  Providers often try to see as many patients as possible daily, making visits rushed and usually impersonal. In this course, we discuss trauma-informed yoga or trauma-sensitive yoga. Dr. Rousseau (2024) includes in her week six lecture, the 'Yoga Service Council's Best Practices for Yoga with Veterans,' a critical point that applies to all trauma survivors is maximizing safety, control, and predictability. Whether in the medical setting or in a yoga class, survivors of any form of trauma will feel safer the more in control they feel.

Control and predictability are critical. Applying these principles to medical care, survivors must know what to expect, and they also must know their provider respects the word "no," something that was likely not respected during their assault.  

Farley, M. (2022). Access Barriers to Long-term Healthcare for Female Sexual Assault Survivors. University of Central Florida STARS.

Rousseau , D. (2024, August). Trauma and Crisis Intervention . Module 6. Boston, MA.

Addressing Childhood Trauma

Childhood trauma can forever shape how we see ourselves, our relationships, and the world around us. Children undergo constant brain development, it is particularly occurring during the first three decades of life. For this reason, childhood trauma can be very complex.  Children who don't feel safe in infancy have trouble regulating their moods and emotional responses as they grow older (Van der Kolk, 2014). To understand childhood trauma, it is important to understand the neurobiology of trauma. The neurobiology of trauma is essential to understand when discussing childhood trauma because it is important to understand what is physically occurring within the human body when undergoing trauma. There is growing evidence that exposure to even a single event can alter the way one's brain functions (Rousseau, 2024). The human brain consists of the following:

Brain Stem: Responsible for our most primitive functions and found in all mammals. The most important functions of the brain stem include unconscious processes such as breathing, heart rate, respiration, and blood pressure.

Cerebellum: Responsible for the coordination of more complex processes, such as posture and blinking.

The Four Brain Lobes: Parietal Lobe, Temporal Lobe, Occipital Lobe, and the Frontal Lobe.

Frontal Lobe: The frontal lobe generates behaviors, forms personality, and maintains verbal fluency; it is the most advanced lobe.

(Rousseau, 2024)

The frontal lobe plays a crucial role in emotional regulation. Childhood trauma can affect the development of the prefrontal lobe in a child. Someone who has experienced severe trauma may have a smaller volume of or developmental issues with the prefrontal cortex. This can lead to hypersensitivity to stressful environments, an inability to self-regulate emotions, and increased levels of fear and anxiety (Rousseau, 2024).Due to this, the childhood mind is very fragile. This could lead to better understanding when working with justice-impacted youth as it could possibly help understand certain behaviors. What children are exposed to or experience at a young age can be detrimental. Childhood trauma can present itself in different ways, such as bullying, medical trauma, sexual abuse, traumatic grief, and early childhood trauma (The National Child Traumatic Stress Network). For this reason, it is crucial for a child to have a supportive and safe relationship with someone in their life where they feel comfortable speaking openly about anything.

The largest study on childhood trauma, the Adverse Childhood Experiences (ACE) study, revealed much information on the topic. It was a collaboration between the CDC and Kaiser Permanente, with Robert Anda, MD, and Vincent Felitti as co-principal investigators. The study generally revealed that traumatic life experiences during childhood and adolescence were far more common than expected (Van der Kolk, 2014). As the ACE score rises, chronic depression in adulthood also rises dramatically (Van der Kolk, 2014). The study found that as the number of ACE categories increased, so did the number of related conditions, such as:

Alcoholism and alcohol abuse

Chronic obstructive pulmonary disease

Depression

Drug use

Heart disease

Liver disease

Risk of partner violence

Smoking

Suicide

Overall decline in quality of life

(Rousseau, 2024)

Childhood trauma can have many negative long-term effects. Therefore, it is important to understand how children can be helped to heal from these effects. Some practices that can aid in healing include yoga, sanctuary mode, sand tray therapy, and trauma-informed behavioral therapy (Rousseau, 2024). TF-CBT (Trauma-Focused Cognitive Behavioral Therapy) is a structured, short-term treatment model that effectively improves a range of trauma-related outcomes in 8-25 sessions with the child/adolescent and caregiver. It addresses many other trauma impacts, including depression or anxiety, cognitive and behavioral problems, improving the participating parent’s or caregiver’s personal distress about the child’s traumatic experience, effective parenting skills, and supportive interactions with the child (About Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) - TF-CBT Certification Program, 2023). Healing childhood trauma is important for enhancing quality of life. It helps individuals move on from experiences where they may have felt helpless, giving them the chance to regain their power and improve their lives. Understanding the foundations of childhood trauma is important within the criminal justice field. We have a responsibility to care and provide rehabilitation and support. Especially to our justice-impacted youth.

References:

Van, K. B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma.

Rousseau, D. Module 2, (2024) BU Learn. Retrieved from https://learn.bu.edu/bbcswebdav/pid-13973861-dt-content-rid-107726427_1/courses/24sum2metcj720so2/course/module2/allpages.htm

Rousseau, D. Module 3, (2024) BU Learn. Retrieved from https://learn.bu.edu/bbcswebdav/pid-13973862-dt-content-rid-107725988_1/courses/24sum2metcj720so2/course/module3/allpages.htm

The National Child Traumatic Stress Network. Trauma types. https://www.nctsn.org/what-is-child-trauma/trauma-types

The ACE Study I: Childhood Trauma and Adult Health. 2015. San Francisco, California, USA]: Kanopy Streaming. Video.

About trauma-focused cognitive behavior therapy (TF-CBT) - TF-CBT certification program. TF. (2023, May 30). https://tfcbt.org/about/

Photos from:

Should you forgive someone who caused your childhood trauma or abuse? here’s what you need to know first for your health’s sake. TODAY. https://www.todayonline.com/features/should-you-forgive-childhood-trauma-abuse-what-you-need-know-first-health-2415816

How to work through childhood trauma. Breeze. https://breeze-wellbeing.com/blog/childhood-trauma/

Enabling Evil: How the Nazi Regime Made Atrocities More Palatable

One of the shocking realizations about the Holocaust and other campaigns of genocide around the world is that these atrocities were perpetrated by seemingly ordinary individuals rather than monsters. In his book “Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland,” Christopher Browning (1992) explores how average middle-aged German police officers became mass murderers. The author’s “multicausal explanation” (Browning, 1992, p. 215) includes a wide range of factors that include propaganda and dehumanization of the Jews, conformity and peer pressure, deference to authority (however tentative), gradual desensitization and routinization, division of labor, assertions of fear of punishment, career advancement, and the context provided by the war.

Another book features similar themes but appears only as a footnote in Browning’s tome. Hannah Arendt’s (1963) “Eichmann in Jerusalem: A Report on the Banality of Evil” discusses Adolf Eichmann, the mid-level bureaucrat who managed the logistics of deportation of Jews to death camps. This man did not consider himself to be evil, found concentration camps revolting, and could not stand the sight of blood (Arendt, 1963). Yet, this was the man who directed the deportation of Hungarian Jews described in Elie Weisel’s “Night” (2006).

Arendt reveals how the context of living in Nazi Germany shaped the non-Jewish citizens’ thinking about the Jews. Through executive action, Jews were excluded from public service work in Germany beginning in 1933 – nine years before the events discussed by Browning (Wikipedia, 2019). Jewish students were not accepted at universities, and Jewish doctors and lawyers were gradually driven from those professional communities. Nazi troopers habitually vandalized Jewish businesses with total impunity. By 1935, Germany had a separate set of laws for Jews (Wikipedia, 2019). As a result, it was not just propaganda but facts of German life at the time that contributed to the perpetrators’ dehumanization of Jews.

Arendt notes that Heinrich Himmler, the architect of the “final solution,” framed the extermination of Jews as a necessary evil that had to be shouldered by the current generation to secure Germany’s future. Himmler told SS leaders that they must be “superhumanly inhuman” (Arendt, 1963, p. 104). In fact, participation in atrocities was framed not in terms of inflicting horrible things on people but rather in terms of having to shoulder the weight of witnessing the horror (Arendt, 1963). This framing allowed the perpetrators to view themselves as tragic heroes making a short-term sacrifice in the name of a thousand-year Reich.

Another linguistic tool for addressing the potential trauma was the elaborate system of euphemistic language that helped obscure the reality of Eichmann’s and others’ actions. Arendt states that documents where the words “killing” or “extermination” appear are extremely rare. The Nazi government instituted strict “language rules” (Arendt, 1963, p. 83) that replaced the above-mentioned terms with code words such as “final solution,” “evacuation” and “special treatment.” This consistent use of euphemistic terms removed perpetrators from the reality of their actions and was strictly adhered to throughout the entire Nazi government, even in interagency cooperation.

Consistent with Browning’s findings, Arendt notes that breaking the process of genocide into small, ostensibly benign steps was another key mechanism employed by the Nazis. The officers from Reserve

Battalion 101 arrived at this idea by trial and error, but in the upper echelons of the Nazi government, this was part of the design. Arendt illustrates this through Eichmann’s role, which primarily involved managing the logistics of deportations. Eichmann viewed himself not as a facilitator of mass murder but as a transportation expert solving complex problems. In fact, prior to the introduction of the “final solution,” he applied himself to making it easier for Jews to emigrate to Palestine with equal zeal. Wading through Eichmann’s revelations, self-delusions, obfuscations, and lies, Arendt arrives at the image of Eichmann as a middle-class, not supremely talented man whose thoughts were primarily occupied by finding ways to excel and build a career. By focusing solely on the tasks at hand, whether they resulted in saving people or killing people, Eichmann avoided considering the moral dimension of his actions.

The Nazi government's systematic approach to enabling atrocities is a frightening reminder that ordinary people can become complicit in morally reprehensible actions. Through gradual dehumanization, manipulation of language, framing terrible actions as necessary sacrifices, and breaking down the process of genocide into small, seemingly benign tasks, the Nazis created a system that enabled and facilitated moral disengagement. Browning's and Arendt's writings show that we are all vulnerable to the influences of authority, social pressure, and ideology. They remind us that we need to remain mindful and actively resist the forces that push us towards dehumanizing or devaluing any group of people.

References

Arendt, H. (1963). Eichmann in Jerusalem: A Report on the Banality of Evil. London: Penguin Books.

Browning, C. R. (1992). Ordinary Men: Reserve Battalion 101 and the Final Solution in Poland. New York: Harper-Collins.

Wiesel, E., & Wiesel, M. (2006). Night. New York: Hill And Wang. (Original work published 1958)

Wikipedia. (2019, May 2). Nuremberg Laws. Retrieved from Wikipedia website: https://en.wikipedia.org/wiki/Nuremberg_Laws

Controlled Substances For PTSD

Over the decades, psychiatrists have prescribed numerous medications for those suffering from PTSD. More recently, scientists have been curious as to the effects of using psychedelics in attempting to treat Post Traumatic Stress Disorder. The drug professionals are most curious about is methylenedioxymethamphetamine, or MDMA. As with all other medications or brain-altering substances, it is encouraged to seek therapy while taking MDMA to treat one's PTSD. The drug has been shown to reduce fear, increase social engagement and openness, increase empathy and compassion, increase emotionality, and many other benefits (Morland, 2024)

Understandably, there are some fears surrounding the use of substances such as MDMA due to their high addiction rates. This is why it is recommended to only take these substances under a controlled environment where patients can be monitored and the treatment can be stopped if the treatment is beginning to harm the patient or if negative effects are beginning to take shape. Another issue patients may have is that these substances can be quite expensive. They can range from $600 to $8,000 (Olmstead, 2023). Health insurance does not cover these procedures yet as they have not officially hit the market and research is still in progress.

There is a lot more research that needs to be done when considering the long-term effects on the brain for the users of MDMA. For many years the drug has been banned from public consumption and mainly used as a "party drug". However, more and more medical uses have been found for the drug and others which are known to alter one's emotions and to make individuals more easygoing and open to the outside world. Scientists are also looking into using the drug to assist with the treatment of anxiety, substance abuse, and eating disorders. Individuals who wish to seek this type of treatment should speak with their current psychologist and discuss if these types of substances could benefit them or if they are the right type of candidate for further research studies.

References:

Morland, L., & Wooley, J. (2024, March 28). Va.gov: Veterans Affairs. Psychedelic-Assisted Therapy for PTSD. https://www.ptsd.va.gov/professional/treat/txessentials/psychedelics_assisted_therapy.asp#four

Olmstead, K. (2023, September 13). New PTSD treatments offer hope, yet people seeking help should exercise caution. RTI. https://www.rti.org/insights/new-ptsd-treatments-offer-hope-with-caution

Introducing Psychological First Aid Techniques to First Responders

Introducing Psychological First Aid Techniques to First Responders

One of my favorite assignments in this class has been the film review project. For this assignment we were tasked with picking a documentary to watch and analyzing the goal of the documentary. I chose to watch and review the documentary Counselors Responding to Mass Violence Following a University Shooting: A Live Demonstration of Crisis Counseling was created by the American Counseling Association and published by Alexander Street. In this film we saw a presentation about a fictional school shooting at a college and techniques mental health professionals use in the immediate aftermath and a follow up session a month later with one of the survivors. The techniques demonstrated were Psychological First Aid (PFA) and Cognitive Behavioral Therapy (CBT). Psychological First Aid is the technique used in the immediate aftermath of the incident and stood out to me as a powerful tool. While there were a lot of documentaries to choose from, I hope at some point everyone in the class can dedicate some time to watching this.

In this fictional scenario, the presentation shows the use of Psychological First Aid with two different survivors of a mass shooting on a college campus. One of the survivors is a bit more visibly shaken, as she heard the gunshots and saw bodies on the ground. The presenters of this scenario then begin to use Psychological First Aid techniques with the survivor. They first begin with helping the survivor return their breathing to normal by introducing the box breathing exercise to them. This breathing method works by having the person breath in through their nose for four seconds, holding that air in their lungs for four seconds and then releasing that air for four seconds. Repeating this method multiple times helps activate the bodies parasympathetic nervous system after a stressful situation.

The next method of Psychological First Aid the presenters use is asking the survivor to describe five non-distressing objects in the room they are in. In doing this, the survivor became more grounded back to reality and into the present situation she was in. To continue grounding the person back to reality, the presenters then had her describe the things she can feel. The survivor went on to express that she could feel the chair she was sitting in, her jeans on her legs and her feet tapping the ground. One last technique they used was having the survivor describe all the feelings she was currently experiencing.

In both scenarios with survivors, the mental health specialists never directly asked the person to describe what they just witnessed and experienced. Doing so could have a negative impact on the long-term effects of surviving this. They let the survivor decide what and how much information they wanted to discuss. All these methods used in Psychological First Aid are extremely useful and easy to implement while working with a survivor or witness to such a traumatic event.

While in this fictitious scenario the mental health professionals were on scene not too long after the event occurred, I wonder how realistic that is in everyday situations. The fictitious scenario of a mass shooting on a college campus is certainly something we can expect a massive response from all sorts of agencies- including mental health professionals. I sadly doubt that there are similar resources readily presented to those who witness something equally traumatic like a stabbing, fatal car accident or fatal fire. I am aware that in the city of Boston the Boston Police have a partnership with the Boston Medical Center’s Boston Emergency Services Team (BEST). These co-response clinicians ride along with officers and respond to calls that deal more with individuals who are in some sort of mental health crisis in hope to avoid the need to arrest the person. There are also currently only 12 of these co-response clinicians on staff, meaning that there may not always be access to someone with this specialty.

As mentioned, the techniques and methods of Psychological First Aid are easy to implement in real-life situations in the moments after the incident occurs. More likely than not, first responders to scenes will be without a mental health professional. Having all first responders familiar with Psychological First Aid methods would be extremely beneficial. Especially giving them an understanding that sometimes-asking direct questions about what someone just survived or witnessed right in the first moments after it happened may have a long-term negative impact on the trauma they endure from the incident.

Counselors Responding to Mass Violence Following a University Shooting: A Live Demonstration of Crisis Counseling. . (2014).[Video/DVD] American Counseling Association. Retrieved from https://video.alexanderstreet.com/watch/counselors-responding-to-mass-violence-following-a-university-shooting-a-live-demonstration-of-crisis-counseling

How To Think When Interacting With Justice Impacted Youth

Youth justice is an essential area of concern for the criminal justice system that is often not given enough attention (Rousseau, 2024). Trauma and crisis related issues involving youth are far more common than society perceives, and the current systems in place, are not equipped to effectively aid justice-impacted youth (Rousseau, 2024). It is important to remember that there are fundamental differences between how youth and adults react to trauma, and as a result, there are two significant considerations that practitioners should keep in mind when interacting with justice impacted youth. Incorporating these suggestions into daily practice will ensure that proper and effective treatment is administered.  

The first consideration to keep in mind is that youth often don’t openly disclose trauma that’s affecting them. Youth do not openly discuss the traumatic experiences of their lives, which can act as a barrier for both diagnosis and treatment (van der Kolk, 2014) - it is impossible to effectively administer treatment if we are unaware of what we are treating. This lack of forthcomingness should not be viewed as youth being intentionally “difficult”, but a consequence of them experiencing trauma at such a young age. Studies have shown that early trauma can affect the development of the prefrontal cortex, which causes increased sensitivity to physical and psychological environments (Rousseau, 2024). Keep in mind that the resulting changes to the prefrontal cortex can lead some youth to become hypersensitive to stressful stimuli, unable to self-regulate emotions, or have elevated levels of fear or anxiety (Rousseau, 2024). Those who interact with which justice impacted youth need to recognize that their demeanor and lack of transparency is a natural part of their reaction to trauma, and therefore interactions should be adapted accordingly. 

Secondly, practitioners should recognize that due to a lack of openness on the part of youth, misdiagnosis is common (van der Kolk, 2014). When working with justice-impacted youth, it is important to look past any previous diagnostic labels since they can be unrepresentative of that individual. False diagnosis can lead to improper treatment, and therefore the underlying issues of that patient, will never be addressed. Diagnoses can stick, meaning that a patient might be destined to an ineffective treatment plan if practitioners don’t look past previous labels. While it’s not suggested to throw out any previous diagnoses, what is important to remember is that based on the nature of how youth respond to trauma as discussed above, practitioners should reasonably question previous diagnosis in order to determine effective treatment plans. 

To better integrate trauma informed practices into juvenile justice there are a number of recommendations that can be implemented such as the following;

• Utilize trauma screening and assessment;
• Incorporate evidence-based trauma treatments designed for all justice settings;
• Partner with families and communities to reduce the potential traumatic experience of justice involvement; 
• Collaborate across all juvenile justice systems to enhance continuity of care; 
• Create and enhance a trauma-responsive environment of care; 
• Reduce disproportionate minority contact while addressing the disparate treatment of minority youth (Rousseau, 2024).

In addition to these recommendations, it would be beneficial to recognize that triggers and stressors are different for every youth, and that every aspect of a youth's life can act as a stressor or trigger to their trauma. Since trauma impacted youth can have their entire lives affected by trauma, it is important for professionals working with youth to understand that everyday interactions can pose significant challenges and should therefore adapt their behavior accordingly (Van Der Kolk, 2014). 

Additionally, practitioners should remember that reactions to trauma can, and often are different for everyone. Labeling a reaction as “not normal” or “unreasonable” would be an improper trauma-informed practice. While tolerance might not always be easy, it is an essential practice when interacting with trauma impacted youth. 

Bibliography

Rousseau, D. (2024). Module 2: Childhood Trauma. Boston University Metropolitan College.

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of  trauma.