TRAUMAINFORMED RECOVERY:

MICRO AND MACRO SYSTEMS CHANGE

TRAUMA INSTITUTE OF NEW JERSEY

ERIC C.ARAUZ MLER
ADJUNCT FACULTY INSTRUCTOR
DEPARTMENT OF PSYCHIATRY
RUTGERS ROBERT WOOD JOHNSON MEDICAL SCHOOL
[email protected]
7328814784

ConsultantsofT.I.N.J.
Heather Forkey, MD AssistantDirectorofFaCES(FosterChildrenEvaluation
ServicesMassachusetts)andanattendingpediatricianatwiththeChild
ProtectionProgram,bothatUMassMemorialChildrensMedicalCenter.
AssistantProfessorattheUniversityofMassachusettsMedicalSchool.
Jill Williams, MD Director of Addiction Psychiatry; Professor Rutgers Robert
Wood Johnson Medical School
Tracey Shors, PhD DistinguishedProfessorintheDepartmentofPsychology
andCenterforCollaborativeNeuroscienceatRutgersUniversity.MAPTraining
BrandonAlderman,PhDAssistantProfessorintheDepartmentofExercise
ScienceandSportStudiesatRutgersUniversity. Hislaboratoryisfocusedon
investigatingtheeffectsofexerciseonneurocognitiveandphysiological
resilience.MAPTraining
JulieCarbray,PhD FPMHNP,PMHCNS,APNClinicalProfessorUniversityof
IllinoisChicagoMedicalSchool;ChairAPNAClinicalPsychopharmacological
Institute;AdministrativeDirectorPediatricMoodDisordersClinicUniveristyof
IllinoisChicagoCollegeofMedicine

..a mind will find only

according to its own
distortion.
Jiddu Krishnamurti

Freedom from the Known Krishnamurti. J. 1969. Freedom From

The Known. NY, NY: Harper Collins. 11.
3

SecondaryTraumaticStress
TherapeuticWorkers
MetaAnalysisofRiskFactorsfor
SecondaryTraumaticStressin
TherapeuticWorkwithTraumaVictims.
JenniferM.Hensel,CarlosRuiz,CaitlinFinney,andCarolynS.
Dewa.AlloutofToronto,Ontario,Canada.
Volume28,Number2,April2015oftheJournalofTraumatic
Stress.PublishedbytheInternationalSocietyforTraumatic
StressStudies.

Therapeutic Workers
Vs.
Therapists

TRAUMA ASSESSMENT BY DCFOF NJ

DONALD SULL PHD
MITSLOAN SCHOOL OF MANAGEMENT
(HARVARD BUSINESS REVIEW MARCH 2015)

NHSHUMAN SERVICES 10KEMPLOYEES

MASSACHUSETTS LESSONS:HEATHER FORKEY MD

MIDDLE MANAGERS
SUPERVISION
LATERAL INTEGRATION
SUPPORT ON INITIAL PUSHBACK
LACK OF TRAUMA RESOURCES
ORGANIZATIONAL TRAUMA

If you get the What, then you will

get the How.
Thomas Hora MD
Hungarian Metapsychiatrist

Whatdowemeanbytrauma

OPERATIONAL DEFINITION OF TRAUMA

5YR.SAMHSARECOVERY TO PRACTICE
NATIONAL GRANT
FIDELITY
REPEATABILITY
INSTANT IMPLEMENTATION

APPLICATION UNDER STRESS

NeurobiologyofHelplessness
TRAUMA:Anylifeeventoccurringinarelativestateof
helplessnessacaraccident,thesuddendeathofa
lovedone,afrighteningmedicalprocedure()can
producethesameneurophysiologicalchangesinthe
brainasdocombat,rapeorabuse.
RobertScaerM.D.
Neurologist,Traumatologist,MedicalDirectorofInternationallyrecognizedPain
ManagementCenteratMapletonRehabilitationcenter,CommunityHospitalBoulder,
Colorado

TRAUMA =
PERSISTENT ACUTE STRESS
RESPONSE ONE CANNOT AVOID,
EVADE OR CONTROL

Tool

ANTICIPATORY STRESS
IS REAL STRESS

BLOOD PRESSURE
HEART RATE
VASCULAR DAMAGE
INFLAMMATION
METABOLIC SYNDROME
ROBERT SAPOLSKY PHD
STANFORD UNIVERSITY
NEUROSCIENTIST

NEUROPHYSIOLOGICAL
NEUROENDOCRINE
FRAMING OF BRAIN DEVELOPMENT
CORTISOL
ESTROGEN
TESTOSTERONE
GENETIC TRANSCRIPTION

19

Neocortex

Limbic

Diencephalon

Brainstem

All rights reserved 2004 Dr. Bruce Perry

Abstractthought
Concretethought
Affiliation
"Attachment"
SexualBehavior
EmotionalReactivity
MotorRegulation
"Arousal"
Appetite/Satiety
Sleep
BloodPressure
HeartRate
BodyTemperature
20

FRACTURING OF GLOBAL IDENTITY:

DESTRUCTION OF LINEAR VISCERAL AND
COGNITIVE NARRATIVES
ChaosNarrative:Nomapordestination
(FrankAW.TheWoundedStoryteller:Body,Illness,Ethics.Chicago:UniversityofChicago
Press,1995,2013.)

StoryofAtrocity/LanguageofAbomination
(HermanJ.TraumaandRecovery.NewYork:BasicBooks,1997.)

autobiographicalmemorydeficitsand
emotionaldeficitsandmadelife'senseless'.
(KalbeE,BrandM,ThielA,KesslerJ,MarkowitschHJ.Neuropsychologicalandneural
correlatesofautobiographicaldeficitsinamotherwhokilledherchildren. NEUROCASE.
2008;14(1):1528.)

21

SpeakingtheUnspeakable
THEORDINARYRESPONSETOATROCITIESisto
banishthemfromconsciousness.Certainviolations
ofthesocialcompactaretooterribletoutteraloud:
thisisthemeaningofthewordunspeakable.
Atrocities,however,refusetobeburied.

Judith Lewis Herman, Trauma and Recovery

Positive Stress
Normal and essential part
of healthy development
Brief increases in heart rate
and blood pressure
Mild elevations in hormonal
levels
Example: Final exam
Playoff game.

Toxic Stress
Bodys alert systems
activated to a greater
degree
Activation is time-limited
and buffered by caring
adult relationships.
Brain and organs recover
Example: Death of a
grandparent, car accident.

Occurs with strong, frequent

or prolonged adversity
Disrupts brain architecture
and other organ systems
Increased risk of stressrelated disease and
cognitive impairment
Example: abuse, neglect,
caregiver substance
dependence or mental
illness

Intense,prolonged,repeated,unaddressed;
Childorfamilyvulnerabilities,limitedsupports,devel.delays

SocialEmotionalbuffering,Learnedskills,Parent/ChildResilience,Early
Detection,EffectiveIntervention

Neocortex

Limbic

Diencephalon

Brainstem

All rights reserved 2004 Dr. Bruce Perry

Abstractthought
Concretethought
Affiliation
"Attachment"
SexualBehavior
EmotionalReactivity
MotorRegulation
"Arousal"
Appetite/Satiety
Sleep
BloodPressure
HeartRate
BodyTemperature
24

Fear/Immobility Cycle
(Levine, P., In An Unspoken Voice. Berkeley: North Atlantic Books,2010, 70.)

Immobility

Arousal

Fear/Helplessne
ss

Unsuccessful
Escape

WITH WHOM ARE YOU WORKING WITH

ADVERSE CHILDHOOD EXPERIENCES

STUDY
(ACES)

27

ADVERSE CHILDHOOD EXPERIENCES STUDY

(ACES)
Physical abuse by a parent
Emotional abuse by a parent
Sexual abuse by anyone
An alcohol and/or drug
abuser in the household
An incarcerated household
member

Someone who is chronically

depressed, mentally ill,
institutionalized, or suicidal
Domestic violence
Loss of a parent
Emotional neglect
Physical neglect

Felitti, V. J., Anda, R. F., Nordenberg, D.F., Williamson, D. F., Spitz, A.M., Edwards, V., et
al. (1998). Relationship of childhood abuse and household dysfunction to many of the
leading causes of death: The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventative Medicine, 14(4), 245-258.
28

ACE Score and Intravenous

Drug Use

N = 8,022

p<0.00

Fellittii,V.et al. (1998). The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventative Medicine, 14(4), 245-258.
1

Childhood Experiences
Underlie
Suicide
25
4+

% Attem pting Suicide

20

15

3
10

Fellittii, V.et al. (1998).

0 The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine,
14(4), 245-258.

ACE Score

ACE Score and Hallucinations

Ever Hallucinated* (%)

12
10

Abused
Alcohol
or Drugs

No
Yes

6
4
2
0
0

>=7

ACE Score
*Adjusted for age, sex, race, and education. Fellittii, V.et al. (1998). The Adverse Childhood Experiences (ACE)
Study. American Journal of Preventative Medicine, 14(4), 245-258.

RiskFactorsforAdultHeartDiseaseareEmbeddedinAdverse
ChildhoodExperiences

Odds Ratio

3.5
3
2.5
2
1.5
1
0.5
0

ACEs

5,6

7,8
Source: Dong et al, 2004

Positive Stress
Normal and essential part
of healthy development
Brief increases in heart rate
and blood pressure
Mild elevations in hormonal
levels
Example: Final exam
Playoff game.

Toxic Stress
Bodys alert systems
activated to a greater
degree
Activation is time-limited
and buffered by caring
adult relationships.
Brain and organs recover
Example: Death of a
grandparent, car accident.

Occurs with strong, frequent

or prolonged adversity
Disrupts brain architecture
and other organ systems
Increased risk of stressrelated disease and
cognitive impairment
Example: abuse, neglect,
caregiver substance
dependence or mental
illness

Intense,prolonged,repeated,unaddressed;
Childorfamilyvulnerabilities,limitedsupports,devel.delays

SocialEmotionalbuffering,Learnedskills,Parent/ChildResilience,Early
Detection,EffectiveIntervention

Neocortex

Limbic

Diencephalon

Brainstem

All rights reserved 2004 Dr. Bruce Perry

Abstractthought
Concretethought
Affiliation
"Attachment"
SexualBehavior
EmotionalReactivity
MotorRegulation
"Arousal"
Appetite/Satiety
Sleep
BloodPressure
HeartRate
BodyTemperature
34

INTERPERSONAL NEUROBIOLOGY
LENGTH OF SENTENCES (PORGESEXTENDED EXHALE)
PARALLELING (PERRY)
EYE CONTACT
FACIAL EXPRESSION
TONE OF VOICE
POSTURE
GESTURE
TIMING OF RESPONSE
DR.DANIEL SIEGEL MD
(TRAUMA,BRAIN &RELATIONSHIP:HELP CHILDREN HEAL.HTTPS://WWW.YOUTUBE.COM/WATCH?V=JYYEEMLMMB0)

A Shared Experience
Physiciansfeelpainandreliefofclients

JensenKB,etal.MolecularPsychiatry.2014;19:392398.

Qualia vs Intentionality
(phenomenal consciousness vs
representation of mental states)

the difference between the patients

experience of the disease and the doctors
attention to the disease
Arthur Kleinman, MD
Psychiatrist Harvard Medical School
Professor, Anthropology
Harvard University

Kleinman, A. 1988. The Illness Narratives: Suffering Healing and the Human
Condition. NY, NY: Basic Books.

NeurobiologyofHelplessness
TRAUMA:Anylifeeventoccurringinarelativestateof
helplessnessacaraccident,thesuddendeathofa
lovedone,afrighteningmedicalprocedure()can
producethesameneurophysiologicalchangesinthe
brainasdocombat,rapeorabuse.
RobertScaerM.D.
Neurologist,Traumatologist,MedicalDirectorofInternationallyrecognizedPain
ManagementCenteratMapletonRehabilitationcenter,CommunityHospitalBoulder,
Colorado

LIKE FATHER, LIKE SON?

BIPOLAR 1 DISORDER W/PSYCHOTIC FEATURES

ADDICTION
POSTTRAUMATIC STRESS DISORDER
COMPLEX TRAUMA
2 SUICIDE ATTEMPTS
265 POUNDS IN 7TH GRADE

Absolute Shattering of the Self

Physiological
Cognitive
Spiritual
Social
Familial

Diagnosis

Bipolar Disorder 1
Addiction
Developmental Trauma
Posttraumatic-Stress Disorder
2 suicide attempts-1 near lethal

My soul is lost, my friend

Tell me how do I begin again?

Bruce Springsteen
My Citys In Ruins
The Rising

AnIntegratedPerspective
BIPOLAR

CHILDHOOD
OBESITY

ALCOHOLISM

ACE

DRUG

TRAUMA

ADDICTION

SUICIDE
51

TraumaInformedRecovery
CLIENT
ORGANIZATIONAL

ACCELERATION OF OUTCOMES

MUTUALLY THERAPEUTIC
DYADIC ATTUNEMENT (MTDA)

Identityisarelationalachievement
(Mokros, HARTMUT B., Suicide and Shame , American Behavioral Scientist, 38:8
(1995:Aug.)

RELATIONAL POVERTY
BRUCE PERRY MD PHD

INTERPERSONAL ATTUNEMENT: THE WAY ONE PERSON

ATTUNES IN AN OPEN AND EMPATHETIC WAY TO THE
INTERNAL STATE OF ANOTHER.

INTERPERSONAL RESONANCE: THE WAY TWO OR MORE

MINDS ALIGN THEIR STATES AND BECOME MUTUALLY
INFLUENCED BY ONE ANOTHER.
DAN SIEGEL MD
CREATOR INTERPERSONAL NEUROBIOLOGY

INTERPERSONAL NEUROBIOLOGY
LENGTH OF SENTENCES (PORGESEXTENDED EXHALE)
PARALLELING (PERRY)
EYE CONTACT
FACIAL EXPRESSION
TONE OF VOICE
POSTURE
GESTURE
TIMING OF RESPONSE
DR.DANIEL SIEGEL MD
(TRAUMA,BRAIN &RELATIONSHIP:HELP CHILDREN HEAL.HTTPS://WWW.YOUTUBE.COM/WATCH?V=JYYEEMLMMB0)

VerbalDeescalation
Whenworkingwithanagitatedpatient,thereare4
mainobjectives:
(1)ensurethesafetyofthepatient,staff,andothers
inthearea;
(2)helpthepatientmanagehisemotionsanddistress
andmaintainorregaincontrolofhisbehavior;
(3)avoidtheuseofrestraintwhenatallpossible;and
(4)avoidcoerciveinterventionsthatescalate
agitation.
Richmond,J.S.,Berlin,J.S.,Fishkind,A.B.,Holloman,G.H.,Zeller,S.L.,Wilson,M.P.,
Ng,A.T.(2012).VerbalDeescalationoftheAgitatedPatient:ConsensusStatement
oftheAmericanAssociationforEmergencyPsychiatryProjectBETADeescalation
Workgroup. WesternJournalofEmergencyMedicine, 13(1),1725.
doi:10.5811/westjem.2011.9.6864

POINT OF
CONNECTIO
N

Safety
Proximity
Intimacy
Vulnerability

POLYVAGAL THEORY:
THERAPEUTIC DYAD
JUMPING TOGETHER
AUTONOMIC NERVOUS SYSTEM

SOCIAL ENGAGEMENT SYSTEM:

NEUROCEPTION
PRO-SOCIAL, FIGHT OR FLIGHT,
FREEZING/IMMINENT DEATH
INTERVENTIONS: HEART TO FACE, HEART TO
VOICE, HEART TO EYES
(PORGES SW. THE POLYVAGAL THEORY: PHYLOGENETIC SUBSTRATES OF A
SOCIAL NERVOUS SYSTEM. INTERNATIONAL JOURNAL OF PSYCHOPHYSIOLOGY
42 (2001) 123-146.)

PolyvagalTheory
Physiologicalstatecharacterizedbyvagalinfluence
onHRVsupportssocialengagement&bonding
Anys mulusthatsfeelingofsafetycanrecruit
neuralcircuitsthatsupportsocialengagementsystem
andinhibitdefensivelimbicstructures
Neuroceptionenablessocialbehaviorby
distinguishingsafefromdangerous
(SWPorges.2009.Thepolyvagaltheory:Newinsightsinto
adaptivereactionsoftheautonomicnervoussystem.Cleveland
ClinicJMed76(3):S86S90)
2012RPBrown&PLGerbarg

POLYVAGAL THEORY:
THERAPEUTIC DYAD
SOCIAL ENGAGEMENT SYSTEM
POSTURE
BREATHE
VOICE
(PORGES SW. THE POLYVAGAL THEORY: PHYLOGENETIC SUBSTRATES OF
A SOCIAL NERVOUS SYSTEM. INTERNATIONAL JOURNAL OF
PSYCHOPHYSIOLOGY 42 (2001) 123-146.)

VAGAL NERVE
PATHWAYS

BROWN RP, GERBARG PL.

2009. HOW TO USE HERBS,
NUTRIENTS, AND YOGA IN
MENTAL HEALTH CARE. NY;
WW NORTON. P79.
64

EXPERIENTIAL EXERCISES
GREGORIAN CHANTING
YES/NO TEST: REACTIVE VS. RESPONSIVE STATE
(SYMPATHETIC VS. PARASYMPATHETIC ACTIVATION)

BEE BREATH: PRANAYAMA BREATHING

EXTEND EXHALE
POLYVAGAL INTERVENTION
SELF REGULATE ANS

PROXIMAL ABANDONMENT: IT IS ALL IN THE

EYES.
DR. ALLAN SCHORE

CultureofNO
YesandNO

IntegrateorRegulate
ReactiveorResponsive
DifferentiationandLinkages
ChaosorRigidity

Neocortex

Limbic

Diencephalon

Brainstem

All rights reserved 2004 Dr. Bruce Perry

Abstractthought
Concretethought
Affiliation
"Attachment"
SexualBehavior
EmotionalReactivity
MotorRegulation
"Arousal"
Appetite/Satiety
Sleep
BloodPressure
HeartRate
BodyTemperature
68

SpeakingtheUnspeakable
THEORDINARYRESPONSETOATROCITIESisto
banishthemfromconsciousness.Certainviolations
ofthesocialcompactaretooterribletoutteraloud:
thisisthemeaningofthewordunspeakable.
Atrocities,however,refusetobeburied.

Judith Lewis Herman, Trauma and Recovery

ORAL EXPLORATORY NARRATIVE PROCESSING

Effectivetreatmentisamatterofhelping
individualskeeptheobservingprefrontal
cortexonlineasitsimultaneouslyexperiences
therawprimitivesensationsgeneratedinthe
archaicportionsofthebrain(thelimbic
system,hypothalamusandbrainstem.)
(Levine,P.,InAnUnspokenVoice.Berkeley:NorthAtlanticBooks,2010,71.)

STILL FACE EXPERIMENT

HTTPS://WWW.YOUTUBE.COM/WATCH?V=AP
ZXGEBZHT0

VALIDATION THERAPY
INTERPERSONAL RESONANCE
INTERPERSONAL ATTUNEMENT
VERBAL COMMUNICATION: PROSODY, SLOW, VOICE TO
HEART

NON-VERBAL COMMUNICATION
AMYGDALA SQUELCHING: TOUCH SPECIFIC
RELATION POVERTY: DR. BRUCE PERRY
LANGUAGE OF THE OTHER: CORTICAL SHUTDOWN,
IMPLICIT MEMORY

HTTPS://WWW.YOUTUBE.COM/WATCH?V=CRZXZ10FCVM

Positive Stress
Normal and essential part
of healthy development
Brief increases in heart rate
and blood pressure
Mild elevations in hormonal
levels
Example: Final exam
Playoff game.

Toxic Stress
Bodys alert systems
activated to a greater
degree
Activation is time-limited
and buffered by caring
adult relationships.
Brain and organs recover
Example: Death of a
grandparent, car accident.

Occurs with strong, frequent

or prolonged adversity
Disrupts brain architecture
and other organ systems
Increased risk of stressrelated disease and
cognitive impairment
Example: abuse, neglect,
caregiver substance
dependence or mental
illness

Intense,prolonged,repeated,unaddressed;
Childorfamilyvulnerabilities,limitedsupports,devel.delays

SocialEmotionalbuffering,Learnedskills,Parent/ChildResilience,Early
Detection,EffectiveIntervention

BreathBodyMindincludesthefollowing
breathingpractices
CoherentBreathing
Rate:3.5to6breathsperminute
Equalinhalationandexhalation
Likenaturalbreathing:quietandgentle

BreathMoving:imaginative
ResistanceBreathingonexhalation
Ha Breath(briefly2to5minutes)
4462CountsBreathing
(RPBrown&PLGerbarg(2012).TheHealingPoweroftheBreath.
Book+CD.Boston:ShambhalaPress.)

Neocortex

Limbic

Diencephalon

Brainstem

All rights reserved 2004 Dr. Bruce Perry

Abstractthought
Concretethought
Affiliation
"Attachment"
SexualBehavior
EmotionalReactivity
MotorRegulation
"Arousal"
Appetite/Satiety
Sleep
BloodPressure
HeartRate
BodyTemperature

MTDAToolBelt

79