1. TRAUMA & SECONDARY TRAUMA

2. WELCOME Offered to you today as a result of a pilot partnership project between Together Georgia and the J.W. Fanning Institute for Leadership  Sandra Corbin, LCSW; Clinical Director, Multi- Agency Alliance for Children (MAAC)  Brian Bride, PhD; Social Work Director & Professor, Georgia State University  David Meyers, MSW; Public Service Faculty, J.W. Fanning Institute for Leadership

3.  Welcome and Introductions  Complex Trauma: Definitions & Misdiagnoses  Complex Trauma and the Caregiver  LUNCH  Secondary Trauma: Definitions  Risk and Protective Factors  Strategies for Self Care for the Practitioner  Activity/Q&A AGENDA

4. COMPLEX TRAUMA AND THE CAREGIVER Sandra Corbin, LCSW Clinical Director, Multi-Agency Alliance for Children (MAAC)

5. WHAT IS COMPLEX TRAUMA?  The term complex trauma describes the problem of children's exposure to multiple or prolonged traumatic events and the impact of this exposure on their development. http://www.nctsn.org/ http://www.nctsn.org/  Foster kids are often exposed to multiple traumatic events before and after entering foster care. Can you think of some examples?

6. LISA’S 911 CALL  http://www.youtube.com/watch?v=G_ht2vAYP oc http://www.youtube.com/watch?v=G_ht2vAYP oc  How does that make you feel?  What behaviors might Lisa exhibit after living through this?

7. ADVERSE CHILDHOOD EXPERIENCE (ACE) STUDY CDC.GOV 1995-97, ANDA AND FELITTI ADVERSE CHILDHOOD EXPERIENCES Emotional Abuse Physical Abuse Sexual Abuse Neglect Emotional Physical Household Dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness Parental Separation or Divorce Incarcerated Household Member

8. ADVERSE CHILDHOOD EXPERIENCES

9. “MIS”-DIAGNOSES WE OFTEN SEE  Anxiety Disorders  Conduct Disorders  Depression/Mood Related  ADHD  Behavior Disorders

10. PTSD DSM-5 DEFINITION Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor- Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the center of public as well as professional discussion.

11. PTSD DSM-5 DEFINITION The diagnostic criteria for the manual’s next edition identify the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:  directly experiences the traumatic event;  witnesses the traumatic event in person;  learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or  experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

12. PTSD DSM-5 DEFINITION The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.

13. WHAT CAN WE DO???

14. COPING Coping skills are essential to:  Decrease anxiety  Regulate emotions  Have healthy alternatives available  Lay the foundation for healing

15. COPING You can:  Make your home a safe place  Involve the youth in their own safety planning  Learn DBT (most of the kids have learned it)  Translate terms into everyday language  Coach consistent use  Model your own coping skills…What are some?

16. HEALING When kids having consistent coping mechanisms in place, then the healing can begin. Things you can do:  Communicate good and concerning things  Advocate for an experienced therapist  Work alongside the treating team  Ask what you can do at home to help  Learn about Evidenced Based Practices  Don’t add traumas (disruptions/police interventions)

17. CHANGING  According to new research (Jim Casey Youth Opportunities Initiative), the brain is not done growing by the age of 3 like we thought.  Kids’ brains can reengage by way of positive/corrective experiences.

18. CHANGING - EXAMPLES Examples:  Actively involve kids in positive activities/relationships (after school, church etc.)  Keep them connected to their existing connections- Partner with birth family  Help them develop a sense of belonging to a community (church, trips “home”, EmpowerMEnt).  Engage kids in their own planning  Be strength based and positive

19. CHANGING - EXAMPLES Examples:  Get peer support  Trips/Cultural Experiences  Take care or yourself  Expect a good team around you  Talk to the therapist  Don’t add to the trauma (disruptions/police intervention)  More???

20. REFERENCES  The Adolescent Brain- Jim Casey Youth Opportunities Initiative 2011  Adverse Childhood Experiences Study (cdc.gov)  developingchild.harvard.edu  The National Child Traumatic Stress Network (nctsn.com) http://www.upworthy.com/heres-a-story-about-what-foster-care-is- like-for-an-abused-child-removed-from-her-home-2

21. CONTACT INFORMATION  Sandra L. Corbin, LCSW  Sandy scorbin@maac4kids.org 404-880-9323. www.maac4kids.org

22. LUNCH

23. TRAUMA-INFORMED PRACTICE AND SECONDARY TRAUMATIC STRESS October 2, 2014 Brian E. Bride, Ph.D., M.S.W., M.P.H. Professor and Director Georgia State University School of Social Work

24. EXPOSURE  Acute Trauma refers to a single traumatic event that is limited in time, such as an auto accident, a gang shooting, a parent's suicide, or a natural disaster.  Chronic Trauma refers to repeated assaults on the child's mind and body, such as chronic sexual or physical abuse or exposure to ongoing domestic violence.  Complex Trauma is a term used by some trauma experts to describe both exposure to chronic trauma, often inflicted by parents or others who are supposed to care for and protect the child, and the long-term impact of such exposure on the child.

25. RE-EXPERIENCING SYMPTOMS  Recurrent and intrusive recollections of the event.  Recurrent distressing dreams of the event  Acting or feeling as if the traumatic event were recurring  Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.  Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

26. AVOIDANCE/NUMBING SYMPTOMS  Efforts to avoid thoughts, feelings, or conversations associated with the trauma.  Efforts to avoid activities, places or people that arouse recollections of the trauma.  Inability to recall an important aspect of the trauma.  Markedly diminished interest or participation in significant activities.  Feeling of detachment or estrangement from others.  Restricted range of affect.  Sense of a foreshortened future.  In children – New fears of separation, being alone, or darkness.

27. HYPERAROUSAL SYMPTOMS  Difficulty falling or staying asleep.  Irritability, frustration, or anger.  Difficulty concentrating.  Hypervigilance  Exaggerated startle response

28. DISTRESS AND IMPAIRMENT  Significant Distress  Impaired Functioning  Family  Social  Educational/Occupational

29. TRAUMA INFORMED APPROACH: The Three Rs  Realizing the prevalence of trauma;  Recognizing how trauma affects all individuals involved with the program, organization, or system;  Responding by putting this knowledge into practice.

30. TRAUMA INFORMED APPROACH: Key Principles  Incorporation of trauma awareness;  Emphasis on safety;  Opportunities to rebuild control and empowerment;  Emphasis on strengths-based approaches rather than deficit-oriented models.

31. EVIDENCE-BASED TRAUMA INTERVENTIONS  Child-Parent Psychotherapy (CPP)  Trauma Affect Regulation: Guide for Education and Therapy (TARGET)  Trauma-Focused Cognitive-Behavior Therapy (TF-CBT)  Cognitive Behavioral Intervention for Trauma in Schools (CBITS)  Parent-Child Interaction Therapy (PCIT)  Trauma and Grief Component Therapy for Adolescents (TGC T-A)

32. NEGATIVE EFFECTS OF EXPOSURE TO TRAUMATIZED POPULATIONS: What do we call it?  Indirect trauma  Emotional contagion  Savior Syndrome  Cost of caring  Secondary victimization  Secondary traumatic stress  Compassion fatigue  Vicarious traumatization  Burnout

33. SECONDARY TRAUMATIC STRESS: What is it? “A syndrome of symptoms nearly identical to PTSD except that exposure to a traumatizing event experienced by one person becomes a traumatizing event for the second person.” (Figley, 1999, p.11)

34. SECONDARY TRAUMATIC STRESS SYMPTOMS  Exposure  Intrusion  Avoidance  Hyperarousal  Distress/Impairment

35. COMPASSION FATIGUE  Conceptually identical to Secondary Traumatic Stress.  Introduced as a potentially less stigmatizing term.  Sometimes used to refer to the combination of secondary traumatic stress and burnout.

36. DEFINITION OF VICARIOUS TRAUMATIZATION  The transformation in the inner experience of the therapist that comes about as a result of empathic engagement with traumatic material. (Pearlman & Saakvitne, 1995, p.31)  Profound disruptions in the therapist’s frame of reference, that is, his basic sense of identity, world view, and spirituality. Multiple aspects of the therapist and his life are affected, including his affect tolerance, fundamental psychological needs, deeply help beliefs about self and others, interpersonal relationships, internal imagery, and experience of his body and physical presence in the world. (Pearlman & Saakvitne, 1995, p. 280).

37. BURNOUT Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, determined by the dimensions of exhaustion, cynicism, and inefficacy. (Maslach, Schaufeli, & Leiter, 2001)

38. PREVALENCE OF STS  Social Workers (N = 282) (Bride, 2007)  55% met at least one of the core criteria for PTSD  24% scored above the clinical cutoff.  15% met the core criteria for PTSD.  Social Workers (N = 529) (Bride & Lee, 2012)  48% met at least one of the core criteria for PTSD  15% scored above the clinical cutoff.  11% met the core criteria for PTSD  Substance Abuse Counselors (N = 225) (Bride, Hatcher, & Humble, 2009)  57% met at least one of the core criteria for PTSD.  26% scored above the clinical cutoff.  19% met the core criteria for PTSD.  Substance Abuse Counselors (N = 936) (Bride & Roman, 2011)  54% met at least one of the core criteria for PTSD.  16% scored above the clinical cutoff.  13% met the core criteria for PTSD.

39. PREVALENCE OF STS – cont’d  Domestic/Sexual Violence Social Workers (N = 154) (Choi, 2011)  66% met at least one of the core criteria for PTSD.  29% scored above the clinical cutoff.  21% met the core criteria for PTSD.  Child Welfare Workers (N = 187) (Bride, Jones, & MacMaster, 2007)  92% experienced some symptoms of STS.  43% scored above the clinical cutoff.  34% met core criteria for PTSD.

40. SUMMARY OF PREVALENCE STUDIES  Most service providers experience some symptoms of STS.  Most service providers have low levels of STS.  A significant amount of service providers have relatively high levels of STS.  CHILD WELFARE = the highest STS rates.

41. RISK AND PROTECTIVE FACTORS Exposure to traumatized populations  caseload – size, composition  child trauma  severity and type of trauma

42. RISK AND PROTECTIVE FACTORS  Demographic variables  Age, experience, gender, ethnicity, trauma history  Social Support  Reliable alliance, helpfulness, discussion, satisfaction, cohesion

43. ROLE OF EMPATHY IN STS  Affective Sharing  Capacity for an automatic or unconscious affective response to others, which may include sharing emotional states.  Perspective Taking  A cognitive capacity to take the perspective of another.  Self-Other Awareness  The capacity for temporary identification between self and other that ultimately avoids confusion between self and other.  Emotional Regulation  The ability to change or control one’s own emotional experience.

44. COMPASSION SATISFACTION & RESILIENCE  Observing and experiencing client recovery and growth  Increased empathy, insight, and tolerance  Appreciation of life  Personal growth  Appreciation of relationships  Improved spousal relations  Improved parenting skills

45. ABCs OF SELF-CARE  Awareness  Recognize and identify STS symptoms.  Monitor changes in symptoms over time.  Recognize and monitor changes in functioning.  Balance  Make personal life a priority.  Attend to your physical health.  Connection  Make relationships with family and friends a priority.  Honor your connection to your community.  Revitalize your sense of life’s purpose and meaning.

46. Putting it All Together ACTIVITY

47.  Q & A  Workshop Evaluation  Ron Scroggy, Together Georgia ron.scroggy@gahsc.org  David Meyers, J.W. Fanning Institute for Leadership  dmeyers@fanning.uga.edu dmeyers@fanning.uga.edu  706-542-5062 THANK YOU!