ANY QUESTIONS COMMUNITY - SanctuaryWeb.com 2016.pdfSEPARATION/DIVORCE •INCARCERATION 1 POINT /CATEGORY –ADD TO GET TOTAL ACE SCORE 0 ACES 36% 1 ACES 26% 2 ACES 16% 3 ACES 10% 4

10/24/2016

© Sandra L. Bloom, M.D. 2014

Sandra L. Bloom, M. D.Dornsife School of Public Health, Drexel University

Simple – anytime, anywhere

Grounds us to help make a transition

Experience of predictable safety

Honors emotions

Levels hierarchy – build team

Keeps relationships at the forefront

Who are you?

What are you feeling right now? (just one)

What is your goal for today’s class?

Who (at the table) can you ask for help if you need it?

ANY QUESTIONS ABOUT

COMMUNITY MEETING?

ACUTE INPATIENT ADOLESCENTS AND ADULTS

GENERAL HOSPITAL PSYCHIATRY

1980

1985

THE SANCTUARY PROGRAMS

CREATING SANCTUARY TIMELINE

Multiple, interactive problems

Polyvictimization

Began in childhood, extended through adolescence and into adulthood

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ACUTE INPATIENT FOR ADULTS WHO WERE ABUSED AS CHILDREN

1980

1991

1996

1999

2001

THE SANCTUARY PROGRAMS

CREATING AND DESTROYING SANCTUARY TIMELINE

1985

COMPLEX EFFECTS

Body

Identity

Relationships

Meaning‐making

When a person’s life becomes fundamentally

and unconsciously organized around the impact of chronic and toxic stress, even when this undermines their

adaptive ability.

They were in danger from themselves or others

They could not keep themselves safe

They did not know what safety was

They didn’t trust others and were very sensitive to betrayal of trust

Experience with disrupted attachment impaired emotional regulation

They had difficulties managing emotional arousal (dysregulation)

They did not understand the connections between what they felt and problems from the past

They wanted to stay emotionally numb rather than feel the pain of the previous experiences – often through using drugs and/or alcohol

They were likely to lash out if something we did or said broke through that emotional numbness

The history of multiple disrupted attachments and the emotional dysregulation interfered with cognitive development.

This impacted academic performance even in the context of normal or superior intelligence.

As a result, they tended to make many repetitious mistakes and felt great shame and loneliness

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They were unlikely to make the connection between their present problems and previous experiences (AMNESIA)

They were unlikely to want to talk about their previous bad experiences (AVOIDANCE)

They had no words for the worst parts of the experiences (ALEXITHYMIA)

They could not communicate well inside themselves or with others (DISSOCIATION)

They had all been exposed to the abusive use of power at the hands of someone else

They did not know how to use their own personal power without hurting self or others

They often engaged in bullying behavior or were bullied by others – or both.

Confused about right/wrong, fair play, social responsibility

Balancing individual needs with the common good

Extraordinary amount of repetitive loss

Inability to grieve

Failure to envision any alternative or positive futures

Their past experience of chronic hyperarousalhad compelled the development of coping skills to protect the CNS

The symptoms we saw were the remnants of original adaptive and necessary coping skills.

These coping skills had over time become bad habits that the person no longer could see or control.

As a result, the capacity to create and sustain interpersonal trust was severely compromised

Children and

Adults

Lack of basic safety/trust

Loss of emotional

management

Problems with cognition

Communication problems

Problems with authority

Confused sense of justice

Inability to grieve and anticipate future

TRAUMA‐ORGANIZED PERSON

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Psychobiology of stress

Impact of trauma

Developmental neuroscience

Social neuroscience

Spiritual neuroscienceTHE BIG DEAL ABOUT TRAUMA

MORAL FRAMEWORK

EMOTION

CHILD DEVELOPMENTTHE PROLONGED PROCESS OF INTEGRATION

YOU

SENSATION

JUDGMENT

KNOWLEDGE

AWARENESS

Scientists now know a major ingredient in this developmental process is the “serve and return”

relationship between children and their parents and other caregivers.

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Brains are built over time, from the bottom up and keep developing until around age 25‐30

In infancy, 700 new neural connections are formed every second.

Pruning follows rapid proliferation so that brain circuits become more efficient.

Biological Regulation

Emotional Development

Cognitive Development

Social Development

Moral Development

THE POISON IN OUR LIVES

The wear-and-tear on the body and brain resulting from chronic over-activity of

physiological systems that are normally involved in adaptation to environmental challenge

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Poverty

Racism

Parenting alone

Multigenerational caregiving

Multiply challenged children

Severe injury/illness in primary caregiver

Severe medical/mental illness/injury in close family

Irritability

Impatience

Depression

Shame

Poor quality decisions

Substance abuse

Violence

Impaired parenting

Intergenerational transmission

33

RELENTLESS STRESS IN PARENTSStrong and prolonged activation of the body’s stress management systems

Particularly problematic during critical developmental periods

Effects basic brain architecture

• when the basic structures of the brain are being organized

Fetal period

• when the brain is doing much of its basic wiring

Infancy and early childhood

• when changes in sex hormones are shaping and altering the way the brain processes chemical messages.

Adolescence

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SMALLER BRAIN

CHRONIC HYPERAROUSAL

LEARNING

MEMORY

LANGAGUE

STRESS HORMONES AFFECT IMMUNITY

WHOLE BODY

DEVELOPMENTAL INSULTS, DELAYS, DISTORTION

THE ADVERSE CHILDHOOD EXPERIENCES STUDY (ACEs STUDY)

In 1998, largest study of its kind ever (almost 18,000 participants)

Examined the health and social effects of adverse childhood experiences over the lifespan

Majority of participants were 50 or older (62%), were white (77%) and had attended college (72%).

• PHYSICAL ABUSE

• SEXUAL ABUSE

• EMOTIONAL ABUSE

• PHYSICAL NEGLECT

• EMOTIONAL NEGLECT

• MENTAL ILLNESS

• SUBSTANCE ABUSE

• DOMESTIC VIOLENCE

• PARENTAL SEPARATION/DIVORCE

• INCARCERATION

1 POINT /CATEGORY – ADD TO GET TOTAL ACE SCORE

0 ACES 36%

1 ACES 26%

2 ACES 16%

3 ACES 10%

4 or more 7%

The ACE Score is used to assess the total amount of stress during childhood and has demonstrated that as the number of

ACE increase, the risk for the following health problems increases in a strong and graded fashion:

Alcoholism and alcohol abuse intimate partner violence

COPD Multiple sexual partners

Depression STDs

Fetal death Smoking

Health‐related quality of life Suicide attempts

Illicit drug use Unintended pregnancy

Heart disease Early smoking

Liver disease Adolescent pregnancy

Autoimmune disease Cancer

Obesity Stroke

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0 1.0 1.0

1 1.9 2.0

2 2.1 2.8

3 2.7 4.2

4 4.5 5.3

5 or more 5.1 8.9

Adverse Childhood Experiences play a significant role in determining the

likelihood of the ten most common causes of death in the United

States.

ACE Score of 0 ‐majority of adults have few, if any, risk factors for these diseases.

ACE Score of 4 or more ‐ majority of adults have multiple risk

factors for these

Twice as likely to smoke

Seven times more like to be alcoholiccs

Six times more likely to have had sex before the age of 15

Twice as likely to have been diagnosed with cancer

Twice as likely to have heart disease

Four times as likely to suffer from emphysema or chronic bronchitis

Twelve times as likely to have attempted suicide

Ten times more likely to have injected street drugs

DISEASES OF STRESSNegative emotions generated by stress trigger immune responses

Same cascade as body deploys against physical pathogents

Wears out heart muscles, vascular system –heart disease, hypertension

Autoimmune disease and other inflammatory processes

INFLAMMATION

Cardiovascular disease

Cancer

Pulmonary disease

Alzheimer’s

Autoimmune disease

Arthritis

Neurological disorders

Diabetes

Digestive disorders

INFLAMMATION AND ACES

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TRAUMATIC STRESS

Occurs when both internal and external resources are inadequate to cope with external threat.Van der Kolk, 1989

AWARENESS

EMOTION

SENSATION

BEHAVIOR

• Integrated Experience • Can be recalled• Weathering of memory

ITS ALL ABOUT TH

E BRAIN

Fight Flight Freeze

Fear simultaneously initiates two information‐

processing systems: the “low road” and the “high road”

(LeDoux, 1996).

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12 milliseconds

24 milliseconds

Epinephrine (adrenalin)

The problem with extreme stress Heart Rate Under Stress

State of high alert

Inability to think clearly

Extreme thoughts

Attention to threat

Intense and prolonged anxiety

Driven to take action

“Hair trigger” tempers

Aggression

Epinephrine (adrenalin)

Cortisol

Endorphins

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Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an

imaginable past. B. A. van der Kolk MD, Bessel (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

ALL TRAUMA IS PREVERBALB. A. van der Kolk, The Body Keeps the Score

One name for the Devil is “Diabolos” which means the divider, the splitter-into-fragments.

Robin Skynner, Life and How to Survive It

Knowledge

Behavior

Emotions

Sensation

MEMORY

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Dissociation = A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the

environment

POST-TRAUMATIC REMINDERS - TRIGGERS FOR BEHAVIOR

Triggered by sensory element

Original fear revived

Traumatic moment re‐experienced

FLASHBACKS

SIGHTS

SOUNDS

TASTES

SMELLS

PRESSURE

PAIN

BALANCE

TEMPERATURE

POSITION

SPEED

Haunting images

Voices, words

Disgust, eating problems

Olfactory hallucinations

Repelled by touch

Recurrent or chronic pain

Faint, falling over

Cold, heat

Lying down, being held

Time perception

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Loss of emotional management

Sleep problems

Daytime fatigue Irritability

Easily triggered by minor stimuli into fight‐flight‐freeze

Intrusive experiences

Avoidance people/places/thing

Always on edge

Triggered outside of conscious awareness by otherwise normal environmental situations

Avoid people, places, things, relationships

Experience danger everywhere – can look like paranoia

Feelings, particularly positive feelings, disappear –numb, shut down, depressed

Haunting images

Disturbing physical sensations

Chronic fear

Exhaustion

Helplessness

Hopelessness

LOSS OF INTEGRATED FUNCTION

7

FRAGMENTED PERCEPTIONS, SENSATIONS

5

ACTION INITIATED

3

PERCEIVE DANGER

1

CONSCIOUS AWARENESS

8

OVERWHELMING EMOTIONS

6

LANGUAGE CAPACITY OFF‐LINE

4

NEURAL OVERLOAD

2

THE TR

AUMATIZED BRAIN IN

SHOCK

Fearless Fearless

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SHATTERED SENSE OF COHERENCE

LIFE IS UNPREDICTABLE

LIFE IS INCOMPREHENSIBLE

LIFE IS NOT MANAGEABLE

LIFE NO LONGER HAS MEANING

Community

Friends, teachers,

other adults

Family

Self

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• AddictionSubstance use

• Anxiety, phobias, AgoraphobiaAvoidance of triggers

• Self‐harming, FightingPain as a distraction

• Depression, suicidalityAvoidance of grief

• Addiction to traumaRisky behavior

• Alienation from othersControlling behavior

• Reenactment, revictimizationDissociation

• Criminal, antisocial behaviorEmpowerment through violence

Ramping down

Habits

Unconscious repetition of painful or negative relationships that become ingrained patterns over time and that are reenacted

with other individuals or groups.

A sudden and passively endured trauma is relived repetitively, until the person learns to remember simultaneously the

emotions and thoughts associated with trauma through access to language.

87

Trapped in time

Haunted by the past

Unable to be fully present in the present

Unable to envision a different future

Repeat the traumatic past

Those who cannot remember the past are condemned to repeat it (p284). George Santayana, 1905,

The Life of Reason: Or, The Phases of Human Progress,

Fearless

HABIT FORMATION

COPING

FAILURE OF INTEGRATION

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Personality disorder

Depression

Generalized anxiety disorder

Panic disorder

Conduct disorder

Oppositional disorder

ETC

ETC

ETCClientsLack of basic

safety/trust

Loss of emotional

management






TRAUMA‐ORGANIZED PERSON

It’s not “What’s wrong with you?”

It’s “What happened to you?”

Children, Adults, Families

Safety Skills

Emotional Management

Skills

Cognitive Skills

Communication Skills

Leadership Skills

Judgment Skills

Grieving and Imagination

TRAUMA‐INFORMED RESPONSES

WHO IS SUPPOSED TO HELP WITH THIS COMPLEXITY?

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TASKS OF RECOVERY

Chronic Stress:Biological stabilization

Basic Safety and Trust:Safety skills with supportive people

Loss of Emotional Management:Emotional management skills

Miscommunication and Alexithymia:Communication skills, words for feelings

Dissociation, Fragmentation:Grounding, reconstruction of memory, integration: trauma‐specific approaches

Systematic Error and Reenactment:Pattern recognition and change

Impaired Executive Function:Healthier use of power and executive functions ‐ self‐control, self‐discipline

Impaired Cognition: Better judgment, decision‐making

Inadequate relationship skills: Social skills, relationships

Learned Helplessness: Mastery Experiences

Aggression: Ability to manage aggressive impulses

Unresolved Grief: Mourning for what is lost

Demoralization and Failure of Imagination: Belonging to a meaningful, worthwhile, nonviolent and caring culture & Imagining a different and better future

Parents

Educators

Other Caregivers

Mental health workers

Child welfare workers

Healthcare providers

Law enforcement, Judiciary, Corrections, Probation, Parole

Secure, reasonably healthy adults,

With good emotional management skills,

With intellectual and emotional intelligence,

Able to actively teach and be a role model,

Are consistently empathetic and patient,

Able to endure intense emotional labor,

Are self‐disciplined, self‐controlled and never abuse power

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A growing proportion of the U.S. workforce will have been raised in disadvantaged environments that are associated with relatively high proportions of individuals with diminished cognitive and social skills.

Knudsen, Heckman et al. (2006)

Proceedings of the National Academy of Science

TOO MUCH TO DO FUNDING

POOR COMMUNICATION

DEMANDS

After law enforcement, persons employed in the mental health sector have the highest rates of all occupations of being victimized while at work or on duty.

An interconnected, complex, adaptive,

living world

STAFFLack of basic safety/trust

Loss of emotional

management






TRAUMA‐ORGANIZED STAFF

Organizations, like individuals, are living, complex, adaptive systems and that being alive, they are vulnerable to stress,

particularly chronic and repetitive stress.

Organizations, like individuals, can be traumatized and the

result of traumatic experience can be as devastating for organizations as it is for

individuals.

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ORGANIZATIONAL TRAUMAORGANIZATIONAL TRAUMA

COMMUNICATION BREAKS DOWNFEEDBACK LOOPS ERODERISK INCREASES

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INTERPERSONAL CONFLICT INCREASES

TASK CONFLICT DECREASES

ORGANIZATIONAL DISSOCIATION

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LOSS OF COMPLEX THINKING SKILLS

Silencing of dissentAuthoritarianism

Bullying as normIncreased aggression

DEMORALIZATION SYSTEM COLLAPSE

ORGANIZATIONLack of basic safety/trust

Loss of emotional

management






TRAUMA‐ORGANIZED SYSTEM

When two or more systems – whether these consist of individuals, groups, or organizations – have significant relationships with one another, they tend to develop

similar thoughts, feelings and behaviors.

K. K. Smith et al, 1989

Expecting a protective environment and finding

only more trauma.Dr. Stephen Silver (1986) An inpatient program for post‐traumatic stress

disorder: Context as treatment. Trauma and Its Wake.

SANCTUARY TRAUMA

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CHRONIC ORGANIZATIONAL STRESS: WHAT NEEDS TO BE DONE?

Reduce hyperarousal

Establish safety to promote trust

Provide emotional management tools and use themClean up network of communication; re-establish feedback loopsIdentify and discuss the undiscussables

Actively engage conflict management tools

Focus on real teamwork

CHRONIC ORGANIZATIONAL STRESS: WHAT NEEDS TO BE DONE?

Recover forgotten strategies that work

Identify repetitive and useless or even destructive patterns

Engage the engageable; help others out the door

Allow dissent, enable democratic processes, discourage authoritarianism

Respond to every episode of aggression as a problem for and of the entire group

Refuse to tolerate bullying

Expect high, creative, innovative activities, thought, and action

From diverse backgrounds

With a wide variety of

experiences

On the same page

Speaking the same

language

Sharing a consistent,

coherent and practical

theoretical framework

pattern of shared basic assumptions that a group has

learned as it solved its problems…and that has

worked well enough to be considered valid and taught

to new members

How we do things around here

Accumulated Wisdom Largely unconscious

Organizational Culture

CHANGING ORGANIZATIONAL CULTURE

Will only happen when fear is not running the show

Must include all levels of safety: physical, psychological, social and moral

Must involve the people who comprise the system – all of them

More transparency, honesty, openness – cognitive and emotional.

Unearth the skeletons and give them proper burial

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CHANGING ORGANIZATIONAL CULTURE

Must deal with power‐who has it, who abuses it, who wants it – who/what has the power to heal?

Must honor the past and allow grieving for what is lost, and know that all change involves loss.

Awaken hope, get people moving, remobilize imagination and innovation.

Social supportSocial supportSocial supportSocial supportSocial supportSocial supportSocial supportSocial supportSocial support

Clients

Staff

Managers

Systems

SHARED MISSION

SHARED PRACTICE

SHARED LANGUAGE

SHARED VALUES

SHARED KNOWLEDGE

WHAT IS A COMMUNITY?

THE SANCTUARY MODEL

Trauma‐informed and trauma‐responsive

Whole culture approach

Clear and structured methodology

Evidence‐supported

Context for trauma‐specific treatment

THE FOUR PILLARS

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SHARED KNOWLEDGE

THE SOLID FOUNDATION

Evolutionary neuroscience

Developmental neuroscience

Psychobiology of stress, toxic stress, allostatic load and traumatic stress

Social neuroscience

Group dynamics

Spiritual neuroscience

Healing and Recovery

Resilience

UNIVERSAL PRINCIPLES

Those beliefs about human conduct that are common to human rights

cultures around the world, regardless of gender, ethnicity, religious belief, or

location on the globe..


cultures around the world, regardless of gender, ethnicity,

religious belief, or location on the globe.

SHARED VALUES

THE SANCTUARY COMMITMENTS

Nonviolence

Emotional Intelligence

Social Learning

Open Communication

Democracy

Social Responsibility

Growth and Change

SHARED VALUES

• Are we morally, socially, psychologically and physically safe with each other?

Nonviolence:

• Do we keep asking questions until we achieve understanding and get the whole story?

Emotional Intelligence:

• Does our system guarantee that each of us learns the maximum knowledge from our mistakes?

Social Learning:

• Are there blocks in our communication network?Open Communication:

• How do we balance the needs of individuals with the needs of the group?

Social Responsibility:

• Does everyone have an opportunity to truly participate?Democracy:

• Do we help people change by honoring their loss and envisioning the future?

Growth and Change:

Nonviolence: Trust

Emotional Intelligence: Recognizing patterns

Social Learning: Constantly learning from failure

Open Communication: Maintain flow of ideas

Social Responsibility: Common goals, common focus

Democracy: Everyone has a contribution to make

Growth and Change: The heart of innovation

THE SANCTUARY MODEL

The Sanctuary Commitments structure the organizational norms that determine the organizational

culture.

SHARED VALUES


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SANCTUARY COMMITMENTS

SHARED VALUES

Nonviolence

Emotional Intelligence

Social Learning

Open Communication

Social Responsibility

Democracy

Growth & Change

BOARD/REGULATOR DECISIONS

LEADERSHIP DECISIONS

DEPARTMENT DECISIONS

TEAM DECISIONS

CLIENT/CAREGIVER

DECISIONS


The defining, characteristic of a flying buttress is that it is not in contact with the wall it supports, like a traditional buttress, and so transmits the lateral forces across the span of intervening space between the wall and the pier.

SHARED VALUES

S.E.L.F.

•WHAT ARE THE SAFETY ISSUES?S

•WHAT ARE THE EMOTIONS?E

•WHAT WILL WE HAVE TO GIVE UP TO CHANGE?L

•WHY CHANGE?F

SHARED LANGUAGE

KEY COMPASS POINTS TO PRODUCE ALIGNMENT FOR ANYBODY, ANYWHERE, ANYTIME

SANCTUARY TOOLKIT




SHARED PRACTICE

• more effectively deal with difficult situations

• build community

• develop a deeper understanding of the effects of adversity and trauma

A range of practical skills that enable individuals and organizations to:




SHARED MISSION

Children

Adults

Families

Organizations

Systems

Communities

Society

• Universal knowledge about trauma, adversity and its effects with universal precautions.

PRIMARY: Trauma‐informed

• Policies and practices in place to minimize damage and maximize opportunities for healthy growth and development in populations at risk and in the staff who serve them.

SECONDARY: Trauma‐responsive

• Therapeutic interventions that specifically explore the trauma in the initial phases of therapy and then utilize those discoveries as a foundation as the therapy moves into current issues

TERTIARY: Trauma‐specific

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TRAUMA‐INFORMED COMMUNITY TRAUMA‐RESPONSIVE SYSTEMS

TRAUMA‐SPECIFIC TREATMENT TOWARD A TRAUMA-INFORMED PHILADELPHIAhttp://www.drexel.edu/dornsife/practice/center‐for‐public‐health‐practice/toward‐a‐trauma‐informed‐city/

Philadelphia ACEs Task Forcewww.PhiladelphiaACEs.org

CAMPAIGN FOR TRAUMA-INFORMED POLICY AND PRACTICE (CTIPP)www.CTIPP.org

The Sanctuary Modelwww.sanctuaryweb.com

SANDRA L. BLOOM, M.D. ASSOCIATE PROFESSOR,

HEALTH MANAGEMENT AND POLICYDORNSIFE SCHOOL OF PUBLIC HEALTH,

DREXEL UNIVERSITYPHILADELPHIA, PA

WWW.SANCTUARYWEB.COM

ANY QUESTIONS COMMUNITY - SanctuaryWeb.com 2016.pdfSEPARATION/DIVORCE •INCARCERATION 1 POINT /CATEGORY –ADD TO GET TOTAL ACE SCORE 0 ACES 36% 1 ACES 26% 2 ACES 16% 3 ACES 10% 4

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