Positive Approaches Journal, Volume 13, Issue 1

Volume 13 ► Issue 1 ► June 2024

Understanding Trauma: From Theory to Practice

Volume 13 ► Issue 1 ► June 2024

Data Discoveries

The goal of Data Discoveries is to present useful data using new methods and platforms that can be customized.

Trauma can be described as a response to a circumstance, event, or series of events that an individual experienced as stressful, frightening, or physically or emotionally distressing.¹ People may experience these events themselves or they may witness them happening to others. These circumstances can present coping challenges.² Trauma can happen in response to serious injuries or violence, and it can affect individuals, families, groups, communities, and generations. Trauma can occur because of natural disasters (e.g., storms and earthquakes) or it can be caused by other people (e.g., war, violence, accidents). Some people feel the effects of trauma immediately while others do not feel the effects for days, weeks, or months. Trauma can affect both physical and mental health.

Trauma can be caused by a single event, repeated events, or sustained and chronic events and can cause emotional, physical, cognitive, behavioral, social, and developmental reactions. Most of these are normal responses to trauma, and very few meet the criteria for mood and anxiety disorders.² Trauma can cause emotional symptoms such as increased anger, anxiety, and sadness, and physical responses like sleep, gastrointestinal, and cardiovascular issues.² Individuals who have experienced trauma may also engage in self-injurious and compulsive behaviors or attempt to self-medicate with alcohol or other substances to cope with their trauma.² Depression and avoidance (avoiding memories, thoughts, or feelings associated with trauma) are also common in individuals who have experienced trauma.²

From a data perspective, trauma is difficult to measure because people experience it so differently and most studies have sought to understand types of trauma more qualitatively.³ While data are limited, autistic people may be more likely to experience potentially traumatic events (PTE) and to develop Post Traumatic Stress Disorder (PTSD) compared to individuals without autism.^4,5 Preliminary findings suggest that trauma-related disorders may be more common in autistic people compared to non-autistic people.⁵ However, more research is needed to understand the prevalence of traumatic stress and PTSD in this population. Nearly 45% of autistic individuals have “probable PTSD symptoms,” which is 10 times higher than those without autism.⁷ Autistic people may experience sensory differences, which may make it more difficult to cope with stressors. Additionally, there is evidence that people with intellectual and developmental disabilities (IDD) have greater difficulty reporting traumatic events, and their symptoms may present differently compared to people without IDD.^8,9 These differences emphasize the importance of trauma screening for autistic people, and for the development of assessments that consider autistic characteristics. 

Research suggesting a higher prevalence of trauma among autistic individuals underscores the importance of trauma-informed care and resilience-building. Identifying PTSD and trauma-related symptoms among individuals with IDD can be challenging for providers. There is an urgent need for multidimensional and individualized assessments to support providers in recognizing PTSD and other trauma-related symptoms in individuals with IDD. 

Understanding trauma and building resilience skills are critical first steps in developing a supportive service system for the IDD population. The ASERT resource dashboard below provides key resources for providers, individuals, families, and communities.

Volume 13 ► Issue 1 ► June 2024

The Importance of Place in Trauma-Informed Care: A Wellness Approach

John Thvedt & Christine Martin

Abstract

This article delves into the synergy between trauma-informed care and positive supports, framed within a wellness perspective. Trauma-informed care emphasizes creating healing environments, while positive supports focus on strengths and resilience. By merging these approaches, practitioners can bolster interventions for trauma-affected individuals. Key principles and strategies for implementing a wellness-oriented approach to trauma-informed care are discussed, emphasizing collaboration, empowerment, and self-care for both providers and recipients. 

Keywords: Trauma-informed care, positive supports, wellness, empowerment, collaboration, self-care, mindfulness, polyvagal theory.

Temple Grandin has expressed how emotions tie to specific places, highlighting the significant impact of environments on individuals, especially those with autism and/or individuals with intellectual and developmental disabilities (IDD). Most of us have fond memories of happy times in a positive environment. Difficult events are also remembered as a picture of the place and time. People, places, and things create our life stories. Whether places are remembered with happy or sad associations, they generally do not impact our daily lives. However, for the significant number of individuals with autism and/or IDD who have a trauma history, the physical environment can significantly impact their reactions, motivations, and fears, causing acting out behavior. These incidents often lead the individual and those who support and care for them into confusion and despair.

Introduction

Throughout the history of the human service system in our efforts to help, the place of service and the environment has been a significant factor. When we sought to treat and to protect people with disabilities, they were placed in an institution. When we believed that we needed to train people in production, workshops were created. As we learned more, we embraced the concepts of normalization, inclusion, and individual rights, as community living arrangements were developed. As we now begin to understand the significant impact of trauma on people’s lives, and the crisis in our workforce and communities, we should consider the need to create inclusive environments that will support peace and reduce potential triggers or conditions that may cause re-traumatization.

Trauma victims experience triggering memories in certain places, leading to disruptive behaviors. While Functional Behavior Analysis (FBA) dominates as best practice for autism and IDD, the analysis becomes more complex when seeking to understand the problematic behavior of an individual who has experienced trauma. We need to acknowledge that a behavior that is a function of post-traumatic stress may serve NO useful function (other than survival) for the person. It may be a visceral reaction based on an altered stress-response system, leading to dysregulation of processes such as heart rate variability, digestion, and immune function (Dale, et.al. 2022).

When teaching individuals replacement skills to manage triggered responses, wellness and mindfulness approaches have emerged as complementary, strength-based, positive supports. The concept of "Setting Events," frequently used in behavioral psychology, refers to situational factors that can influence behavior. People can be triggered by places, sounds, and odors. These associations with environments often trigger a "flight or fight" response. As we look to support people who have experienced so much trauma in their lives, it is vitally important that we create environments where setting events are identified and addressed/reduced as much as possible.

Polyvagal Theory emphasizes the physiological aspect of trauma healing, suggesting that safety cues are pivotal in mitigating trauma's impact. Safety, in this context, isn't just the absence of threat, but encompasses a sense of safety detected through positive social cues. Additionally, the theory underscores how trauma alters physiological responses, emphasizing the importance of creating safe, supportive environments.

Mindfulness-based practices represent a promising approach for addressing aggressive and destructive behaviors in individuals with an intellectual disability and autism (ID/A). These interventions not only reduce challenging behaviors, but also significantly enhance the quality of life, offering a holistic alternative to traditional treatments. Mindfulness and acceptance training programs can significantly improve the quality of life for individuals with developmental disabilities and their families (Hastings, R., & Manikam, R. 2013). Mindfulness is “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally, to the unfolding of experience moment by moment” (Kabat-Zinn,2003).

Resilience, vital in navigating life's challenges, is nurtured through wellness practices. Acknowledgement that supporters may have a trauma history is important when attempting to “support the supporters.” Direct care providers need resources to prioritize self-care so that they can maintain the quality of service they provide. Trauma informed care includes the need for shared wellness for all stakeholders.

Ultimately, the goal of supporting individuals with ID/A is to enhance their well-being while recognizing and addressing the impact of trauma on both individuals and supporters. This approach emphasizes understanding environmental factors and psychological dynamics for all involved parties. Shared Wellness is an example of how person, place, and relationships are served, resulting from the practical integration of trauma informed care, behavior analysis, mindfulness, and polyvagal theory. Shared Wellness, a project under the umbrella of Shared Support South (SSS), is located in Hatfield, Montgomery County. Shared Wellness provides essential services to individuals with intellectual disabilities (ID) and extends its reach to various community populations facing challenges.

Principles of a Wellness-Oriented Approach to Trauma-Informed Care:

The core principles included in the Shared Wellness philosophy include:

Strategies for Implementation:

The center is dedicated to wellness approaches that can have a transformative impact on trauma-informed care by providing a supportive environment that prioritizes healing, resilience, and holistic well-being. Shared Wellness serves as a safe and empowering space where individuals affected by trauma can access comprehensive services and supports tailored to their unique needs.

An example schedule for an individual would be the following:

Conclusion

A wellness-oriented approach to trauma-informed care, within the context of positive supports, offers a holistic and empowering framework for promoting healing, resilience, and well-being among individuals affected by trauma. By integrating principles of empowerment, collaboration, and self-care, practitioners can enhance the effectiveness and sustainability of interventions, while honoring individuals' strengths, dignity, and inherent capacity for growth and recovery. Moving forward, continued research, training, and implementation efforts are needed to advance this approach and ensure that all individuals have access to trauma-informed care that supports their holistic wellness and flourishment.

Setting events are places and/or inner spaces deeply embedded within cultural contexts, shaped by norms, values, and beliefs, that influence individuals' experiences and responses to trauma. Culturally competent trauma-informed care acknowledges the diversity of settings and recognizes the impact of culture on individuals' coping mechanisms, help-seeking behaviors, and healing practices. 

Incorporating these places into trauma-informed care requires practitioners to adopt a comprehensive approach that considers the physical, social, and cultural dimensions of individuals' environments. This may involve conducting thorough assessments, collaborating with individuals to identify triggers and coping strategies, and creating supportive environments that prioritize safety, trust, and empowerment. By addressing setting events (i.e., places and/or inner spaces) within the context of trauma-informed care, practitioners can enhance the effectiveness and relevance of interventions, ultimately promoting healing, resilience, and holistic well-being for individuals affected by trauma, to improve their everyday lives.

Volume 13 ► Issue 1 ► June 2024

Understanding Complexity: The Convergence of Disability and Trauma in Clinical Practice

Jessica S. Reinhardt & Aidan Campagnolio

The incidence of trauma has seen a notable rise across both the general populace and among those with disabilities. This paper is rooted in an understanding of the concurrent presence of disabilities and trauma, aiming to enhance practitioners' work. This overview provides practitioners with concise guidelines on diagnosing trauma, implementing trauma-informed care, and selecting trauma-specific treatments appropriate for individuals with disabilities. It is important to note, however, that a comprehensive review of these complex and interwoven topics is beyond the scope of this paper. Nonetheless, we highlight the critical need for more extensive research to further our understanding and to guide the development of more evidence-based interventions in this area.

Individuals with intellectual disabilities (IDD) are more vulnerable to psychological trauma compared with the general population ¹ . Similarly, research indicates that children diagnosed with IDD² and autism spectrum disorders³ (ASD) are more susceptible to repeated instances of maltreatment, including bullying, abuse, and sexual assault. Exploring the intersection of various disabilities and trauma/trauma-related disorders such as Post-Traumatic Stress Disorder (PTSD), presents a significant challenge for professionals in selecting the most suitable clinical intervention strategies. Mehtar and Mukaddes ⁴ found that there was a 26% overlap in the incidence of autism and potentially traumatic experiences, with 17% of the individuals fulfilling the diagnostic criteria for both PTSD and autism. That said, differentiating between symptoms of trauma, and IDD and/or ASD, presents a challenge to clinicians, as there are several shared characteristics between autism/IDD and PTSD, and other stressor related disorders ^{5 6} . Research suggests that those who reported experiencing traumatic life events, in both child and adulthood, had a significantly higher risk of aggression, self-injurious behavior, in addition to symptoms of psychological distress ⁷. Problematic and aggressive behaviors in individuals with IDD are thought to be mediated by past traumatic experiences and mental health ^{8 9}. The overlap or mediation of externalizing symptoms of trauma, internalizing symptoms are difficult to distinguish. More specifically, Kildahl and colleagues ¹⁰ found that altered arousal was easily observable, but symptoms of avoidance present differently, and symptoms of re-experiencing were difficult to recognize (unless the clinician knew of the person’s trauma). Challenges with diagnosis are likely exacerbated by the lack of instrument designed specifically for populations with disabilities. Of note, the recently published Diagnostic Interview Trauma and Stressors – Intellectual Disability (DITS–ID), has shown promising psychometrics ¹¹. Given the multifaceted challenges inherent in accurately diagnosing trauma within populations with disabilities, it becomes imperative to pivot focus towards developing an understanding of trauma-informed care and interventions that are specifically designed to address the unique needs of these individuals.

Trauma-Informed Approaches (TIA) and trauma-specific treatments are two complementary, yet distinct approaches in mental health care. TIA is an organizational framework that pervades the policies, practices, and culture of an institution. A key underlying belief guides TIA: any individual may have experienced trauma at some point in their lives. Thus, TIA aims to minimize re-traumatization, promote safety, and support healing by adjusting the overall environment and interactions. TIA does not directly treat trauma but creates a supportive setting that acknowledges the prevalence and impact of trauma on individuals’ lives. Substance Abuse and Mental Health Services Administration’s (SAMSHA) guidance around TIA speaks of the four Rs, namely: ¹²

To achieve these, SAMSHA’s model is centered around six key principles summarized below^{12 13}.

The present authors argue that cultural, historical and gender issues should not be treated as a separate principle. Rather we advocate that attunement to cultural context is a critical overarching concept which informs the other five principles in trauma informed care. Readers interested in adopting a trauma-informed framework are encouraged to view: SAMSHA’s Practical Guide for Implementing and Trauma-Informed Approach. ¹³

Many different fields have begun adopting TIA, including, but not limited to, education, counseling, nursing, social work, and yoga. In addition to systemic TIA , there is a great need for trauma-specific treatments designed for individuals with disabilities. A dual approach using both TIA and specific treatments is critical. Trauma-specific treatments refer to research-supported clinical interventions specifically designed to address the consequences of trauma. Examples include: Cognitive Behavioral Therapy (CBT) for PTSD, Eye Movement Desensitization and Reprocessing (EMDR), and trauma-focused cognitive-behavioral therapy (TF-CBT), among others. Individuals with intellectual disabilities, autism, and other developmental disabilities, are often lacking in trauma-specific treatment research. Specifically, there is a gap in the current literature containing randomized, controlled trails (RCTs) to further support the effectiveness of many treatment modalities ¹⁶ . That said, the early stages of research show promise.

A recent systematic review investigates the literature on EMDR and CBT interventions for children and adults with an intellectual disability  presenting with PTSD or trauma-like symptoms¹⁶ . EMDR has capacity for producing meaningful therapeutic outcomes in adults with ID ^{14, 15, 16}. There is specific support for EMDR as a useful and effective intervention for people with ID, noting EMDR’s applicability with non-speaking clients and its efficient treatment timeline compared to alternatives¹⁶. CBT informed treatments and TF-CBT also show promising evidence, although the research has been limited ¹⁶ . While it is recognized that considerable methodological limitations persist in much of the current research, these studies nevertheless offer practitioners a foundation of hope. This research paves the way for more inclusive and effective therapeutic interventions. Indeed, it is essential to tailor these methodologies to the nuanced needs of individuals with disabilities. The burgeoning body of early-stage research offers a beacon of hope, illuminating the path toward a future where all individuals, irrespective of their abilities, receive the compassionate and specialized care they deserve for trauma recovery. 

In synthesizing the literature on trauma within populations with disabilities, the imperative becomes clear: We must continue to evolve our clinical practices to better understand and address the complex layers of trauma experienced by individuals with disabilities. The convergence of trauma-informed approaches and trauma-specific interventions offers a promising horizon for practitioners. Advancing this dual approach will not only deepen our grasp of trauma's multifaceted nature, but also enhance the healing and empowerment of those who have been historically marginalized in our health care narratives.

References 

1.     Dion J, Paquette G, Tremblay K, Collin-Vézina D, Chabot M. Child Maltreatment Among Children With Intellectual Disability in the Canadian Incidence Study: AJMR. American Journal on Intellectual and Developmental Disabilities. 2018;123(2):176-188,190,192. doi:https://doi.org/10.1352/1944-7558-123.2.176.

2.     McDonnell CG, Boan AD, Bradley CC, Seay KD, Charles JM, Carpenter LA. Child maltreatment in autism spectrum disorder and intellectual disability: results from a population‐based sample. Journal of Child Psychology and Psychiatry. 2019;60(5):576-584. doi:https://doi.org/10.1111/jcpp.12993.

3.     Hoover DW, Kaufman J. Adverse childhood experiences in children with autism spectrum disorder. Current Opinion in Psychiatry. 2018; 31 (2): 128-132. doi: 10.1097/YCO.0000000000000390.

4.     Mehtar, M., & Mukaddes, N. M. (2011). Posttraumatic stress disorder in individuals with diagnosis of autism spectrum disorders. Research in Autism spectrum disorder, 5(1), 539–546. Research in Autism Spectrum Disorders Journal Article.

5.     Haruvi-Lamdan, N, Horesh D, Golan O. PTSD and Autism Spectrum Disorder: Co-Morbidity, Gaps in Research, and Potential Shared Mechanisms. Psychological Trauma. 2018; 10(3) 290-299 doi: 10.1037/tra0000298.

6.     Michna GA, Trudel S M, Bray M A, Reinhardt JS, Dirsmith J, Theodore L, Zhou Z, Patel  I, Jones P, & Gilbert ML.  Best practices and emerging trends in assessment of trauma in students with autism spectrum disorder. Psychology in the Schools 2022 1 16. Psychology in the Schools Journal.

7.     MasonRoberts, S., Bradley, A., Karatzias, T., Brown, M., Paterson, D., Walley, R., Truesdale, M., Taggart, L., and Sirisena, C. (2018) Multiple traumatization and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: a preliminary study. Journal of Intellectual Disability Research, 62: 730–736. Temple University.

8.     Clark M, Crocker AG, Morin D. Victimization History and Aggressive Behavior among adults with intellectual disabilities: the mediating role of mental health. International Journal of Forensic Mental Health 2016; 14(4) 303-311. Temple University.

9.     Rittmannsberger D, Kocman A, Weber G, Lueger-Schuster B.  Trauma exposure and post‐traumatic stress disorder in people with intellectual disabilities: A Delphi expert rating. Journal of applied research in intellectual disabilities, 2019; 32 (3), 558-567 doi: 10.1111/jar.12549.

10.  Kildahl, A. N., & Jørstad, I. (2022). Post-traumatic stress disorder symptom manifestations in an autistic man with severe intellectual disability following coercion and scalding. Journal of Intellectual & Developmental Disability, 47(2), 190–194. Temple University.

11.  Hoogstad A, Mevissen L, Kraaij M, Didden R. Assessment of Posttraumatic Stress Disorder in Adults with Severe or Moderate Intellectual Disability: A Pilot Study Using the Diagnostic Interview Trauma and Stressors – Severe Intellectual Disability. Journal of Mental Health Research in Intellectual Disabilities, 2023. Doi: Temple University.

12.  Substance Abuse and Mental Health Services Administration. SAMHSA'S Concept of Trauma and Guidance for a Trauma-Informed Approach 2014. Department of Health and Human Services, Rockville, MD.

13.  Substance Abuse and Mental Health Services Administration (2014) Practical Guide for Implementing a Trauma-Informed Approach, 2023. Department of Health and Human Services, Rockville, MD.

14.  Penninx Quevedo R, de Jongh A, Bouwmeester S, Didden R. EMDR therapy for PTSD symptoms in patients with mild intellectual disability or borderline intellectual functioning and comorbid psychotic disorder: A case series. Research in Developmental Disabilities 2021; 117 doi: 10.1016/j.ridd.2021.104044.

15.  Verhagen, I., van der Heijden, R., de Jongh, A., Korzilius, H., Mevissen, L., & Didden, R. (2023). Safety, Feasibility, and Efficacy of EMDR Therapy in Adults with PTSD and Mild Intellectual Disability or Borderline Intellectual Functioning and Mental Health Problems: A Multiple Baseline Study. Journal of Mental Health Research in Intellectual Disabilities, 16(4), 291–313. Temple University. 

16.  Byrne G A Systematic Review of Treatment Interventions for Individuals With Intellectual Disability and Trauma Symptoms: A Review of the Recent Literature. Trauma, Violence & Abuse. 2020; 43(2) Temple University.

Biographies

Dr. Jessica S. Reinhardt (she/her), is a nationally certified school psychologist and licensed psychologist. She is the Coordinator of the School Psychology Program at Temple University.  Her overarching professional interests include mental health of children and adolescents, culturally-responsive counseling, trauma-conscious practices, and assessment of neurodevelopmental disorders.

Aidan Campagnolio (he/him), is a PhD student in the school psychology program and research assistant at the Institute on Disabilities (IOD) at Temple University. After completing his undergraduate studies at Temple, Aidan matriculated into the school psychology program to further his understanding of children's and adolescents' psychopathology. Aidan also worked toward this goal by securing a position at the IOD and was soon promoted to research assistant, where he immersed himself in the rigorous research projects at the Institute. Today, Aidan is a key part of the Health Equity and Research and Evaluation teams that serve Pennsylvanians with disabilities. 

Volume 13 ► Issue 1 ► June 2024

A Review of Top-Down and Bottom-Up Trauma Interventions

Julie Vayner & Kate Jakubovic

Abstract

The objective of this article is to review literature and modalities pertaining to positive approaches in treating trauma and posttraumatic stress disorder, with the use of expressive interventions in individuals with intellectual disabilities and/or mental health and behavioral challenges. 

Key Words: Posttraumatic stress disorder, trauma therapy, expressive therapy, top-down, bottom-up, cognitive, behavioral, somatic, mind-body connection.

It is not known exactly how much of the population has been exposed to a traumatic event, but it is estimated that most people in the United States will be exposed to at least one traumatic event in their lifetime.¹ While there is a specific set of criteria of symptoms one must endorse to be diagnosed with post-traumatic stress disorder (PTSD), the lasting effects of trauma can manifest in a variety of ways that may not be exclusive to PTSD. The effects of traumatic stress on the brain and physical body have been researched for over forty years. There is an increased understanding that traumatic experiences can cause short-term and long-term effects on various organs and systems in the body, due to the disruption in homeostasis.² As a result, interventions used to treat post-traumatic distress should consider adopting a holistic approach to target cognitive, behavioral, emotional, and physiological processes. It may be useful to combine elements from both, top-down (cognitive) and bottom-up (physiological) approaches based on the client’s individual needs. This literature review explores several top-down and bottom-up therapeutic interventions targeting post-traumatic distress.

Trauma therapies tend to fall into two very distinct categories: top-down or bottom-up. Top-down approaches include traditional talk-based, cognitive, and behavioral therapies. This approach works to resolve symptoms by working with the area of the brain known as the neocortex. The neocortex is responsible for logic and reason. Alternatively, bottom-up approaches, such as expressive and somatic ones, target the limbic system of the brain. This part of the brain focuses on feelings, automatic reflexes, and sensory receptors that run throughout the body. Both therapies have strengths, and therefore holistic approaches that include both, help better facilitate a mind-body connection, resolve unprocessed memories, and move the individual from a state of stress response to stabilization. Additionally, stages of trauma recovery typically involve three phases that include, 1) Safety and stabilization, 2) Remembering, mourning, and grieving, and 3) Integration and connection.³

To facilitate these phases, a diverse array of evidence-based modalities, which include expressive components, can be deployed. Both top-down and bottom-up approaches will be examined. Keep in mind, these modalities can be utilized on their own, simultaneously by the same practitioner, or adjectively by another practitioner working with the same client. Considering top-down modalities from Cognitive Behavior Therapy (CBT) developed by Aaron Beck in the 1960s, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was expanded by Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006, to assist children and adolescents in recovering from trauma. TF-CBT seen as a short-term (8-25 sessions) option and includes sessions with both the identified client and their caregiver or another trusted individual. The sessions are highly structured and cover psychoeducation, effective parenting skills (relating to the caregiver’s personal distress about the client’s experience), relaxation skills, affective modulation, cognitive coping and processing, trauma narration, in vivo mastery, conjoint parent-child sessions, and enhancing safety in the client’s natural ecology.⁴ The primary intervention focuses on trauma narration and processing, which can be assisted through writing, storytelling, drawing, and even music. For example, clients can select songs or music that help express their experiences, which are otherwise difficult to verbalize. It was initially developed to address the needs of children who experienced sexual abuse but has expanded and adapted to treat other populations and age groups across developmental levels and cultures.⁵

Alternatively, prolonged exposure (PE) developed by Edna Foa, Ph.D. in 1991, is another cognitive behavioral or top-down approach, which is based on emotional processing theory, and focuses on assisting clients in emotionally processing their traumatic experience (s). It is intended to be a short-term intervention consisting of approximately 15, 90-minute sessions. The sessions are also highly structured and involve psychoeducation, breathing retraining, imaginal exposure, cognitive and emotional processing, and homework review. Outside of session, the client practices imaginal exposure as well as in vivo exposure. The intervention targets fear and avoidance by focusing on the client repeatedly exposing themselves to the trauma memory in a variety of ways, until habituation occurs and the memory becomes less distressing. While a person may want to avoid reminders of their trauma and other trauma related stimuli due to the unpleasant feelings they trigger, avoidance serves to maintain post-traumatic distress. Decreasing avoidance through repeated exposure to the trauma memory and emotional processing, allows the client to build tolerance to the trauma related stimuli and experience less distress overall.⁶

Bottom-up approaches include interventions that focus on physiological and somatic processing. Expressive therapies are a group of interventions that target the expression of thoughts and feelings through nonverbal and alternative means of communication. Through this process clients can regain a sense of control. Some examples of expressive therapies may include but are not limited to visual arts therapy, music engagement, movement based creative expression, and expressive writing.^7,8 These approaches are centered around creative arts and are considered non-traditional. Existing research on expressive therapies contains limitations that affect generalizability across populations; however, preliminary research demonstrates that creative and artistic approaches may have an impact on decreasing post-traumatic distress and improving overall physical health.^7,8 Visual arts therapies involve clients using an artistic medium (e.g., painting, drawing, sculpting) to represent their emotions related to the trauma. Music engagement teaches clients to self-regulate through playing musical instruments and form interpersonal connections through playing with others. Movement based creative expression promotes release of tension and stress through dance and body movement (e.g., yoga). Expressive writing promotes emotional expression using language and creative writing. Due to the limitations in research on expressive therapies, it may not be appropriate to rely exclusively on them as the primary source of trauma treatment. However, employing expressive therapeutic techniques in conjunction with other interventions, can help the client adopt a variety of outlets for emotional expression and coping.

Speaking of bottom-up approaches, Eye Movement Desensitization and Reprocessing (EMDR), established by Francine Shapiro in the 1980s, has become highly popularized in recent years. The goal of this therapy is to target distressing memories, themes, and uncomfortable body sensations while installing more adaptive outlooks utilizing eye movements or bilateral body exercises, such as self-tapping, tactile buzzers, and auditory music. Expressive takes on this modality can also incorporate drumming, coloring/scribbling back and forth, acting/role-playing (psychodrama), walking/marching, and dancing, which is notably useful in addressing preverbal and communication deficit needs.⁹ This modality is based on the premise that unhealed traumatic memories become stored maladaptively and lead to maladaptive responses. It is particularly beneficial in reducing risk for flooding and re-traumatization through less intense desensitization practices, wherein the client simply imagines the stimuli versus direct exposure as is conducted with other therapies.¹⁰ EMDR includes an eight-phase protocol, consisting of 1) History taking and treatment formulation, 2) Resourcing, preparation, and coping strategies, which is an ongoing process in the treatment, 3) Assessment, 4) Desensitization, 5) Installation, 6) Body Scan, 7) Closure, and 8) Re-evaluation. Through this process, the client can work on a singular event or cumulating patterns and themes causing them distress.

From EMDR, a more somatic-based approach, Brainspotting, was adapted by David Grand in the early 2000s. It was initially discovered through work pertaining to creativity and performance enhancement, and therefore has been opted for by athletes and artists alike. Brainspotting is used to locate points in the client’s visual field to facilitate the accessing of unprocessed trauma in the subcortical region of the brain.¹¹ This part of the brain targets cognitive, affective, and emotional functioning. When memories aren’t properly processed (i.e. moved into long-term storage), they remain stuck in this region. Brain spots can be located in a variety of ways, including the client organically coming upon or the clinician noticing a particular focal point as the client looks about the room (Gazespotting), or the client and clinician working together to detect a spot of activation or grounding in the client’s visual field using a pointer. Clients can elect to work on a topic from a brain spot that is more activating or less activating (grounding). This type of approach allows for deeper access and reprocessing. It seeks to connect emotional, mental, and physical responses to trauma and releases stress held in each domain. Another benefit of this approach is that the client does not need to “relive” a traumatic event, which can be especially accommodating for clients with high dissociation. 

Holistic approaches to treating post-traumatic distress are gaining popularity as more research emerges supporting the connection between the effects of traumatic stress on the mind and physical body. In this literature review, we highlighted several therapeutic interventions from both top-down and bottom-up approaches. Trauma treatment does not fall into a one size fits all category. It is recommended to consider an individual’s strengths and limitations when selecting therapeutic interventions. For instance, a high functioning, neurotypical individual may benefit from cognitive behavioral therapies (top-down) with expressive components, whereas a lower functioning, neurodivergent individual may benefit from bottom-up approaches, focusing more on expressive and creative means of communicating than cognitive components.¹²

Volume 13 ► Issue 1 ► June 2024

Key Elements of Trauma-Informed Care and Potential Misconceptions

Gordon R. Hodas, MD and Cären L. Rosser-Morris, PhD

Introduction

This article, intended for agencies and organizations seeking to implement trauma-informed care (TIC) and for others seeking to learn more about it, identifies key elements of TIC and potential misconceptions related to TIC.

What Trauma-Informed Care Involves

Trauma-informed care is a universal public health principle that recognizes the prevalence and potential consequences of trauma and adverse childhood experiences in the population, and it seeks to address these. In mental health and other human services, TIC involves intentional efforts on the part of systems, agencies, and their staff to mitigate the impact of trauma and to prevent re-traumatization. TIC is a growing priority in children’s services, and it is relevant to mental health and other human services across the lifespan. The principles of TIC are also relevant in other systems and social contexts.

In 2014, the federal Substance Abuse and Human Services Administration (SAMHSA) identified 6 guiding principles for a trauma-informed approach to care.¹ These principles have been widely adopted and involve the following:

A central theme is that the above interpersonal elements need to be present in relationships between individuals served and staff providing services. Of equal importance is that these same elements apply to the relationships between agency staff and their organization.

The Growth and Evolution of Trauma-Informed Care

For many reasons, awareness of the pervasiveness and consequences of trauma has increased over the past 35 years, along with greater interest in addressing trauma and preventing it in service settings. Contributing elements included increasing awareness of the potential negative effects of restrictive procedures in mental health, outcomes from the landmark Adverse Childhood Experiences (ACE) Study,² and strong advocacy on the part of trauma survivors in support of what came to be known as trauma-informed care.³

In 2001, Harris and Fallot identified trauma-informed care, a concept distinct from trauma-specific treatment, as an orientation and commitment to all individuals irrespective of the type of service they might be receiving. ⁴ In 2009, these individuals highlighted the benefits of an intentional organizational commitment to TIC, which when implemented systematically can lead to a self-sustaining trauma-informed culture. ⁵

While the prevention of potential harm in care remains a TIC priority, TIC now also involves efforts to promote positive practices in treatment and care, which include supporting the autonomy and empowerment of individuals receiving services. In this way, TIC can help mitigate the negative impact of past trauma and also promote growth, resilience, and healing among individuals receiving care.

Key trauma-informed practices include the following:

At a policy level, the Commonwealth of Pennsylvania, which has been promoting trauma-informed interventions in behavioral health for many years, made a formal commitment to become a trauma-informed state in 2019.⁶ This entails the envisioned attainment of TIC in public institutions and in communities. Within the Office of Mental Health and Substance Abuse Services (OMHSAS), the authors have developed specific tools to help agencies assess and promote a range of trauma-informed practices. These tools are available for use within Pennsylvania at no charge.⁷ In addition, OMHSAS has been pursuing a partnership around TIC implementation in Pennsylvania with the five behavioral health managed care organizations that serve Medicaid-enrolled individuals.

Trauma-Informed Care Implementation

The implementation of TIC is not easily achieved and requires an explicit agency commitment, an intentional approach, and persistence. Other important TIC facilitators, as described by Huo and colleagues (2023)⁸ include strong agency leadership, staff engagement, training, allocation of human and financial resources, service-user involvement in design and quality improvement, and collection and use of data. The absence of any of the above elements could undermine an agency’s efforts to implement TIC.  Effective TIC implementation also involves recognition of common misconceptions related to TIC. Below we identify and consider some of these. 

Specific TIC Misconceptions

Conclusion

Current efforts to provide TIC and to create TIC systems build on decades of advocacy and the efforts of trauma-survivors, community advocates, and professionals concerned with the well-being of those impacted by trauma. Trauma-informed care involves an intentional effort on the part of health and human service agencies, public institutions, and their staff to recognize and address the widespread impact of trauma in the population, while also working to prevent trauma and re-traumatization in care provision. 

Organizations seeking to provide effective trauma-informed care need to recognize the long-term nature of this commitment in order to build on current resources and address potential barriers. One kind of barrier discussed in this article involves potential misconceptions related to TIC.  Building on a genuine understanding of what TIC is and what it can offer, we encourage human service agencies and other organizations to engage in self-assessment in order to identify both their strengths and their opportunities for improvement. These efforts can facilitate effective TIC implementation and the desired attainment of a trauma-informed culture.

Gordon R. Hodas, MD: A Board-Certified Adult and Child Psychiatrist, who has been a policy consultant for the PA Children’s Bureau and the PA Office of Mental Health and Substance Abuse Services (OMHSAS) since 1992. He received his medical degree from the Pearlman School of Medicine at the University of Pennsylvania. His residency in Adult and Child Psychiatry was at Boston University Medical Center, and his Child and Adolescent Fellowship at the Philadelphia Child Guidance Clinic. Dr. Hodas is a Distinguished Life Fellow of both the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. In his role with the Children’s Bureau, Dr. Hodas has advocated for trauma-informed care since approximately 1999. In 2006, Dr. Hodas’ paper, “Responding to Childhood Trauma: The Promise and Practice of Trauma Informed Care,” was published by the National Association of State Mental Health Program Directors (NASMHPD). Currently, Dr. Hodas is helping OMHSAS and the Department of Human Services in its efforts to implement trauma-informed care and related trauma-informed practices. 

PA/Train/Interagency Conference/2024 Conference-GRH Short Bio-1-24-24 

Cären L. Rosser-Morris, PhD: A licensed psychologist and consultant for the Pennsylvania Office of Mental Health and Substance Abuse Services since 2016.  She earned her doctorate in clinical psychology from Vanderbilt University under the mentorship of Dr. Hans Strupp in 1993 and has since become a subject matter expert on trauma-informed care. For over 30 years, she has provided psychological services to adults, children, youth and families struggling with the impact of trauma on mental and behavioral health in a variety of outpatient, inpatient, residential treatment, and educational settings.

 

Contact Information

Gordon R. Hodas

Email: gordonhodas@hotmail.com

Cären L. Rosser-Morris, PhD

Email: c-crosserm@pa.gov

Phone: 717-772-7639

Volume 13 ► Issue 1 ► June 2024

Bridging Theory to Practice: Trauma Proficient Services for Youth with Autism and Developmental Disabilities

Kimberly Blair, Teri Pentz, Alonzo Alston, and Tara Pavlocak

Children with intellectual and developmental disabilities (IDD) are more likely to experience trauma than neurotypical children. ¹ This higher prevalence is due to several risk factors including but not limited to: communication and language barriers, behaviors that can be mistakenly attributed to their disability rather than a traumatic experience, more frequently needing medical procedures or hospitalizations resulting in medical trauma, and the frequent need for multiple caregivers across multiple settings (increasing the risk of trauma from exploitation). ² They are also more likely to experience bullying and rejection by peers in schools, communities, and on social media. ³ 

Despite these individuals being more vulnerable and at higher risk, youth with IDD and their families may find it difficult to obtain trauma treatment. Mental health services and IDD services are typically provided through siloed systems of care, presenting a barrier to receiving trauma-informed care within either system. Additionally, providers in the mental health system are often hesitant to engage in trauma therapy with this population, often lacking the necessary expertise and possibly even being unaware that children with IDD can benefit from this type of care.³ Existing trauma therapies can be just as effective with children with IDD as it is with children without – by providing good quality, person-centered treatment in a way that appreciates their unique abilities, strengths, hopes, and goals. 

The National Child Traumatic Stress Network (NCTSN) provides a wealth of resources for clinicians, service providers, and caregivers on the impact of childhood trauma and available interventions for children and adolescents who have experienced trauma. For practitioners who need additional resources, information is available about how to adapt existing trauma treatments for children with IDD, as many of these evidence-based treatments can be effective with modifications to standard protocols. These recommendations include the types of adaptations appropriate for all children in various contexts. For example, adaptation may include adjusting the length, frequency, and pace of content in treatment sessions; significantly involving parents and other caregivers into treatment sessions; adjusting content to meet the needs of the child by breaking information into smaller chunks, simplifying information, or engaging in frequent repetition of key concepts; and using accommodations effective for the child in other contexts, such as frequent movement breaks, reinforcers, or rewards. ³ Despite the demonstrated need for access to trauma therapy, families with children who have IDD continue to struggle to find quality care. As described above, there are many reasons why finding trauma-proficient therapists to serve this population can be a challenge. 

For decades, young children and families have sought treatment from the Matilda Theiss behavioral health programs at UPMC Western Psychiatric Institute and Clinic (now UPMC Western Psychiatric Hospital). In 2012, the University of Pittsburgh Department of Psychiatry was awarded a federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). With this grant, UPMC and the University of Pittsburgh became     part of the National Child Traumatic Stress Network (NCTSN) and implemented evidence-based treatment options through their outpatient program for children and families who have experienced trauma. Since the initial grant (2012-2016), two more rounds of funding were awarded, which allowed the programming to grow and evolve into what is now the Theiss Center for Child and Adolescent Trauma. Over the years, the program has attempted to provide high quality trauma therapy to all children who have experienced significant trauma and has engaged children with and without intellectual and developmental disabilities. 

A Case Example

The following is a case example illustrating how Theiss has successfully provided trauma treatment for a child with autism and comorbid mental health issues. 

Levi is a 17-year-old male referred by his residential program to the Theiss Center for Child and Adolescent Trauma at UPMC Western Behavioral Health for outpatient trauma therapy. Levi had a long history of trauma, including the death of his father from community violence and the death of his grandmother due to an overdose – all while he was still a toddler. Levi lived with his biological mother and her boyfriend until seven years of age, where he experienced severe neglect, physical abuse, and suspected sexual abuse. He was removed from this home at age seven and placed with his paternal grandmother. However, he was returned to his biological mother’s care several times before being permanently placed with his grandmother at age 11. While living with his grandmother, Levi exhibited extreme physical aggression, rage, and extensive property destruction, resulting in multiple hospital and residential placements throughout his adolescence.

Since the time of referral, Levi has resided within a specialized residential program for children and adolescents with complex needs. Staff members from this program contacted Theiss after attending a virtual training on child trauma, not only referring Levi for therapy, but also seeking additional training and consultation to support him in the residential setting given his extensive trauma history.   

Prior to his initial evaluation for services, Levi received a variety of diagnoses including Autism Spectrum Disorder, Intellectual Disability, Disruptive Mood Dysregulation Disorder, Post Traumatic Stress Disorder, Intermittent Explosive Disorder, and Reactive Attachment Disorder. He continued to exhibit rage, physical aggression, and property destruction within this residential placement. This behavior necessitated the need for two staff to accompany him for most of the day. These staff members felt it was unsafe to transport Levi into the community due to aggression and elopement concerns. Staff communicated that Levi wanted to talk about his painful early experiences and that he was requesting the support of a therapist. Therefore, after extensive safety planning, Levi began treatment in-person at the outpatient clinic. 

When he began trauma treatment, the initial focus was establishing rapport and providing Levi with a safe space to talk. The therapist focused on ways that Levi could communicate his wants, needs, and feelings without resorting to aggression. The therapist also provided Levi with feeling words and helped him identify nonverbal signals that he could utilize to label what he was feeling. They also worked on identifying Levi’s triggers and helping him connect these feelings with his past trauma experiences. During the early days of Levi’s treatment, both the therapist and the trauma consultant have maintained contact with the residential staff who support him, helping them to establish a “safe space” in his home. They helped Levi learn how to let staff know when he is becoming dysregulated and how to utilize the space, ultimately preventing him from having to resort to aggression. These strategies were very effective, particularly early in treatment when Levi was still having difficulty putting his emotions and pain into words. The therapist further supported the residential staff by helping them understand all the ways that Levi was trying to communicate with them. Later in treatment, the therapist began working with Levi to talk about his future dreams and how he could move toward these goals, while working with residential staff and Levi to focus on more than just behaviors and consequences – including processing early trauma and understanding how his early experiences have impacted Levi emotionally.

Throughout treatment, the therapist also adjusted the more typical treatment strategies as needed, taking into consideration the following:

Initially, one of the residential staff attended all of Levi’s therapy sessions to help him feel comfortable. Gradually, as Levi and his therapist developed rapport and Levi was feeling safe, the residential staff member was more frequently able to step back and allow the therapist and Levi to meet alone.

A year since initial referral, Levi continues to participate in trauma therapy at Theiss. His incidents of aggression have greatly declined, and he is beginning to move toward increased time in the community with reduced levels of support. Levi’s ultimate goal is to transition out of residential placement into his own home with minimal support. As everyone recognizes that success is not a “straight line” process, the therapist and residential staff continue to maintain open communication and adjust treatment strategies as needed and at Levi’s own pace, in order to support his progress. Levi’s success has been largely due to the collaborative work between the trauma therapist and the care providers, all becoming much more skilled in applying our knowledge of early trauma to Levi’s day-to-day needs.

Trauma-Proficient IDD Services

Professional development opportunities about trauma and the impact of those traumatic experiences on the mental health of children and adolescents are becoming increasingly accessible. Few professionals working with children today would reject the notion that trauma can have a profound impact on development and behavioral health outcomes. However, there is significant variation in how being trauma-informed impacts the day-to-day work of teachers, therapists, caseworkers, etc. It is therefore important to move beyond trauma-informed care, to trauma-proficient care. This demands a different type of training, one that moves from providing information to caregivers to the application of knowledge about trauma to everyday practice. 

The Theiss Center for Child and Adolescent Trauma not only supports the implementation of evidence-based treatment within UPMC’s child and adolescent trauma specialty outpatient clinic, but it also provides a mechanism through which child and adolescent clinicians may become trauma proficient, not just trauma informed. This mission is supported through training UPMC clinicians and graduate students in evidence-based treatments for trauma, as well as by offering professional development opportunities that provide practical, practice-oriented information, and a mechanism through which to assist programs in becoming trauma proficient in the work they do with traumatized children and families. 

The Theiss Training Center was established to develop and deliver professional development programs that better equip professionals to provide services to children and adolescents with trauma histories across the UPMC Western Behavioral Health Network and beyond. The inaugural offering of the Theiss Training Center is a child trauma curriculum that provides a framework for use by clinicians and programs across target populations, clinical specialties, and levels of care. This curriculum begins with foundational general concepts in trauma and child development and moves toward integration into practice, focusing upon training tailored to individual clinic/population needs. Ideally, participants are encouraged to progress in sequence through the components to achieve the best training outcomes. Overall, the curriculum helps participants understand how early traumatic events can impact the emotional and behavioral functioning of children with a variety of clinical presentations and treatment needs. More specifically, the Theiss child trauma curriculum includes the following components.

Biography

Contact Information

Kimberly Blair: blairka@upmc.edu

Tara Pavlocak: pavlocakta@upmc.edu

Teri Pentz: pentzt@upmc.edu

Alonzo Alston: alstonal@upmc.edu