From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Intermediate-Term Steps to reduce and eliminate the effects of Post-Traumatic Stress and related Disorders Long-Term Steps to reduce and eliminate the effects of Post-Traumatic Stress and related Disorders Questions and Answers Discussion and Next Steps Workshop Outline 3:00 pm – 4:00 pm
From Maltreatment to Well-Being: Imaginative Applications from Trauma Intervention for People with Disabilities Intermediate-Term Issues Following Discovery of Abuse 1. Trauma Assessment Continues a. Hindman’s Trauma Factors b. Sgroi’s Trauma Factors c. Post-Traumatic Stress Disorder d. Vicarious Trauma 2. Therapeutic Investigation and Early Treatment Efforts a. Examination of the History and Current State of the Victim b. Education/Re-education Efforts c. Corrective Emotional Experiences d. Participation in Prosecution Efforts 3. Continuation of Prosecution Efforts a. Identifying the offender b. Interviews c. Discussions with police, crown attorney 4. Review of Safeguards, Policy and Procedure, Prevention Efforts
Longer-Term Issues in Trauma Intervention Long-Term Issues Following Discovery of Abuse 1. Therapeutic Interventions a. Hindman’s Trauma Factors b. Sgroi’s Trauma Factors c. Post-Traumatic Stress Disorder d. Personality Disorders and Severe Mental Health Problems 2. Prosecution/Remedy Seeking a. Trial of Offender b. Criminal Injuries Compensation c. Civil Action 3. Safeguards a. Policy and Procedure b. Prevention Efforts c. Supervision d. Employee Assistance
The Dilemmas of Therapeutic Intervention in Trauma To help a person recover from a traumatic experience, one must often begin the healing journey by first making things worse (at least in the person’s view).
Goals of “Survival Strategies” Rescue (Re-)Attachment Assertiveness (Goal Achievement) Adaptation (Goal Surrender) Fight Flight Competition, and Cooperation
Survival Strategies and the Appraisals Which Evoke Them 1. Must rescue others 2. Must be rescued by others 3. Must achieve goals 4. Must surrender goals 5. Must remove danger 6. Must move from danger 7. Must obtain scarce essentials 8. Must create scarce essentials Rescuing Attachment Asserting Adapting Fighting Fleeing Competing Cooperating
Survival Strategies and the Appraisals Which Evoke Them A trusting relationship is necessary. Yet this is the very damage done by many forms of trauma – loss of trust in others. For some people, to trust in others proves an impossible task and they avoid seeking help. They may also develop a wide range of familiar, preferred “survival” strategies, some of which are very dysfunctional.
Post-Traumatic Therapy Principles The normalization principle: There is a general pattern of posttraumatic adjustment and the thoughts and feelings that comprise this pattern are normal, although they may be painful and perplexing, and perhaps not well-understood by individuals and professionals not familiar with such expectable reactions. Those working with people affected by trauma should know these.
Post-Traumatic Therapy Principles “ The emotional healing process often includes reexperiencing, avoidance, sensitivity , and self-blame. These symptoms are easily described, explained, and &quot;set&quot; in a context of adaptation and eventual mastery. By sharing such information, the second principle of PTT, the collaborative and empowering principle , is recognized: The therapeutic relationship must be collaborative, leading to empowerment of one who has been diminished in dignity and security.“ (Ochberg, 1991).
Post-Traumatic Therapy Principles “ A third principle is the individuality principle: Every individual has a unique pathway to recovery after traumatic stress. Cannon (1939) and Selye (1956) may have identified common physiological and psychological reactions in states of extreme stress, but Weybrew (1967) and others noted the complexity of the human stress response and the fact that one's pattern is as singular as a fingerprint. This principle suggests that a unique pathway of posttraumatic adjustment is to be anticipated and valued, and not to be feared or disparaged. Therapist and client will walk the path together, aware of a general direction, of predictable pitfalls, but ready to discover new truths at every turn. “ (Ochberg, 1991)
Post-Traumatic Therapy Strategies 1. Education : books and articles, pictorial representations of concepts teaching basic concepts of physiology to allow an appreciation of the stress response, educating about civil and criminal law (for those who have been a victim of a crime), and consideration of fundamentals of good health. The victim may contribute greatly to the resources considered and discussed. 2. Good Health Practices ( holistic health tips and practices), i.e. physical activity, nutrition, rest and relaxation, spirituality, and humor.
Post-Traumatic Therapy Strategies 3. Enhance Social Support and Social Integration . Family, marital or other forms of group therapy may be included Self-help and support groups Sensitive assessment and enhancement of social skills Work on reduction of irrational fears, and Expert timing of encouragement to risk new relationships. Traditional analytical tools and traditional social work skills are employed to promote healing in supportive human groups Social Skills groups and behaviour programs for development of social skills and continued work on integration
Post-Traumatic Therapy Strategies 4. Clinical Techniques : “ working through” grief extinguishing fear response that accompanies traumatic imagery medication for target symptoms, telling of the trauma story role play many individualized methods that are consistent with the principles of Post Traumatic Therapy. Cognitive-behaviour therapy and Rational-Emotive Therapy (Ellis)
Disastrous Response For those who did report in childhood (21% of Hindman's Severely Traumatized Group), every single one resulted in a more traumatic process (more abuse, beatings, institutionalization, total family abandonment) following the disclosure. The outcome is perceived by the victim (and almost everybody else) to indicate they would have been better off not to have reported. Massive betrayal of trust and reinforcement of powerlessness, helplessness and stigmatizing of the victim obviously occurred.
Footprints Victims appear to treat their abuse much the same as offenders with respect to coping: minimizing, denying, rationalizing, rearranging facts to avoid accurate perception The coping methods chosen by the young, developing child, or the individual with less mature mechanisms for coping, set the stage for developing and sometimes lifelong trauma depending on the method chosen.
Footprints The methods of coping chosen are influenced by: the relationship between the victim and the abuser, age and developmental level of the victim, and the information available to the victim at the time. Two main types of coping are: 1. memory impairment or suppression reflected by amnesia, dissociation, denial, withdrawal or disengagement, or other “dulling of the senses”- i.e. to mask psychic pain; and 2. self‑recriminations or “turning against the self” including self‑abuse ‑ in which one explanation (a cognitive view) has it that the non‑congruence of an offender who is viewed as &quot;good&quot; becomes congruent (for the victim) if they view themselves as &quot;bad&quot;.
Footprints Another explanation for self-abuse might be that the same neuropsychological mechanism that links self-destructive tendencies and cognitions with clinical depression is elicited in the case of trauma from sexual abuse. In any case, some examples of use of this coping skill are: alcohol and drug abuse, domestic violence, eating disorders, suicide attempts, non‑compliant and oppositional behaviour, slashing, etc.
Under Age 12 The issue may not be the chronological age Rather, more likely it is the accumulated time out of the normal development process caused by the earlier onset of abusive incidents in these victims Also, proceeding through a prolonged period of dependency upon others increases the damage done over time by both commission and omission. The length of time in development or dependency without treatment or without being rescued from the abuse
Terror Anticipation of the abuse being repeated was a large part of “terror building” activities. Note: Terror can be a traumatizing factor in the absence of violence. One can be terrorized, not with weapons, physical damage, or violence ‑ but by long, drawn‑out periods of suspense in anticipation of the next abuse incident. In some cases, victims were told to anticipate an incident several days before the event (which might be erotically stimulating for the offender). This caused mounting terror and dreadful anticipation for the victim.
Sexual Responsiveness The majority of Hindman's patients in the Severely Traumatized group reported sexual responsiveness. &quot;The stimulation or pleasure received from the experience seemed overwhelming and a tremendous source of trauma.&quot; (Hindman, 1989 p. 78). Furthermore, the offender's interest, either verbal or non‑verbal, in the victim's sexual responsiveness, exacerbated trauma. Vibrators, for example, appeared to be more upsetting to patients than guns or knives in Hindman's Severely Traumatized sample. Because of this responsiveness, patients would report continued arousal toward either the perpetrator or towards activities similar to their abuse. Because sexuality is normal and even valued in adulthood (compared to violence, for example), patients were constantly reminded of their abuse or were impaired in their expression of normal, healthy sexuality in their adulthood .
Distorted Victim Identification Severely traumatized patients could not see themselves clearly as victim, as &quot;innocent&quot; child. Offenders were seen to choose children already struggling with low self‑esteem, who already had difficulty seeing themselves as &quot;worthwhile&quot; in their own right. Offender behaviour sometimes directed itself toward making the child victim feel guilty, wrong or unacceptable. Other victims used the “coping skill” of making themselves responsible for the abuse and trying then to control it. This is more typical when abuse occurs infrequently with periods of time between episodes in which the victim might try to be more compliant, a better child etc. in a misguided attempt to accept blame for the abuse and to try to control it (reduce its probability) through their own &quot;good&quot; behaviour. Of course, failure is most often the outcome.
Trauma Bond The majority of Hindman's Severely Traumatized group had &quot;continued demands for a relationship with the perpetrator or those significant to the perpetrator... Even if the perpetrator was incapacitated, incarcerated, or absent, the victim remained connected in a trauma bond...&quot; Hindman (1989, p. 88). This was like a continued reminder of the abuse, and, when the offender is or was high profile, the continued presence stimulates feelings and concerns that are difficult for the victim to resolve.
Distorted Offender Identification In a large majority of cases of those Severely Traumatized, victims could not accurately identify their perpetrator as guilty, responsible, an offender. The perpetrator was held with a positive image (or at least an ambiguous one) in the victim's mind. Offenders who were respected in the community, had physical or personality characteristics which in other respects were highly positive, at least in the victim's mind, were seen to hold greater traumatic power over the victim's life. Also, it should be remembered that abuse can occur despite strong attachments between the victim and perpetrator, and in some cases the perpetrator actively works at establishing an attachment with the victim.
Withheld Report Refusing to report abuse and keeping the secret was typical of a majority of the Severely Traumatized group, even though a number had only one incident of abuse. The same number had only one incident of abuse in the Asymptomatic group (Minimal Trauma) but the major difference was in reporting. All of the one‑incident Asymptomatic patients reported the abuse immediately.
More on the Trauma Bond A trauma bond occurs when the perpetrator cannot, or does not, take on the role of the guilty person, the offender, and/or when the victim cannot, or does not, take on the role of the victim, the aggrieved person. Orgasms or sexual responsiveness (which are largely autonomic responses) during abuse makes it more difficult for victims to identify themselves (as victims) and perpetrators (as perpetrators). This promotes or perpetuates Trauma Bond.
Turning Memories “On” and “Off” Trauma victims have a difficult time &quot;turning on&quot; and &quot;turning off&quot; the memories. Multiple interviews, for example, require the &quot;turning on&quot; of memories. Later, memories may intrude when they are not wanted and may not be easily &quot;turned off&quot;. Although most trauma victims are not required to repeat or simulate their scenarios of abuse or tragedy, sexual abuse victims are required to repeat similar sexual behaviour if one is to have a &quot;normal&quot; life with a person who is loved.
Recreation/Simulation of Abuse by the System’s Response &quot;From the victim's viewpoint, a sexual abuse examination [can] be like sexual abuse. Their legs are spread, lights are shined, and another individual, perhaps similar to the abuser, probes, picks, and causes pain in the genitalia area...Evidence of trauma or damage is often rejoiced! Lack of trauma or damage is often met with disappointment. It is typical for the sexual victim patient to leave the medical examination feeling further traumatized and feeling as though whatever was seen and examined between the legs caused tremendous response from those individuals conducting the evaluation.&quot; (Hindman, 1989, pp. 100‑101)
Conditioned Arousal and Deviancy Because of the conditioning process, victims may be aroused by deviant sexual images and practices, and may be left cold by &quot;normal&quot; sexual arousal situations. People with this problem may not receive much sympathy from therapists or people around them, since these are not the &quot;traditional&quot; symptoms which normally warrant a non‑judgemental, comforting and supportive response.
The “Raging Child” and the “Pleading Child” The “Raging Child” is outraged at the reality of the sexual abuse, although this is hardly ever directed at the perpetrator. Instead, they may be acting out in school, abusing drugs or alcohol, or themselves. The “Pleading Child” wants to be rescued, cared for, and finally loved. They may be showing obsessive, compulsive, perfectionistic behaviour ‑ to finally become worthwhile. Since both extremes are impossible to sustain for any length of time, the victim may cycle between the two extremes and have very little &quot;middle ground&quot; where they are merely “real” or “normal”.
Hindman’s “Potholes” Pothole #1 First Sexual Step a. early pubescence or during sexually developing years b. hormones raging, “body betrayals”, sensory reminders, reawakening of the experience c. recognition of significance of sexual behaviour Pothole #2 Arousal Reality a. the first attempt to become sexual in the &quot;normal&quot; way b. emerging thoughts of deviant fantasy or repulsiveness c. can become horrified or humiliated d. those who have used amnesia or dissociation (forgetting/ repressing) most at risk for having a tough time with this Pothole #3 Sanctioned Sex a. as the victim attempts to sanction sex or resolve the conflict in their own mind ‑ &quot;if I could only... then I would be OK...&quot; b. ‑ i.e. if I was married, when I meet the right person, if I love them, etc., everything will be OK c. often disappointed, which creates a new sense of trauma (“there’s something wrong with me!”)
Hindman’s “Potholes” Pothole #4 And Baby Makes Three a. victim is often in a conflict between the adult and the neglected child b. paranoia toward the protection of a child c. jealous anger when a child captures another's attention d. outrage toward the innocence of the child e. guilty and humiliating feelings toward the victim's child within f. especially if the child is of the same sex as the victim Pothole #5 Age at Onset Crisis a. the victim's child turns the age of the victim when the abuse in the victim's childhood took place b. anger toward the child within c. reminds the victim of the many uncomfortable feelings and events d. causes a return to trauma or upheaval
Family Approaches Eleven criteria distinguish functional from dysfunctional families where trauma and treatment is concerned (McCubbin and Figley 1983): 1. traumatic stressors are clear, rather than denied 2. problems are family-centered rather than assigned completely to the victim 3. approaches are solution-oriented rather than blame-oriented 4. tolerance is practiced 5. commitment to and affection among family members is obvious 6. communication is open 7. cohesion is high 8. roles are flexible rather than rigid 9. resources outside of the family are utilized 10. there is no violence 11. drug or alcohol use is infrequent
Phases of Family Treatment Phase 1: Building Commitment to Therapeutic Objectives. requires that “as many family members as possible disclose their individual ordeals, and the therapist demonstrate recognition of their suffering. The therapist's sense of respect for each family member's reaction, coupled with optimism and expertise, promotes trust and commitment to therapy. Highlighting differences in individual responses leads to the next phase.” (Ochberg, 1991)
Phases of Family Treatment Phase 2: Framing the Problem. Each family member tells his or her view of the traumatic event attempts are made to interpret and understand how each member was affected. Therapists reinforce discussion that shifts any focus away from the “scapegoat”, towards family functioning issues and impacts as a whole. There is recognition, exploring, and attempts to overcome bad feelings toward the 'victim’ and projected blame on them versus the way in which situations can be “set up” by others’ agendas or to fulfill other members’ agendas. When positive consequences of the ordeal are mentioned (e.g., a greater appreciation of life after a close brush with death), they are duly noted.
Phases of Family Treatment Phase 3: Reframing the Problem. “ After individual experiences, assumptions, and reactions are expressed and understood, the critical work of melding these viewpoints into a coherent whole begins. “ The therapist must help the family reframe the various family member experiences and insights to make them compatible in the process of constructing their healing theory,“ Figley (1988) illustrated this principle with an example from his work with Vietnam veterans. A combat veteran felt rejected by his wife who avoided talking with him. She felt like a failure as a spouse because she could not help him overcome PTSD symptoms. In this treatment phase, &quot;he began to reframe his perception of her behavior from a sign of rejection to a sign of love.&quot; Eventually, the whole family rallied, seeing obstacles as challenges to be overcome.” (Ochberg, 1991).
Phases of Family Treatment Phase 4: Developing a Healing Theory. “ The goal of posttraumatic family therapy is consensus regarding what happened in the past, and optimism regarding future capacity to cope. An appraisal that is shared by all family members, that accounts for the reactions of each, and that contributes to a sense of family cohesion is a healing theory. Figley (1988) suggested a fifth phase that builds upon this consummation, emphasizing accomplishment and preparedness. However the therapist chooses to clarify the closure of successful therapy, the family will know that they have fulfilled their potential as a healing, nurturing human group.” (Ochberg, 1991).
Antidotes to Emotional Abuse and Neglect Instead of Rejecting , Isolating , Denying Emotional Responsiveness or Ignoring there exists Inclusion and Acceptance, Attention and Positive Regard : &quot;to acknowledge, believe, receive; to accept, to tolerate, to promote; to hear; to enjoin; to support; to love; to nurture; to attend to...&quot;
Do the Following Stimulate and systematically promote and acknowledge overtures (initiating and returning smiles and vocalizations, initiating and engaging in interactions, being extra alert to, and avoiding any situations which stimulate fears of, or simulations of, a child’s abandonment experiences); Make sure a person does not spend excessive time in the same location or position (i.e. crib, playpen, bed, wheelchair, etc.); Ensure ample socializing with friends, relatives and neighbours. Deliberately plan and implement family outings (which can be difficult with the child who has technological dependencies); Demonstrate warmth and affection; Systematically encourage and ensure hugs and kisses, even for a child with deformities who may not be the most naturally attractive, or obstructed by tubes and medical devices; Promote socializing with individuals, play groups, or age-appropriate peers.
Do the Following Speak to the person (even if relatively non-verbal) and include him/her in conversation as if they were. Celebrate his/her accomplishments, Refrain absolutely from labelling (referring to him/her by her/his “diagnosis”), or speaking about the person’s problems in their presence; Enrol the person in extra-curricular clubs and associations. Ensure age-appropriate treatment and avoiding potentially damaging references such as diagnostic labels; Ensure plenty of opportunities to take part in dances, age peer activities, dates, etc.
Antidotes to Emotional Abuse and Neglect Instead of Degrading , there exists Dignifying and Respect : “To elevate from a lower to higher rank or degree; to advance a person’s inherent dignity. To bring positive repute or favour; to appreciate...&quot;.
Do the Following Refrain absolutely from labelling with derogatory or diagnostic terms or other terms which communicate a negative image. Referring to people with disabilities by their diagnostic label is a very subtle form of degrading treatment (i.e. autistics, retardates, firesetters, etc.) because it focuses on negative aspects of their being. There are many other more powerful and less subtle ways in which this can take place, however, and pejorative names such as “retard” etc. are examples of this. Not only eliminate them from your vocabulary, insist upon “People First Language” in all of your dealings with others. Wolfensberger’s workshops, books and monographs, especially the PASS workshops, books and materials, operationalize positive ways in which dignifying and positive approaches can be implemented in professional life.
Antidotes to Emotional Abuse and Neglect Instead of Terrorizing , there exists Reassurance and Encouragement : &quot;To believe in a person’s capacity to achieve, to encourage their striving and calm their fears and inhibitions&quot;.
Do the Following Engage in playful but not excessive teasing Refrain from scaring and unpredictable or extreme responses to the person's behaviour, Allow some frustrations but not too much Reward the child’s overtures towards challenge and their environment. Refrain from extreme threat or intimidation implying punishment or danger, Refrain from use of childhood fears to exert power and control over the child (i.e. not using &quot;ghosts&quot;, &quot;monsters&quot; etc.). Refrain from placing the person in extreme dilemmas (&quot;damned if you do, damned if you don't&quot;).
Do the Following Refrain from extreme inconsistency in punishment; Set achievable standards and reward striving, if not achievement; Help the child or youth to conquer their “normal” fears as a way of teaching the overcoming of adversity. Refrain absolutely from embarrassment or humiliation Refrain from public ridicule Continue to reaffirm worth and capacity, benefits of striving, and expectation of achievement.
Antidotes to Emotional Abuse and Neglect Instead of Corrupting there exists Positive Socialization Experiences, and Education : &quot;To render social or socialized; to adapt to social needs or uses; to educate to a state of uprightness, correctness, truth, etc., to work towards good...&quot;.
Do the Following Teach positive social behaviours “ Street-Proof” and provide safety and prevention training as well as values teaching and other moral education opportunities.
Antidotes to Emotional Abuse and Neglect Instead of Exploiting there exists Altruistic Behaviour : &quot;To serve the interests of the person with disabilities; to put the interests of people with disabilities ahead of one’s own...&quot;.
Do the Following Protect children from sexual predators Have age-appropriate expectations on the child Refrain absolutely from requiring a child or dependent person to be responsible beyond their years or capacities in order to benefit from their labour, material goods, or to take advantage of them in other ways.
Do the Following Model the highest degree of inclusive, accepting, valuing and hopeful behaviour with and towards the person with the disability. By such example others are more likely to be persuaded to similarly value and accept the person. Wolfensberger calls this process Positive Image Transfer. Calmly but assertively identify offensive behaviour in others, state why this behaviour is offensive, and recommend corrective action.
Interventions by Stage &quot;Do your best&quot; ‑ there is a state of chaos, high anxiety, professional inadequacy, hostility, even fear. Good tactics are to: diffuse anxiety, reinforce reality that sexual abuse does exist, participate in fact‑finding, direct the validation process, assist in initial intervention planning. Advantages: enables clinician to establish relationship quickly with child by presenting concrete services. Entry by an advocate‑therapist at this stage reduces the number of times child must recite story of abuse. The clinician's skills may serve as role‑modeling tools and teaching aids for other professionals involved. Crisis intervention (Unplanned Intervention)
Interventions by Stage suppression of publicity, information and intervention. This can be intense within the family circle. denial of the significance of disturbances suffered by the child victim firm belief that the victim will simply &quot;forget&quot; demands to &quot;stop reminding&quot; the victim of the abuse there may be &quot;ganging up&quot; on the victim exploitation of power and authority of suppressors isolation, ostracism of victim or advocates sabotage of treatment of victim Dealing with the Suppression Phase: Assess and Intervene when Necessary
Interventions by Stage abusive or threatening verbal pressure on victim threats similar to those from secrecy phase pressure to recant, or stop complying with intervention process physical abuse is possible undermining of the credibility of the victim and allegation accusations against the victim of being &quot;pathological liar&quot;, &quot;disturbed&quot;, &quot;crazy&quot;, etc. previous victim &quot;problems&quot; cited, victim is &quot;untrustworthy&quot; profile of all previous misbehaviours of victim may be used to undermine credibility. Dealing with the Suppression Phase: Assess and Intervene when Necessary
THE 12 WARNING SIGNS OF GOOD HEALTH* (If several or more appear, you may rarely need to visit a doctor.) 1. Regular flare-ups of a supportive network of friends and family. 2. Chronic positive expectations. 3. Repeated episodes of gratitude and generosity. 4. Increased appetite for physical activity. 5. Marked tendency to identify and express feelings. 6. Compulsion to contribute to society.
THE 12 WARNING SIGNS OF GOOD HEALTH* 7. Lingering sensitivity to the feelings of others. 8. Habitual behavior related to seeking new challenges. 9. Craving for peak experiences. 10. Tendency to adapt to changing conditions. 11. Feelings of spiritual involvement. 12. Persistent sense of humor. *Adapted from a posting on a computer bulletin board in Waldport, Oregon, author unidentified. Reprinted in Whole Earth Review (Winter 1994), a compendium of brash thinking and lofty ideas.