The Neurobiology of Kindness- Presented at the May 2013 PGS Conference
Maggie Bennington-Davis MDThe Neurobiology of Kindness
Care that is grounded in and directed by athorough understanding of the neurological,biological, psychological and social effects oftrauma and violence on humans and is informed byknowledge of the prevalence of these experiences inpersons who receive mental health services.(NASMHPD, 2004)
4Effects of experience on the brainDepend on: Single vs. repeated experience Age when experiences occurredor began Agent – natural vs. human Nature of the experience –accidental vs. purposeful Environmental supports Innate resilience Practice!
A responsive environment will Facilitate physiologic calm Avoid triggering thefight/flight/freezeresponse Encourage thinking,problem-solving, decision-making, flexibility KEEP EVERYONE SAFE These things apply to bothstaff and those they areserving
Neurobiology of Exposure toTrauma and ViolenceNeurobiologyof Thinking
What have we used the brain for?100,000 years:Homo SapiensHunter/Gatherer5,000 years:Recorded historyBuilding civilization250 years:“Modern” civilization
Prefrontal Cortex (Thinking Part) Newest brain region in human development Thin outermost layer, behind your forehead 4-5% of total brain mass Sets goals, plans ahead Controls impulses Solves complex problems Visualizes situations/images - creativity Helps with focus Can be strengthened (take your brain to the gym)
Here’s How the Brain Develops The brain needs safe experiences to live. It grows,is “pruned”and learns It formsconnectomes50 trillion 1000 trillion 500 trillion
“Whats wrong with you?"TO“What happened to you?”Change the question from…
The people we serve Have tremendous exposure to events (trauma)especially as children that cause a wash of threat detection all the timeThose of us who serve them Have created ways of thinking about and perceivingthe people we serve and their behaviors and ourenvironments These patterns of thinking sometimes get in our way We must begin with ourselves!
The Adverse Childhood Experiences Study(ACES) Largest study ever done examining effects ofadverse childhood experiences over one’s lifespan(>17,000 people) Majority were >50 yo, white, and attended college Original study done in California www.acestudy.org
ACES Categories Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuser in thehousehold An incarcerated household member Someone who is chronically depressed,mentally ill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglect
ACES ResultsAbuse: Emotional 10% Physical 26% Sexual 21%Neglect: Emotional 15% Physical 10% Two-thirds had at least one ACE ACEs tend to occur in clumpsHousehold Dysfunction Mother treatedviolently 13% Mental illness 20% Substance abuse 28% Parental separation or divorce 24% Household member imprisoned 6%
ACES Deadly Outcomes ACEs influence the likelihood of the 10 most commoncauses of death in the U.S. With an ACE score of “0”, the majority of adults havefew, often none, of the risk factors for these diseases With an ACE score of 4 or more, the majority of adultshave multiple risk factors for these diseases or thediseases themselves
Positive, linear correlation between ACEsand health problems Smoking COPD Hepatitis Cardiac disease Diabetes Fractures Obesity Alcoholism Other substance abuse Depression Attempted suicide Teen pregnancy and teenpaternity Sexually transmitteddiseases Occupational health Poor job performanceHealthproblems# ACEs
Positive, linear correlation between ACEsand Alcoholism High ACE scorepredicts alcoholabuse Higher yetin people whoseparents abusedalcohol Self-perpetuating cycleover generations The presence of alcoholabuse in the familyincreases the likelihoodof sexual and physicalabuseAlcohol abuse &dependence# ACEs
Positive, linear correlation between ACEsand suicide Depression affects19 million Americans <25% have access totreatment Depression is the leadingcause of disability in theUS Depression is the 4thleading contributor to“global burden of disease”;by 2020, it will be the 2ndleading contributor ACE score of 7correlated with 51fold increase in suicideattempts in children andadolescents ACE score of 7 correlatedwith 30 fold increase insuicide attempts inadults Presence of emotionalabuse in the home is thestrongest correlate withlater depressionSuicide# ACEs
Epinephrine (adrenalin)CortisolBeta-endorphinsHypervigilanceAction, not thoughtCognitive diminishmentIncreased aggressionLoss of impulse controlSpeechless terror
Stress Response to RECURRENTTHREAT Reset CNS: the hallmark isHYPERVIGILANCE Brain awash in cortisol Traumatic re-enactment Aggression become chronic Dissociation is common Chronic hyperarousal interferes with cognitive clarity Loss of (or failure to develop) affect modulation Injury or inhibition of prefrontal cortex andhippocampus Bloom, 2001
HYPERVIGILANCE… Changes the way you view the world – literally andneurologicallyHypervigilance is anenhanced state of sensorysensitivity accompanied byan exaggerated intensity ofbehaviors whose purpose isto detect threats.
Between Stimulus and ResponseS StimulusSensory Thalamus(LeDoux, 1996)
Between Stimulus and ResponseS StimulusSensory Thalamus AmygdalaVery Fast(LeDoux, 1996)
Your Brain Decides Your brain decides what it is going to do before thesignal gets to the “thinking” part of your brain Once you do become aware of what you are about todo… you have very little time to change the impulse Your prefrontal cortex is responsible for impulsecontrol… “Cognitive Wedge” Impulse control furthermore requires language…which becomes important later on, so hold thatthought!
Between Stimulus and ResponseS StimulusSensory Thalamus AmygdalaCortexVery FastSlowerHippocampusResponse(LeDoux, 1996)
Once you are in threat status… The prefrontal cortex bows out quickly – and bloodflow and hormones make sure that it does (“thinkingcan kill you”) Then you are in the hands of your limbic system:amygdala, hippocampus, cingulate gyrus, orbitalfrontal cortex, and insula: these then drive yourbehavior The limbic system wants you to MOVE – away fromthe threat and TOWARD safety (but mostly AWAY)
Threat Easily triggered (what triggers you…?) Diverts brain energy to the limbic system Activity at this point becomes primitive (F/F/F) Difficult in this moment to be self-aware Very likely in this moment to interpret things asdangerous or bad – you will not take risks Hypervigilance is the poster child formisinterpretation Constant threat causes allostatic load, and youexperience a chronic sense of threat and a lowerthreshold for additional threat
Between Stimulus and ResponseS StimulusSensory Thalamus AmygdalaVery FastSlowerHippocampusResponseCortex(LeDoux,1996)
Between Stimulus and ResponseS StimulusSensory Thalamus AmygdalaVery FastSlowerResponseCortexHippocampus(LeDoux,1996)
PlayIn Panksepp JP (1998): Affective Neuroscience: The Foundation of Human andAnimal Emotions,Oxford, New York
Play and FearIn Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions,Oxford, New York
Between Stimulus and ResponseS StimulusSensory Thalamus AmygdalaVery FastSlowerResponseCortexHippocampusNeuroregulatoryInterventionCognitive engagementPsychopharmacologySocial /EnvironmentalIntervention(LeDoux,1996)
What we see Disengagement Aggression and loss of impulse control in the faceof novel situations Immediate deterioration into power and controlstruggles Aggression and fear in the contextof rule enforcement “Minor” events precipitatingcatastrophic reactions
Cognitive Wedge: making the mostbefore emotions set inTrigger Responsecognitive wedgesocial/environmental neuroregulatoryIntervention intervention
Taking your brain to the gymIncrease blood flow & use of the “thinking” brainStrengthen pathways to the neocortexDecrease reliance on the “primitive” brainHard wire new “habits”Change predictions in novel situations
Working out the Brain – How?Mindfulness and MeditationCognitive enhancement therapiesCognitive behavioral therapiesCognitive exercisesPhysical exercises and bodymovementWhat works for YOU?
Changing gears a little… Physiologic changes during F/F/F… Increased heart rate Increased BP Increased respiration Do you run because you are afraid or are you afraidbecause you run… (Kohut)
Stress Research from Jerusalem Ariah Shalev at Hadassah Medical School Survivors of suicide bombers Following ER treatment Those that do not develop stress symptoms are ableto decrease heart rate, calm, quiet their bodies Those that do develop stress symptoms still havehyperarousal, high heart rates, high blood pressure Regulated states appear to be correlated withdecreased likelihood to develop stresssyndromes
How do you “center”yourself? Deep breath Notice internalsignals Think positivethoughts Pay close attention tothe present Be aware of your ownexperience as itoccurs Find your cognitivewedge…
Goals of Treatment•Maintain Regulating State; noticethe present•Prevent Re-experiencing States:stay in the thinking brain•Use strategies to employ thecognitive wedgeSaxe, 2001
Do you believe in Recovery? People will live up to your expectations Situations will unfold according to your expectations Your brain is very invested in your predictions comingtrue – so you will do things unconsciously to ensurethat happens
Language and Vocabularyclaimsdeniesrefusesnoncompliantallegesfailed
Physical Environments Have an impact on attitude, mood, and behavior Physical environment is the program as much as groups,routines, and therapy Its manipulation by skilled staff becomes an essentialaspect of the educational process Strong link between physiologic state, emotional state, andthe physical environment Natural environment promotes increased dopamine, fasterhealing, and less pain in surgical patients ACES have less impact if child is in natural environment Kids with ADD are more relaxed and focused in “green”environments
Color matters (UBC, 2009) (Drunk Tank Pink – 1970s)CreativityAttention todetail
Triggers for violent events in mental healthtreatment settings Enforcement of agency rules Perception of unfair treatment Waiting Anger about past experience in mental healthsystem Controlling, restrictive environment Shame and humiliation Crowding Boredom
Alternatives to Coercion Choices (choice relax the threat alarm) Prediction/routine (information and no surprises) Navigators with lived experience Individual Safety Plans Triggers Early Warning signs Strategies Preferences Practice!
Lived Experience – Been There,Done That Learning from those whohave been through thesystem System navigators Role models Glimpse of what could be Hope!
Coercion… overt and covertMicroaggressions Visible or audible keys on staff Rules, rules, rules Strip searches Directive staff language Taking personal property Privileges Invasive security checks and level checks Demanding explanations Insisting on participation Asking intimate questions without context ofrelationship
On Stage:Treating each other well How staff treat each other is not a secret How staff treat each other has an impact on those theyserve How staff treat each other sets the cultural norm Respect is contagious
Parallel Process Collective disturbance We do unto others as is done to us Coercion is infectious So is respect Response to organizational trauma Hypervigilance Easily triggered Sense of community Cultural norms Deep democracy: having a voice
Celebration and Support:Engagement of staff members Discover small victories Public recognition Celebrate milestones Set people free to be creative Leaders accountable for challenges Promote interactions among staff Staff credited with successes Create a culture of giving
Five Squirrels Donald Geisler 2005. “Meaning from Media: the Powerof Organizational Culture”. OrganizationDevelopment Journal 23 (1): 81-83.
Suggestions for furtherreading www.sanctuaryweb.com (Sandra Bloom’s website) “Creating Sanctuary”, “Destroying Sanctuary”, and “RestoringSanctuary” by Sandra Bloom “Restraint and Seclusion: the Model for Elimination of their Use inHealthcare” Murphy and Bennington-Davis “The boy who was raised as a dog” & “Born for Love” Bruce Perry & Maia Szalavitz “Trauma systems theory” Glenn Saxe Anything by Bessel Van der Kolk SAMHSA website “trauma informed care” “Your Brain At Work” – David Rock