1.RetraumatizationPowerpoint created by Ann Jennings PhDwww.TheAnnaInstitute.Org
Retraumatization Powerpoint Slides
Article: On Being Invisible in the Mental Health System.
Definition of “Retraumatization”
How systems of care can retraumatize consumers with histories of trauma
Impacts of retraumatization on both consumers and on staff
Identify examples of retraumatization in own service settings
Adopt a Universal Assumption of Inclusion
Above All Else, Do No Harm “Primum non nocere”
5.What is “Retraumatization”?
A situation, attitude, interaction, or environment that replicates the events or dynamics of the original trauma and triggers the overwhelming feelings and reactions associated with them
Can be obvious - or not so obvious
Is usually unintentional
Is always hurtful - exacerbating
the very symptoms that brought
the person into services
6.Some examples from healthcare
The Dental Office
Emergency room at the local hospital
The Family Doctor’ Office
Another Emergency Room example
7.What mental health consumers report:
Consumers across the country report retraumatization in both institutional and community service settings.
Psychiatric inpatient settings, where coercive practices replicate the dynamics of their original trauma, are generally experienced by consumers as the most frightening and dangerous environments (physically and emotionally)
“I was told that people were helping me be safe. Then they rushed me in a hallway and pinned me to the ground and lay on top of me and strapped me down and injected me against my will, and equated that over and over again with being safe. That’s the same lie I grew up with – ‘I am just doing this for your own good; you really like this.’” (LP, 2003)
“I would rather die than go back to the hospital” (focus group member)
9. “Somehow the idea that we are human just as they are human has to come across, or they will never treat us humanely.”
10.South Carolina Studies on Re-traumatization“Sanctuary Trauma” and “Sanctuary Harm”
First empirical investigations of trauma and retraumatization within psychiatric settings
199 consumers self-reported and/or were interviewed. All diagnosed with serious mental illness and psychiatrically hospitalized at least once
87% - 99% had histories of multiple types of trauma exposures over the course of their lives.
47% had been physically assaulted and 33% sexually assaulted during childhood and/or as adults
27% met criteria for PTSD, though few (3%) were diagnosed as such.
11. Study Findings
Nearly half (47%) experienced “Sanctuary Trauma” – events that met DSM IV criteria for extreme traumatic stressor leading to PTSD symptoms
91% experienced “Sanctuary Harm” – events involving highly insensitive, inappropriate, neglectful or abusive actions by (often a small minority of) staff, which produced or exacerbated symptoms from prior trauma.
12.Those especially vulnerable….
Consumers with lifelong histories of multiple traumas
Consumers with sexual abuse histories
13.Retraumatization from Sanctuary Trauma
Being physically assaulted by staff or other patients (31%)
Being sexually assaulted by staff or other patients (8.5%)
Witnessing others being physically or sexually assaulted (63%)
14.Retraumatization fromSanctuary Harm
Being placed in seclusion (60%)
Being around other persons who were very disturbed, violent or frightening (56%)
Being handcuffed and placed in a police car (65%)
Being taken down or witnessing other people being taken down (47%)
Being put in restraints (33%)
Being strip searched
15.Not having adequate privacy for bathing, dressing, or using toilet
Having police or security guard outside seclusion room with no explanation
Medication or commitment being used as a threat or punishment (20%)
Being forced to take medication against one’s will
Use by staff of derogatory names toward the consumer or toward other patients – badgering or bullying them in some verbal way. (23%)
16.Impacts of Retraumatization on Consumers
Decrease or loss of trust
Higher rates of self-injury
Significantly less willingness to engage in any treatment
Increase of intrusive memories, nightmares and flashbacks
Reexperiencing of symptoms and emotions from previous trauma – when extreme may take on delusional intensity
Increase in chronicity of stress with greater risk for psychiatric morbidity, e.g. PTSD, chronic depression
Higher distress rates – for longer periods of time after discharge
Increased symptom relapse and re-hospitalization
18.Impacts on Staff
Higher rates of staff assault and injury
Need to accommodate longer hospital stays
Significantly less treatment compliance
High rates of consumer complaints
Significantly more difficult to develop trust
Increased level of stress and secondary trauma experienced by staff
Higher rates of staff turnover and low morale
Increased rate of staff absence and illnesses
“One of the things that doesn’t get talked about very much is the trauma of the staff. We talk about the trauma paradigm for our clients or people in recovery. But not very often in my 20 years of work in the field of mental health have I heard much about what happens to us, the workers. And I think that’s an area where we need to do some work. I’ve seen some pretty traumatic things from when I first started 20 years ago. Some of those things still haunt me that I’ve seen.”
Female direct care staff
Jorgenson et al, 2006
20.Seeing the Patterns
21.Child’s Experiences Replicated in Services
Unseen & Unheard
Blamed & Shamed
Unprotected & Vulnerable
No Privacy or Boundaries
The information in the following case example is expressed repeatedly by consumers across the country who are diagnosed with a serious mental illness, have histories of severe childhood and ongoing trauma and have experienced both inpatient and community services
23. Childhood Trauma Re-trauma in Service Systems
Child’s psychiatrist, pediatrician, mental health staff did not inquire about or see signs of sexual abuse. Child misdiagnosed. No treatment or misguided treatment.
Child’s attempts to communicate abuse were unheard, disbelieved, ignored, misunderstood. Silenced.
Not screened or assessed for trauma. Trauma impacts not identified. Client misdiagnosed. Treatment misguided - sometimes harmful.
Reports of past and current abuse ignored, disbelieved, discredited. Interpreted as delusional. Deemed inappropriate to talk about. Silenced.
Unseen and Unheard
24. Childhood Trauma Re-trauma in Service Systems
School psychologist evaluation suspected some kind of trauma. Did not inquire or discuss with child or parents
Abuse occurred at pre-verbal age. No one saw the signs of sexual abuse expressed in child’s artwork, play, hyperactivity, behaviors, body movements
Only two psychologists saw trauma as core treatment issue. Their reports ignored by hospitals and community MH service providers
One art therapist saw sexual abuse trauma in client’s artwork. Her insights ignored. No one else linked the art, behaviors or symptoms to unaddressed childhood trauma.
Unseen and Unheard
25. Childhood Trauma Re-trauma in Service Systems
Child was trapped by perpetrator, unable to escape his abuse
Child dependent on family, caregivers.
Client unable to escape abuse in locked facilities, residences.. Outpatient commitment feels like a trap. Vulnerable to involuntary commitment. Trapped by MH diagnosis. Mandated counseling
Client kept dependent on system. Strengths, talents, competencies not nurtured. No education provided. No skill development to live and work in community. Cyclical nature of unaddressed trauma can affect ability to stay employed at any job.
26. Childhood Trauma Re-trauma in Service Systems
Abuser stripped child, pulled t-shirt over head to hide face.
Child stripped by abuser/rapist to “with nothing on below”
Child tied up, held down, arms and hands bound
Client stripped of clothing when searched, secluded or restrained, often by or in presence of male attendants.
To inject medication, patient’s pants pulled down, exposing buttocks and thighs, often by male attendants
“Take-down”, “restraint” – arms and legs shackled to bed
27. Childhood Trauma Re-trauma in Service Systems
Abuser blindfolded child with her t-shirt pulled over her head
Abuser forced child’s legs apart
Abuser was “examining and putting things in me” (Abuse included torture and rape)
Cloth thrown over patient’s face if she spat or screamed while strapped down
Forced four-point restraints in spread-eagle position
Medication injected into body against patient’s will.
28. Childhood Trauma Re-trauma in Service Systems
Child was taken by abuser to places hidden from others
Child isolated in her experience, “Why just me?” Belief she alone was singled out. Is different from all others. Child thought she was only one in the world to be sexually violated
Separated from community in locked facilities. Forced, often by male attendants, into seclusion room. In community, isolated from others by living conditions, effects of meds, stigma
No inquiry or discussion with clients about their childhood or adult trauma experiences. No one talks openly or educates clients about prevalence and impacts of trauma. Client is left isolated and alone with the experience, just as a child.
29. Childhood Trauma Re-trauma in Service Systems
Child was left with a feeling of being “bad” and thought of herself as a “bad seed”, defective in a fundamental way
Child acting out because of her trauma, became the “difficult to handle” child
Clients stigmatized as deficient, mentally ill, defective. Their brains are thought of as diseased. Attitudes, practices and ugly environments convey low regard for clients, tear down self-worth
Clients with trauma-based behaviors are often seen as “noncompliant,” “treatment-resistant,” manipulative, attention seeking, difficult-to-handle.
Blamed and Shamed
30. Childhood Trauma Re-trauma in Service Systems
Child was blamed, spanked, confined to her room – for her anger, screams, cries.
Cause of child’s “bad” or unusual behaviors placed within child. Seen as due to something inherently wrong with the child. Child blamed for behaviors. Impact of environmental factors (e.g. trauma) not recognized or considered.
Clients rage, terror, screams, result in medication, restraint, involuntary commitment, loss of privileges, seclusion, expulsion from services
Cause of client’s emotions and behaviors placed within the person of the client and his/her inherent defectiveness or “mental illness”. Impact of environmental factors (e.g. childhood traumas) not recognized or given import.
Blamed and Shamed
31. Childhood Trauma Re-trauma in Service Systems
Perpetrator had absolute power/control over child
Pleas to stop violation were ignored. Perpetrator ignored child’s cries of pain and continued to hurt her
Child’s expressions of intense feelings, especially anger directed at parents, were often punished and suppressed.
Institutional staff and psychiatry have great power/control over patients. Community provider s control referrals, treatments, services, entitlements. Can initiate involuntary commitment. Can force medication.
Pleas and cries to stop abusive treatment, restraint, seclusion, overmedication – commonly ignored
Intense feelings, especially anger at staff, suppressed, not allowed expression, punished by coercion or expulsion
32. Childhood Trauma Re-trauma in Service Systems
Child defenseless against perpetrator abuse. Attempts to tell were unheard or ignored. There was no safe place for child, even in her own home or room.
Secrecy: Those who knew of abuse did not tell. Priority was to protect self, family relationships, reputations.
Child, once sexually violated, was vulnerable to other sexual abusers
As patient often defenseless against staff or patient abuse. Reports deemed not credible. Policies fail to effectively protect clients. Can be difficult to dismiss abusive staff.
Secretiveness replicates family’s. Priority is to protect institution, jobs, reputations. Patient reports of abuse not reported up line.
People with SMI and unaddressed trauma histories significantly more vulnerable to rape, physical violence - in facilities and in community
Unprotected/Vulnerable to Harm
33. Childhood Trauma Re-trauma in Service Systems
As a child, constant threat of being sexually abused . Threat pervaded child’s life
Perpetrator retaliation if abuse revealed
As mental patient, constant threat of being stripped, thrown into seclusion, restrained, overmedicated, loss of privilege.
In community, threat of involuntary commitment for behaviors to cope with trauma such as self injury, suicidality, acting out of dissociation, etc.
Reporting of staff abuse by client is retaliated against
34. Childhood Trauma Re-trauma in Service Systems
Child’s privacy rights and emotional and physical boundaries were grossly violated by perpetrator. Body, room and home were entered against her will. She felt exposed and vulnerable to harm at any time
Appropriate right to privacy is often violated in psychiatric hospital setting, residential programs, prisons, jails.
Touching and body contact without permission often occurs
35. Childhood Trauma Re-trauma in Service Systems
Child was viewed and treated by perpetrator solely as an object for his use
Child was not seen or experienced as whole person capable of experiencing hurt
Perpetrator was not capable of feeling empathy for child and what child was experiencing and feeling as a result of his abuse of her
Clients objectified. Viewed as diagnosis or symptom: a “borderline”, a “schizophrenic”, a “depressive”, a bulimic, a cutter – to be managed or treated.
Clients often seen only in their role as “sick” individuals - with symptoms to be managed. Clients personal history and lived experiences of trauma not viewed as core to their distress.
Providers ability to be empathic limited by narrow view of client which excludes client’s history of violence and abuse and the pain they feel as a result.
36. Childhood Trauma Re-trauma in Service Systems
Appropriate anger at sexual abuse seen as something wrong with child. Abuse continued, unaddressed.
Child’s appropriate fear of threat of being abused was misunderstood and considered unreasonable.
Sexual abuse of child unseen or silenced. Message: “You did not experience what you experienced”.
Appropriate anger at hurtful institutional and community mental health practices judged pathological. Practices were continued.
Appropriate fear of abusive and threatening practices and behaviors, labeled “paranoid” by those producing the fear.
Denial of sexual abuse and its impacts. Message to client, “You did not experience what you experienced.
37. Childhood Trauma Re-trauma in Service Systems
Child was violated by trusted caretakers and relative
Disciplinary interventions were “for her own good”.
Child’s family relationships fragmented by separation, divorce, abandonment, substance abuse, etc. Connections broken. Child learns not to trust or depend on others as trustworthy.
Patients and clients trust was violated by helping professionals and psychiatric settings
Hurtful or unwanted interventions presented as for the good of the patient or the client
Relationships of trust arbitrarily disrupted based on needs of system, shift changes, staff turnover, limits of insurance coverage. No continuity of care or caregiver. Ability to trust is further compromised.
38.Antidotes to Retraumatization