Trauma Informed Practice how is it relevant to

Trauma Informed Practice: how is it relevant to lawyers? DOMESTIC VIOLENCE LEGAL TRAINING DAY Thursday 23 July 2015 (C LC Legal Training Day) Pam Stavropoulos, Ph. D

1. What is trauma informed practice? - why it is necessary - implications for legal practice

What is trauma informed practice? • A new paradigm from the field of mental health • Applicable to all contexts, professions and institutions • Rests on understanding of the impacts of overwhelming stress on the brain and body • Seeks not to compound stress and to minimise re-traumatisation • Does not require clinical knowledge • Basic principles can be practised by all

Why is it necessary? Trauma is prevalent! • `Single incident’ (PTSD) • `Complex’ (cumulative, underlying, interpersonally generated; Courtois & Ford, 2009) COMPLEX TRAUMA IS MORE COMMON (`There is more to trauma than PTSD’ (Shapiro, 2010: 11) • Presents in diverse forms • Frequently undetected • Leads to difficulty regulating emotion and internal states (`easily triggered’) Trauma informed practice recognises this reality and organises services accordingly

`Problems with affect-regulation have pervasive effects on the development of mind and brain & lead to significant increases in the utilization of medical, correctional, social, & mental health services’ (van der Kolk, 2011: xii)

Implications for the practice of law • Contact with legal processes is stressful for most people • This is even in the absence of prior trauma • Engaging with clients in a trauma-formed manner is beneficial for all parties (i. e. including legal practitioners) Basic understanding of the effects of stress on the body and brain: - smooths interactions - decreases tension - enhances the co-operation on which professional relationships depend

Areas of law to which trauma informed practice applies • Criminal law (including sexual assault; domestic violence) • Child protection (includes assault and abuse) • Family law • Engagement with Aboriginal Australians • Immigration; refugee/asylum seeker advocacy • The work of community legal centres (where funding is restricted and much work is pro bono) • Legal aid • Personal injury

Trauma and the law are closely related Most if not all, situations of conflict and harm involve questions of justice and injustice, and situations of injustice frequently involve trauma. (Zehr, 2009) Trauma and law. . . are interconnected. 2013: 503) (Randall & Haskell,

`As a powerful institution in society, law regularly encounters and deals with people, both as victims and offenders, whose lives have been shaped and harmed by traumatic events’ (Randall & Haskell, 2013: 523).

Looking through a trauma lens…. `Difficult’ behaviour may be the product of coping mechanisms and attempted self-protection in light of prior adverse experiences. Client behaviour is `often and inappropriately labelled as pathological, when [it] should instead be viewed as adaptations a person has had to make in order to cope with life’s circumstances’ (Randall & Haskell, 2013, `Trauma-Informed Approaches to Law. . . ’, p 508).

Premises of trauma informed practice • Not what is `wrong’ with the person but what happened to the person • Not just what the service is but the way in which it is delivered `the law too should strive to become trauma-informed’. (Randall & Haskell, `Trauma-Informed Approaches to Law. . . ’, p 505. EMPHASIS ON `HERE & NOW’ PROCESS CAN ASSIST MOVEMENT TO OUTCOMES

Core principles of trauma informed practice • Safety • Trustworthiness • Choice • Collaboration • Empowerment (Fallot & Harris, 2009; Jennings, 2004) NEED TO BE BUILT IN AND EMBEDDED AT ALL LEVELS – SYSTEMIC, INTERPERSONAL, POLICY AND SERVICE CULTURE

2. The neurobiology of experience: stress, overwhelming stress & the dynamics of mental strain

`The field of mental health is in a tremendously exciting period of growth and conceptual reorganization Independent findings from a variety of scientific endeavours are converging in an interdisciplinary view of the mind and mental well-being’ (Siegel, 2003).

Experience shapes the brain: implications for mental health 1990 + Towards `an interdisciplinary view of the mind & mental well-being’ and the rise of `Interpersonal neurobiology’: `the structure & function of the mind & brain are shaped by experiences, especially those involving emotional relationships’ (Siegel, 2003)

The impact of experience: `the social brain’ • Experiences of relationship activate neural networks (`neurons that fire together, wire together’) `[t]he organization of the social brain is initially sculpted via parent-child interactions’ (Cozolino, 2002: 217) _____________________________ • `Interactions with loved ones are our major stress-modulating mechanism’ (Perry, 2006: 90) (thus the adverse effects of suboptimal caregiving) But neural growth can occur ACROSS THE LIFESPAN

Stressful experience and the brain `[A]n important paradigm shift in our understanding of health & disease across the lifespan’ (Shonkoff, Garner et al, 2012). OVERWHELMING STRESS: • Has multiple health impacts • If occurs in early life can impair adult functioning (both psychological and physical; ACE Study, Felitti, Anda et al, 1998; 2010) Effects of overwhelming stress analogous to recognition of the links between microbes & infectious diseases (`the psychological version of the germ theory’ (Bloom & Farragher, 2011: 123)

There is `extensive evidence of the disruptive impacts of toxic stress’ in early life (Shonkoff, Garner et al, 2012) And on long-term health in a range of registers NOTE: - Early life trauma need not comprise `abuse’ as such - Caregivers may be non maltreating but transmit their own unresolved trauma via disrupted attachment styles (Hesse, Main, et al, 2003).

`[A]daptation to trauma, especially early in life, becomes a `state of mind, brain and body’ around which all subsequent experience organizes’ (Cozolino, 2002: 258 -259)

`Unresolved experiences tend to haunt us until they can be finished’ (van der Hart et al, 2006: 246; Levine, 2008; van der Kolk, 2003)

`Relationships of this magnitude are rare in epidemiology’ (Felitti & Anda, 2010: 82). Sample slides from presentation of Robert Anda MD

A diverse research base (`consilience’; Siegel, 2003) • Neuroscience • genomics, • epidemiology molecular biology developmental psychology, sociology, & economics (Shonkoff, Garner et al, 2012). • Neurobiology of attachment (`affective neuroscience’; `interpersonal neurobiology’) • Trauma theory/Clinical research • Epigenetics ____________________________________________ Implications for the practice of medicine and a range of fields `are potentially transformational’ (ibid)

. . and also for the practice of law • Law plays a pivotal role in regulating human behaviour. • Current insights of neuroscience, interpersonal neurobiology, attachment, psychology etc need to be incorporated and acted upon • But stereotypical `rational actor’ models often prevail • Self-interest is a primary motivator of human behaviour but is far from the only one. The multiple neurobiological effects of unresolved traumatic experience impair people’s capacity to select and implement courses of action which progress and enhance their overall well-being.

The structure of the brain • Cortex symbolic; representational; ideas; concepts; reflection • Limbic region `old mammalian brain’; emotions & evaluation • Brain stem the `reptilian brain’; `survival’ responses; controls states of arousal `At a. . . minimum, integrating the brain involves linking the activity of these three regions’ (`vertical integration’; Siegel, 2010: 15) Left & right hemispheres: • Left `the thinking brain’ Right `the emotional brain’ Integration of these spheres = `horizontal integration’ TRAUMA IMPAIRS INTEGRATION & RESTRICTS THE CAPACITY TO RESPOND FLEXIBLY (Siegel & Solomon, 2003: xv).

The hand model of the brain Daniel J. Siegel, Mindsight (Melbourne: Scribe, 2010), p. 15

Signs of the stress response Hyperarousal • Increased heart rate * Increased respiratory rate * Blood flow from extremities to organs & major muscle groups * Muscle tension Hypervigilance (for threat) * Digestive problems * Sleep & energy disturbance Hypoarousal Subjectively feeling ‘shut down’ or `cut off’ Avoidant Withdrawn Loss of humour, pleasure, motivation & connection with others Sleep and energy disturbance

Overwhelming stress = trauma • `. . . a state of high arousal that impairs integration across many domains of functioning’ (Cozolino, 2002: 270). • stems from activation of instinctive `fight-flight-freeze’ responses to perception of overwhelming threat • We are innately equipped with these `survival’ responses • Overwhelming stress impairs reflective capacity; people may not seem to act `rationally’ or appear `credible’

`When we are calm it is easy to live in our cortex, using the highest capacities of our brains [to reflect] But if something. . . intrudes on our thoughts. . we become more vigilant & concrete, shifting the balance of our brain activity to subcortical areas to heighten our senses in order to detect threats’. (Perry, 2006: 49) `As we move up the arousal continuum towards fear. . . we necessarily rely on lower & faster brain regions. In complete panic. . . our responses are reflexive & under virtually no conscious control’ (ibid)

Trauma and memory • Memory not unitary but a complex network (Cordon, Pipe, Mayfan, Melinder, & Goodman, 2004). • Different types of memory stored in different parts of the brain • Explicit (`autobiographical’; `declarative’) = consciously experienced, verbal • Implicit (procedural, non-verbal, somatic) = nonconscious, `situationally accessible’ Hippocampus is central to the encoding of explicit, conscious memory Trauma impedes this process; release of cortisol with shock

Trauma informed practice decreases anxiety and lowers arousal • Positive relational experiences are soothing and validating • Assist calm and reflection (movement from lower `brain stem’ responses (fight/flight) to higher cortex functioning) • Interactions become easier; promotes safety and reassurance • Potential for retraumatisation is minimised

Can assist the practice of law for all parties in innumerable ways (`a program cannot be safe for clients unless it is simultaneously safe for staff and administrators’ (Bloom, 2006: 2) Basic knowledge of: • Brain functioning and stress response • Different types of memory • Trauma informed principles

3. Translating to practice - Interpersonal - Organisational /systemic

A trauma-informed approach. . . • Adheres to the core principles of safety, trustworthiness, choice, collaboration & empowerment (Fallot & Harris, 2009: 3). Recall: • These principles are critical when relating to trauma survivors • Experience of unresolved trauma takes many forms and is highly prevalent • Experience of relationships & environment (both positive & negative) affects brain structure & functioning • Positive relational experiences – including experience of services – decreases stress and assists interactions

(a) Interpersonal Unresolved trauma = • Sensitivity to `triggers’ • Affects capacity to trust • Elicits both `hyper’ (visible agitation) and `hypo’ (dissociative) responses • Evokes negative experiences with authority figures of which the law, especially, is representative (and where legal contexts are inherently stressful for many)

Trauma-sensitivity involves: Not only: • `Standard’ respect for client diversity (culture, gender, age, ethnicity, sexual orientation), confidentiality But also: • Respect for diverse coping mechanisms • Attunement to all interactions, including the mundane, with all clients and at all times * NB that this is not possible in the absence of YOUR OWN well-being

Sandra’s statement Sandra is soon to give a statement regarding her experience of sexual assault. While she has been prepared for what this involves beforehand, she announces suddenly that she `can’t do it’. When asked why not, she seems to shut down completely. _____________________ • What might be going on for Sandra at this point? • From what part of the brain might she be operating? • How might a trauma informed response assist in this instance, and what might it look like?

The `volatile’ client: Brandon requires legal representation but his lawyer finds it hard to assist him. Despite attempts to explain the nature of the lawyer-client relationship, and the various dimensions it involves, he becomes visibly agitated, consistently interrupts, and angrily disputes that he can be helped by `people like you’. _________________________ • How might Brandon’s prior experiences, and potentially with authority figures, shed light on this interaction? • Are persistent `attempts to explain’ likely to be effective in this instance? • What approach/es might be more effective? • What might a trauma informed response look like in this instance?

(b) Organisational Physical AND emotional safety need to be promoted within your legal service at all times and at all levels (both formal & informal) QUESTIONS TO ASK IN THIS CONTEXT: • Is the physical environment (all buildings, sites, office spaces, etc) not only objectively safe but conducive to feelings of safety? • What modifications/improvements need to be made in this regard? • Are there aspects of procedure & setting which may exacerbate client discomfort? (e. g. disclosure of confidential details which can be overheard) • How does use of physical space (e. g. interruptions, open doors) contribute to potential embarrassment for any party in the delivery of your legal service?

`Bottom up’ and `top down’ From individuals to organisations • Research shows that effective treatment of trauma needs to be both `bottom up’ AND `top down’ (ie involve not just cognitions but emotions and somatic experience; Fosha, 2003; van der Kolk, 2003; Ogden, 2006) • Has implications for the organisational shifts required for service settings to operate as `trauma-informed’ • A trauma-informed service system affects all components of the system, & requires `a process of reconstitution within our organizations top to bottom’ (Bloom, 2006: 2).

Incentives for introducing trauma-informed practice: it combines & upholds central workplace requirements • • Professional practice Ethical practice Self-care (has both individual & organisational components) Risk management (reduces risks of vicarious trauma) The above principles are: • interrelated and inseparable (i. e. none can exist without the others & each requires the others) • Safeguarded & advanced by implementation of trauma-informed practice `[I]t is] the shared responsibility of staff & administrators to become `trauma sensitive’ to the ways in which past & present overwhelming experiences impact individual performance, leadership style, & group performance’ (Bloom, 2006: 2)

How to begin? • Step 1: Identify key formal & informal settings • Step 2: Ask key questions about each activity and setting • Step 3: Prioritize goals for change • Step 4: Identify specific objectives & responsible persons

Systemic shifts: mapping to practice • Review all policies & procedures to incorporate trauma-informed principles • Ensure education, training and professional development reflect trauma-informed principles • Foster & monitor co-ordination & integration of services

`The manner of my lawyer made a big difference: the process was hard but I got through it’

Contact details for follow up Pam Stavropoulos, Ph. D Consultant, researcher, clinician pstavropoulos@iprimus. com. au 0418 613 871