Trauma-Informed Peer Support

Most people recovery from mental health or addictive disorders are likely to have experienced trauma. As a peer support specialist, you may have your own trauma history.  Understanding the centrality of trauma is an important part of lived experience that makes peer support services effective. Upon completion of this section learners will be able to:

  • Understand the role past or current trauma plays in the lives of people with mental health and addictive disorders.
  • Discuss the principles of trauma-informed care within the context of peer support.
  • Implement ‘universal precautions and practices that help establish safety.

The Centrality of Trauma in Mental Health and Substance Use Disorders

It is often said, the first principle of trauma informed peer support is to do no harm.  There are steps that can help people who have experienced trauma (including you) feel safer.  When peer support specialists apply these ‘universal precautions’ to all their interactions with others, it benefits people who are dealing with the effects of trauma and poses no risk those who are not. When we refer to the lasting impact of trauma, we are not just talking about with people with trauma-related disorders.

Trauma can have a lasting impact on the way people see the world, cope, and how they relate to others.  Responses and defense mechanisms are reframed as survival strategies that served a safety function and are recognized as evidence of strengths that can be useful in recovery.

Some of goals of trauma-informed peer support in any type of service setting are making sure people who have felt powerless in the past are empowered.  Peer specialists accomplish this by supporting many pathways toward recovery, providing information about options and choices, letting people know exactly what they can expect from a peer support specialist, and helping people learn to recognize their own strengths.  It takes time to establish safety, gain someone’s trust, and make a healing connection, but peer support specialists are uniquely qualified to make the kind of healing connections that offer hope to those seeking recovery.

According to SAMHSA, “trauma-informed peer recovery support utilizes a strength-based framework that emphasizes physical, psychological, and emotional safety and creates opportunities for survivors to rebuild a sense of control and empowerment.”

What is trauma?

Trauma occurs when extreme stress—brought on by unusual, terrifying, unexpected, or overpowering events and conditions that are experienced as life-threatening—overwhelms a person’s ability to cope. When this happens it leaves people feeling, helpless, hopeless, and fearful. When these things happen to a child whose coping skills are not well-developed, the chances of lasting impacts are greater. When they occur in adulthood, they have an impact, but are less likely to have lasting effects.

The defining factor that separates a traumatic experience from distressing one is the perception of a violation that is threat to one’s survival. These threats activate a type of “primal” fear that elicits distinct responses from the body and the mind. The memory of a traumatic experience is stored differently that other memories. When this happens, the memory can trigger all the sensory, physiological, and emotional responses that accompanied the traumatic event. If individuals repeatedly ‘relive’ the memory and their response, it starts to affect arousal, attention, perception, and emotion.

How does trauma affect the body, brain, and behavior?

When someone’s internal system remains in elevated state, it’s like having an alarm going off all the time.  It means the stress chemicals that flood your body in a state of emergency are circulating all the time, making it easier to trigger these aroused states and harder to get back to a normal.

This can interfere with sleep, cause people to avoid situations that remind them of a past event, lead to problems in personal relationships, and interfere with a person’s health and wellbeing.  Psychological signs may include confusing what is safe and what is dangerous, trouble focusing, hypervigilance, and difficulty imagining a future.

It is helpful to understand some of the dynamics of primitive survival response and understand the functions they serve.

Fight
  • Hypervigilance on conscious and unconscious levels, prepared to defend; flooding of physiological changes related to aggression.

Flight

  • During flight, blood flows to the limbs preparing to run. When flight is not possible there is no relief for a revved-up nervous system.

Fright

  • Anxiety and fear can permeate all areas of life, or seemingly benign situations may bring on sudden terror, startle responses, shortness of breath, and inability to focus. Fear can also manifest as bravado, thrill seeking, or reckless behavior.

Freeze

  • Freeze is accompanied by a slowed and shut down metabolism. It is an attempt to remain invisible and safe. When victims are paralyzed, helplessness is reinforced in each new situation, increasing their vulnerability.

Flail

  • Flailing is often perceived as aggression, but is a reactive physical movement, such as flailing the arms, to create a safe space around the body.

Flirt

  • Flirting is a defensive behavior, especially for women who were sexualized as girls who feel overpowered and revert to placating behaviors that helped them survive in violent and abusive homes.

Submit

  • Submitting makes the victim vulnerable, but more in control. Animals will submit to a predator if flight is impossible. Submission and under-arousal in the face of danger may be labeled “risk taking” behavior. (Miller 2009)

The good news is that people can learn about their triggers, learn new, safe coping skills, exert greater control over their response, and gain authority over their memories. There are many different types of treatments and approaches that help people with trauma improve on many different levels. They include many effective, specialized, therapeutic approaches as well as wellness practices such as mindfulness-based stress reduction and equine therapy.

Most people will use more than one approach over the course of their recovery journey. People recover by finding their way back to varying degrees of health through:

  • Practicing self-regulating and self-healing
  • Using the strengths and skills many already possess
  • Trying different effective treatments at various points over the course of recovery
  • Making meaning through expressive therapies, cultural, altruistic, or spiritual pathways

Adverse Childhood Experiences (ACEs) Study

What are ACEs?

Adverse Childhood Experiences (ACEs) are potentially traumatic events that are experienced or witnessed by a child (ages 0-17). These include violence, abuse, or neglect as well as things that effect parents or caretakers to the degree that it is experienced as a hardship by children. The ACEs in the graphic below are not an exhaustive list of every category, but they represent the ones that have been included in research studies. They also comprise screening tools used in some settings to help understand how ACEs may have affected an individual’s development, sense of safety and stability.

When children have an opportunity to develop resilience, they may not be adversely affected by any one or two of these experiences, but when they grow up dealing with four or more, research has shown it exponentially increases the risk of developing mental health problems and addictive disorders.

The main types of abuse, neglect, and family hardship included in ACEs research. Each category = 1 point. For example, having an incarcerated father who physically abused a child’s mentally ill mother = an ACE score of 3. If anyone subsequently sexually abused that child, it would add another point = a total ACE score of 4.

ACEs and other types of traumas are often culturally specific and may include exposures to violence and premature death.  For example, in certain urban areas, Black children witness gun violence, see people they know get beaten by police, and are warned at an early age that getting stopped by police is a life-or-death situation.  Many also had a parent who spent years incarcerated in a prison far away.  

A generation of children grew up during the prescription opioid overdose epidemic in hard-hit communities and experienced deaths of grandparents, uncles, teachers, and neighbors beginning in the late 1990s.  Many subsequently lost parents, siblings, and friends to the next wave of heroin overdose deaths and grew up in foster care.  As adults, some of those individuals are now watching helplessly as their own teenage children become caught up in a flood cheap, potent, fentanyl and methamphetamine.

We will learn more in the next section about the impact of cultural and historical trauma as well as some of the unique cultural strengths and resiliencies that can help promote recovery and healing. By now you probably can see how ACEs can cluster in families and the intergeneration aspects of trauma.  For example, children from families dealing with untreated mental health and addictive disorders may inherit some genetic predisposition.  They also see certain behaviors modeled, and every ACE they have makes them a little more vulnerable to the next one, until a cycle is set in motion in childhood that looks something like this by adolescence.

Responses include fear, anxiety, mistrust, isolation, and avoidant behavior. When young people begin using drugs and alcohol in response to the effects of trauma, the relief they find reinforces the behavior, making them more vulnerable to re-victimization, mental health problems and so on.

How much impact do ACEs have on mental health and substance use disorders?

The original ACE study included a group of working individuals with private health insurance that filled out a survey given to them when they went to their doctor for a check-up. Only 7% of the tens of thousands of research subjects reported an ACE score of 4 or more. But researchers found incredibly higher rates of a multitude of physical and behavioral health problems among those respondents. Statistical analyses allowed them to calculate the proportions of risks for the various conditions that were attributable to ACE scores. Below is a snapshot of some of the findings.

Impact of ACEs on Mental Health and Substance Use Disorders
Mental Health PAR* Drug Abuse PAR*
Current depression 54% Alcoholism 65%
Chronic depression 41% Drug abuse 50%
Suicide attempt 58% IV drug use 78%

*PAR: That portion of a condition attributable to specific risk factors

Since that 2005, ACEs research has been conducted among with various groups with compelling results. For example, when researchers looked at the percentages of individuals with an ACE score of 4 or more among youth involved with juvenile justice, 65% had plus 4 scores as opposed to 7% in the original study. Researchers have also studied the effects of trauma among prison populations, where ACE scores of 6 or more are common.

How much does this have to do with severe addictive disorders?

A male child with an ACE Score of 6, compared to a male child with an ACE Score of 0, has is 4,600% more likely to become an IV drug user sometime later in life.

A female child with an ACE score of 4 or more has a 78% attributable risk factor for IV drug use, as compared with a female child with an ACE score of 0 who has an .05% attributable risk.

Types of traumas that tend to have a lasting impact.

  •  Are interpersonal in nature and intentional. In other words, traumatic experiences such as a sexual assault or childhood neglect that involve one person intentionally inflicting pain on another a generally harder to deal with than trauma that is the result of a car accident. Sanctuary trauma occurs when an individual seeking refuge experiences trauma instead. For example, when people seeking help for a mental health problem are put in four-point restraints.
  • The original event is not as painful as the prolonged effects people experience. It is a mistake to assume people with trauma-related difficulties can’t get over somethings that happened in the past. They are more likely to have a hard time dealing with the impact of trauma on the present. This can include unpredictable responses to triggers that cause them to re-experience panic and fear or the inability to fully recall certain events.

What does it mean to be trauma-informed?

SAMHSA has identified six principles of trauma-informed care. It is not surprising that peer support is one of them. During childhood abusers are usually adults, authority figures, or others who have control over a child’s life. The dynamic peers support specialists bring with them is their status as another person in recovery without any stake in controlling or coercing anyone. The other five principles offer guidance to peers working with people likely to have experienced trauma:

  • Safety: Peer support specialists can help people feel safer when they seek services. In many settings, the presence of peers helps reassure people. For example, peer support specialists working in a mental health crisis unit may help explain the schedule of activities, the types of staff members and when they are available and can listen to an individual’s concerns.
  • Trustworthiness & transparency: Peers establish trust by remaining honest about what they can and cannot do, by never promising more than they can deliver, and by following through on their commitments. Peers can also help create transparency by taking the time to explain what to expect from various treatment options and service settings.
  • Collaboration & mutuality: Peers work with people to achieve the self-directed recovery goals that are important to them. Peer specialists model mutual respect for different recovery pathways and choices. They offer acceptance, understanding and a non-judgmental advocate ready to really listen to the people they support.
  • Empowerment & choice: Peers help others to find their voice in recovery, speak up for themselves, and make autonomous choices. They also support self-efficacy by helping people build on their successes, and break down big goals into small, manageable steps. They offer information on options, choices, and alternatives.
  • Cultural, historical & gender issues: Peers seek to understand the barriers to recovery different subgroups encounter. They remain humble enough to ask questions and learn more about disparities and about the healing traditions of different cultures. They are informed about resources that support recovery in underserved communities and link individuals to available recovery community supports.

Considerations for Peer Specialists

We can all relate to experiences that seem to evoke that panicked, irrational child who feels unsafe. Those feelings can be much more intense for someone just beginning to learn new ways of coping. Here are a few tips:

When someone is having difficulties, avoid recounting their problem behaviors with statements such as:

  • “I see you withdrawing.”
  • “You have been isolating.”
  • “You’ve stopped going to meetings.”

Instead, offer choices, point out strengths, and invite them to talk about what helps:

  • “I know it’s hard to get to a support group, but a lot more options are available online.”
  • “You must have been a very resilient child. Can you tell me about some things that helped you cope?”
  • “It seems like a lot of people trust you. Why do you think they feel they can?”

Redirect people to the present if they get stuck recounting upsetting traumatic events from the past.

  • “How do you think all that influenced your drug and alcohol use?”
  • “You were very productive when you were away at college. Why do you think that is?”
  • “I’m so sorry that happened you. Leaving that situation must have taken a great deal of strength.”

Part of trauma-informed peer support is being transparent about limitations. Peer support specialists operate within the scope of their experience and do not have the kind of expertise people are looking for when it comes to trauma-specific treatments. However, expressions of empathy and information about the many effective treatments that help people recover from trauma can be reassuring.

REFERENCES

Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):174-86. doi: 10.1007/s00406-005-0624-4. Epub 2005 Nov 29. PMID: 16311898; PMCID: PMC3232061.

CDC Center for Preparedness and Response. (2020). Infographic: 6 Guiding Principles To A Trauma-Informed Approach | CDC

Miller, N. A., & Najavits, L. M. (2012). Creating trauma-informed correctional care: A balance of goals and environment. European journal of Psychotraumatology3, 10.3402/ejpt.v3i0.17246. https://doi.org/10.3402/ejpt.v3i0.17246

Miller, N. (2009). Trauma informed Offender Management Curriculum. Police Standards and Training Academy. Concord, NH.

SAMHSA (2015) Core Competencies for Peer Workers in Behavioral Health Services (samhsa.gov) Pg 2

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