FacultyFaculty/Author Profile

Understanding and Responding to Trauma in Justice-Involved Individuals


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CHRISTINE EDWARDS: My name is Christine Edwards. I'm the Assistant Deputy Counsel to the Office of Policy and Planning, under the leadership of the Honorable Sherry Kline Heitler, who spoke earlier this morning. The Office of Policy and Planning oversees all of New York state's problem-solving courts, including the mental health courts. I will be moderating the next session and have the of introducing our presenter, Dr. Anthony Waters, who's the Deputy Director of Mental Health Correctional Services for the New York City Health and Hospitals Corporation.

Dr. Waters obtained his psychology doctorate from the George Washington University. He has trained and worked extensively at the intersection of government, law, and behavioral health, including at Walter Reed Army Medical Center, the NYPD, New York City DOHMH, and within the New York City jail system, where he currently designs innovative mental health treatment units and delivers cutting-edge training programs.

He is also the founder of ACCORD Training and Consulting, a firm dedicated to training personnel and implementing programs across industries and trauma-informed care and the verbal de-escalation of crises. Dr. Waters presents and trains widely on these topics, as well as on the diagnosis of mental disorders. He also maintains a small forensic clinical practice. Dr. Water's peer-reviewed publications are concentrated in mental health programming and correctional settings. He will now be speaking on understanding and responding to trauma and justice-involved individuals.

[APPLAUSE]

ANTHONY WATERS: Good morning.

AUDIENCE: Good morning.

ANTHONY WATERS: First of all, thank you, Christine, for the introduction. I'm going to grab my water from you. Yeah. I'm supposed to have this. All right. A few thank yous to begin. Thank you to PLI for putting this together, and Leonard for really driving a lot of this. To Carol Fisler for organizing a lot of today's presentations. And probably most importantly, thank you to all of you for being here.

This is such an important topic. As a psychologist, obviously, trauma has always had a lot of meaning in the work that I do. And my philosophy, as a psychologist, has evolved in my time as a practitioner, and hopefully that will become evident with an anecdote I'm going to share shortly.

But I'm heartened by the response from so many folks from within the legal community here today, wanting to come and hopefully inform their own practice as prosecutors, defense attorneys, civil attorneys, and, of course, judges as well. So thank you for being here. I do know what a challenging topic this can be to address at times, and just want to reiterate a comment that Carol made earlier, to be sure to take care of yourself as well.

And so with that, I want to start with a little story about my time practicing as an early career psychologist from a very idealistic and, in many ways, naive perspective. We heard this morning from Kenton, who mentioned that he had to look at how he may have caused harm in his work, despite trying to do what was best from the organizational perspective and from the perspective of his position. There were still times that he looked back and recognized that he had done harm. It was much the same for me.

And so looking back at my work as a really idealistic practitioner who believed that insight was the root of change, and that no matter how much confrontation was necessary, by gaining that insight with the patient, we would be able to create the kind of change necessary to avoid the sorts of cycles that so many people within our justice system find themselves revolving through. And so I was interviewing one particular patient. And by the way, I'm going to be referencing several cases over the course of the presentation. And each case is a composite that's being done in order to preserve the confidentiality of patients.

But for this individual who I was interviewing, we were in an institutional setting on a psychiatric ward, and he had a long history of justice involvement. And he was provocative on the unit, highly assaultive towards peers, as well as towards staff. He would even engage in extremely off-putting behavior, like feces smearing, which really was designed for him to keep people away. So we'd see a lot of this really antithetical behavior, moving towards people with the intention of extorting and hurting others, but then also, at the same time, keeping people away by smearing feces on his body. Because who would want to approach somebody covered in feces?

And because of all of the challenges that this was causing within the milieu, or treatment unit, I was asked to evaluate him to understand what was at the root of the behavior, so that we could, as a team, develop a treatment plan to hopefully transform things, to create a safer environment for him and for the staff. But remember, at the time, I was awfully idealistic. And so as I began to interview this individual, my questions became increasingly personal.

And with increasingly personal questions, he was losing more and more control over the process. And what we hopefully will take away from today is that for traumatized individuals, control is critical. A traumatizing event strips someone of their sense of control and agency over a situation. The feeling of overwhelm and instinctual protective mechanisms that kick in during a time of trauma, but still the event leaving the individual feeling overwhelmed, creates a chronic anxiety over the next occurrence that may leave them feeling vulnerable once again.

And this was the case for this individual, which I was naive to at that time, again, thinking that if I asked the right questions and achieve the right insight, we will create the change necessary to establish safety. But as I was asking these questions, as I mentioned, he was losing control. And I was misattuned to the behavioral signs that this was happening, focused much more on my own agenda, until, at one point, his stress response system kicked in. He got up. He stood over me, made a fist, and said, Doc, how would you feel if I punched you in the head right now?

Now, his tone in that moment wasn't so even. His language wasn't so kind. And I'm a skinny guy. I was a late bloomer. My fight, flight, or freeze system kicked in, and usually, that, for me, means I'm running. But in that situation, I couldn't. He was standing over me. And so the next defense mechanism to kick in after fight or flight is the freeze mechanism. And that's what happened for me.

Fortunately, colleagues were around that were able to intervene and escort this individual out of the consultation room. But I look back on that scenario quite frequently, because it reminds me of the fact that trauma and control are intimately related. And when individuals who have been traumatized start to feel some loss of control, their instinctual mechanisms begin to kick in, and they do what is necessary to reassert control in that moment for their own sense of safety.

What he was doing, historically, that was seen by others within our unit as problematic-- the violence, the aggression, the feces smearing-- this was adaptive behavior designed to keep him safe. Just like in the moment of the interview, when he lost the sense of control with me, he reasserted it through his fight mechanism, that which was most effective for him in circumstances similar to the one that he encountered with me.

And so anger, for him, was power over vulnerability. And trauma highlights vulnerability. And so hopefully, with that as a backdrop, we can jump in a little bit to trauma, the consequences of trauma, and what we, as individuals who intersect with traumatized folks, can do to hopefully evolve our practice to be more trauma-informed.

So this is an imperfect description, but we can think of experience as existing on a continuum. And on either end of the poles, on either pole, we have emotionally-driven experiences. On one end of the pole, it's the extremely positive emotionally-driven experiences, and on the other end, it's the extremely negative emotionally-driven experiences. Both may result in similar phenomena, such as a loss for words. There's a wonderful scene in the movie Contact, which as a kid, I saw two days in a row in the theater. I loved it so much.

But anyway, Jodie Foster finally makes contact with the extraterrestrial life. And she's so taken aback by the beauty of their world that she says, I have no words. They should have sent a poet. And that's an illustration of how positive experiences can strip us of the capacity for words. But what we're going to be focusing on today are the negative experiences that result in a similar phenomenon, an inability to articulate or to apply a normal narrative with a cohesive beginning, middle, and end to the traumatizing experience.

Because in those moments of fear, we're driven by impulse and reactivity, geared towards self-preservation. But in those moments, we lack words. We lack thoughtfulness. And ideally, what we have is a nice balance between our emotional side and our thoughtful side. We want to be somewhere in the middle third of that continuum.

Not exclusively thoughtfully-driven, because then we'll come across as robotic and detached, but with a nice balance of our emotional side and our thoughtful side. That allows us to be able to connect with the people around us, to be able to feel emotionally what others are feeling in the moment, but still make a thoughtful decision about what we want to do next. It empowers us with the ability to connect to people, but retain the capacity for choice behind our actions.

But when we move to that extreme negative end of the pole, where behavior is driven by negative emotionally-charged experiences, we lose the capacity for rational choice and we are impulsively guided by our stress response system. And we'll be talking quite a bit about the stress response system and its neurobiological heritage. But really, at the end of that pole of negative experiences, we're driven by fear.

And so let's start with the question, is fear a good emotion? And I imagine, for most of the folks in the room, we would probably say, well, it has both good and bad aspects to it. It's certainly evolutionarily necessary. We need to feel fear.

It's built into every mammalian brain. Because without fear, we lose the capacity to act in our own most basic self-preservative nature. We have to know if the threat we're experiencing is significant enough that we need to act. But we can't take the time to think our way through it, because if we think, it may be too late. And so fear guides our action through emotion.

You may have heard someone describe that they encountered some sort of stressful experience. Perhaps they woke up and the apartment was on fire, and they just got up and ran. Before or even consciously recognizing, I need to get out of here, the behavior was occurring because fear kicked in and it drove the action. It is evolutionarily necessary. The time to think would position people for greater risk.

So in that respect, fear is good. But there are circumstances where fear can become bad for us as well. And it's when our capacity to appropriately analyze circumstances and determine whether or not the fear is warranted that we run into problems. When our threat detection meter is skewed towards seeing fear where it doesn't exist, we run into problems.

But again, I'm going to reiterate this point multiple times throughout our time today, that for individuals who do have that skewed threat detection meter, it comes from somewhere. Every behavior has a purpose. And it's incumbent upon us to try to understand what the purpose of that behavior in that moment was, and recognize that, more often than not, particularly for traumatized individuals, it's being done to save the self, to protect against future traumatization or retraumatization.

But a there's a typical pattern that we go through when we encounter fear or a stressor. First, we get arousal. We feel the anxiety and the tension in our bodies, and we might notice that our heart begins to race. Our palms get a little sweaty. And our capacity to think maybe gets impaired. But then once we realize that we're safe, we go into an exhaustion phase. And depending on the extent of the threat, that exhaustion phase can be as brief as a deep breath, or it can be as significant as something much more that might require a long sleep or even a psychiatric hospitalization to preserve safety in that moment.

But then after that period of exhaustion, we return, typically, back to our baseline. So we go through arousal, exhaustion, then back to our baseline, under ideal circumstances. We're essentially like a rubber band. Under stress, we're malleable. We're able to adapt. And so like a rubber band at its natural state, it retains some shape, but it's pliable. It's flexible. And then under stress, a rubber band stretches out to accommodate whatever it needs to accommodate.

But with each successive ounce of pressure applied to it, the rubber band becomes less and less capable of accommodating more pressure. And we, as humans, in response to stress, operate in a very similar way. When we encounter stressors, we're oftentimes able to adapt to it. Even if it's on the periphery of our comfort zone, we're able to stretch, just like that rubber band. But with each successive demand placed upon us, we become less and less capable of accommodating that stressor.

But then once the tension eases, the rubber band returns back to its natural state, just as we, as humans, do after we've had that period of exhaustion. So long as the stress didn't break us, we return back to our baseline and continue on without much impairment over the long-term.

And so in that respect, humans are very resilient. And so when we think about trauma, it's important not just to think about trauma as risk in isolation, but to think about it in concert with resiliency factors as well. We've heard that mentioned from a couple of the panelists this morning. And it's so important to do so. And this is an imperfect metaphor, but you're going to hear a lot imperfect metaphors from me today. I'm kind of a metaphorical and visual learner, so I try to take what's best and throw it out there and see what sticks.

But if we think of risk in resiliency like a cocktail-- think of a glass. And into that glass, liquor may be poured. And into that glass, something to mix the liquor with may also be poured. And it's a matter of how much of both that affects how the individual is able to metabolize that drink. If there is a lot of liquor poured into that glass with very little other liquids, and the individual takes it in, it's going to affect the metabolism pretty significantly. It's going to have an effect on the person's constitution and subsequent behavior.

But if you flip the script and pour just a little bit of liquor into it and an awful lot of whatever else, then the individual is probably not going to have much of a consequence. And that's the way we work with stress as well. Even when we're exposed to really stressful, and maybe even, in part, traumatizing experiences, if we have a whole lot of other liquid poured into our glass, we're going to be more capable of buffering against the consequences of that stress.

And so it's about the balance between the two, how much risk is evident as well as how much resiliency is evident. And when we talk about resiliency, there are both individual resiliency factors as well as external resiliency factors. And individual resiliency factors include things like, what is the person's sense of self-efficacy? How capable does that individual believe that he or she is to manage demands? How creative is that individual at thinking through things and responding to stress?

And the next external factors are things like, does the individual have a supportive family, supportive friends that they can turn to help make meaning of the event? And meaning, more than perhaps anything else, is an indicator about whether or not somebody who experienced the trauma will subsequently become traumatized. We'll talk more about that later.

It also means how accessible are services? Does the person have a clinic in the neighborhood that they can easily access? Or is the nearest doctor a subway ride away and a three month wait list to get in? All of these things have a significant impact on whether or not a stressor will be appropriately managed or not. And so it's not just about risk, but it's about resiliency.

And what we hope to do with people who have been traumatized is identify those factors within the individual that suggests strength and resiliency, and work those like any other muscle until they're strong enough to buffer against future stressors. And we try to look at various things within the community that can be tapped to help provide that individual with additional resiliency as well.

But what happens when the event is too much? When the person's rubber band stretches to its max, and then there's a little bit more pressure applied and it snaps. Well, in those circumstances, that natural pattern of going through an arousal period, exhaustion, and then a return to the baseline, is altered. The baseline does not go back to where it once was.

Trauma fundamentally changes an individual. It alters their perspective on whether or not the world is a safe place or a dangerous one. It changes whether or not the people with whom they intersect are sources of support or potential retraumatization. And it changes one's own sense of self-efficacy. Am I someone who can manage the challenges of the world? Or am I someone who is overcome by them? In extremely traumatizing events, sometimes no matter the resiliency of the individual from the outside, can be overcome by it, and like that rubber band that's stretched to its maximum, eventually breaking under the pressure, resulting in lasting consequences.

And so it's important, also, to differentiate between single incident traumas, which really fit the pattern that I just described, where a person's baseline may be one way, but after the traumatic event, the baseline shifts. And by baseline, I'm just referring to who the individual is on a normal basis, what their world view is, how they interact interpersonally, how they view their place in the world.

Well, after a single incident trauma, like perhaps a car accident, or a single sexual assault, or being exposed to a natural disaster. One of our colleagues today mentioned Sandy as a potential source of trauma. Those are single incident events, where, for the individual, as well as for the people who intersect with the individual, they're often able to see a dramatic pre versus post event change in their behavior.

But for many of the folks that we work with within the court system, particularly within the criminal justice system, those individuals have been exposed to chronic trauma, chronic developmental trauma. And we're going to talk about the ACE Study later, which I know we've heard mentioned a couple of times already, but it is of such monumental importance that it bears reiterating. But that chronic developmental trauma skews development right from the outset down a trajectory that primes the individual for outsized reactions to otherwise normal and innocuous stressors.

And there is a very behavioral and neurobiological rationale behind that altered trajectory, and we'll be talking about that a little bit as well. But for those individuals, it becomes particularly challenging to identify trauma as the source of the behavior that's being labeled problematic. It becomes difficult because there's no dramatic pre versus post traumatic shift, because it was chronic throughout development.

And so oftentimes, what ends up happening is we end up treating the wrong symptoms. We end up focusing on that which is most observable, whether it be the substance abuse, whether it be the criminal, recidivism whether it be the interpersonal provocation, or depression. That's where the focus, clinically and within the courts, often ends up being placed. But it's not until we do a much more trauma-informed assessment and shift away from that perspective-- as it was mentioned before-- away from, what is wrong with you, towards what happened to you, that we begin to understand that the picture is much more complicated than just what's on the surface.

And so trauma has a very consequential impact on an individual's comfort zone. And I apologize. There were some formatting issues with the slides as they went from one computer to another. So it's a little off, but we'll be able to work our way through it together.

So trauma causes a shrinking of an individual's comfort zone. What was once safe becomes potentially threatening. And so again, this is really evident within the pre versus post for single incident traumas. And for people who experience chronic developmental trauma, the comfort zone never grows to be as expansive as it is in most others because there's such a focus on self-preservation and safety.

Novelty becomes threatening after exposure to a traumatizing event. Because with novelty comes unknowns, and unknowns carry with it the potential for retraumatization. And so not only does the comfort zone shrink, but it becomes much less flexible at its periphery. No longer is it like that rubber band that can accept increasing amounts of tension.

But instead, it becomes kind of like that dried out rubber band in the bottom of your drawer, that when you're finally moving out of your office years later, you find. Oh, maybe I can use this to bound up some of my materials. But the moment you apply pressure to it, it cracks and it breaks. And like that rubber band, people who've been chronically traumatized are oftentimes much more rigid at the periphery of their comfort zone because of the danger in novelty.

But what that means is that, within that comfort zone, the person may appear well related, engaged, otherwise healthy and appropriate, because that's where they feel safe. But then very quickly, almost like the switch of a light bulb, once novelty is introduced, or once a stressor is applied that threatens the constitution of the individual, the behavior changes.

And it's not because they've made a conscious decision to respond emotionally, or to become provocative, or to curse somebody out, it's because their stress response system was activated and a very instinctual process began that's designed to keep the individual safe. Something in that moment extended them outside of their comfort zone, threatened the constitution, and demanded an instinctual, safe response for the individual, which is governed by our fight, flight, or freeze mechanisms. You'll have to excuse me. I get a little parched when I talk.

So how exactly do we define trauma? Well, I think we heard judge Hirsch give this very definition earlier today. And I'm going to read it for you once again, because there are a couple of points that I really want to highlight within this definition. This is from the Substance Abuse and Mental Health Services Administration, which is a fantastic resource for folks to really learn more about trauma. They even go so far as to publish free books on how to understand trauma-informed approaches and to make your institution a trauma-informed organization.

But they write that, "Trauma results from an event, series of events, or a set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening, and that has lasting, adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being." It's quite a mouthful. But importantly, the definition highlights that traumatization has a lasting consequence on the individual.

That's what differentiates a stressor from a trauma, the lasting impact on functioning. All of us, when we go through a stressful event, we're thrown off our baseline temporarily. But we're able, like that rubber band, to bounce back to our natural state and remain resilient in the face of that stressor. But for traumatized individuals, the impact is lasting. And we'll talk about exactly what that lasting impact looks like behaviorally shortly.

But another really important aspect of this definition is not what's in it, but what is missing from it. And it doesn't give any examples of what trauma is. It doesn't identify car crashes, sexual assaults, living within a domestically violent relationship. And that's because it's up to the individual to define what's traumatizing for them. Anything can represent a trauma for an individual if it causes that lasting adverse effect.

And so by labeling events that are traumatizing, we run the risk of limiting our scope, of understanding what trauma can be. And what we want to do is expand our scope and understand that it's the individual's response to it that defines whether or not an experience was traumatizing, not our perception of the event as the person intersecting with that person.

And that's particularly important for us, to remain open-minded. We hear a lot within the mental health field about the importance of being non-judgmental. But that's so hard to do when we're so darn good at it, not to mention the fact that it's an instinctual process that we all engage in.

And so I like to reframe that as the value of being minimally judgmental, and being curious with the person that we're sitting across from, to allow them to define their experience for us because they are the experts on their experience. Yeah, I went to an awful lot of school and I've got the student loan debt to prove it, but I'm not the expert when it comes to my patients. They're the expert, and it's up to me to learn from them.

But what does trauma look like behaviorally? Well, we've probably all heard of post-traumatic stress disorder, and post-traumatic stress disorder represents a constellation of symptoms. And first of all, there has to have been some sort of event that the individual experienced as stressful. In following exposure to that event, there has to be intrusive symptoms. Symptoms of intrusion are things like flashbacks or nightmares. And there has to be avoidance symptoms.

You'll notice that I'm using the word symptoms, and that's because, in diagnostics, it comes from a pathological model. But what we really want to reinforce here is shifting away from a pathology model towards a resiliency-based model, and we'll get into that shortly. But there is relevance for our discussion of post-traumatic stress disorder as well.

Avoidant symptoms are things like avoiding persons, places, and things that might remind the individual of their trauma. And so by avoiding them, they're staying within their comfort zone and they're not risking being exposed to something that might be a source of retraumatization. And then we have alterations in thinking and mood, and those are typically negative alterations. In 1976, Aaron Beck released his theory of depression, called the Cognitive Triad, where he attributed depression to a chronically negative perspective on one's self, the world, and the future.

And it's as applicable for understanding trauma as it is for understanding depression, particularly as it relates to the negative alterations in thinking and mood. So that shift from one's self as efficacious, creative, and capable, and the world as safe to one as hurt, unlovable, and the world as dangerous, is a part of the negative thinking and mood alterations that are consistent with post-traumatic stress disorder.

And lastly, our alterations in arousal and reactivity. And these are things like hypervigiliance, being chronically on guard for a future stressor to cause retraumatization. And it also involves things like reckless, or self-destructive, behavior and interpersonal provocation. And this is particularly relevant when we talk about the criminal justice system, where individuals might become enmeshed in the justice system because of violent or interpersonally provocative behavior. And we look at the behavior as the problem, and sometimes fail to look behind the behavior at trauma as one of the governing factors of it. And this was a change in the DSM-5 to include that as diagnostic, and it's so relevant for our work at intersection with the courts.

But the reality is that most people who are exposed to a trauma do not become traumatized, and it's in part because of our resiliency factors. But for those who do become traumatized, post-traumatic stress disorder represents only the minority of the consequences of that traumatic stress. And so we see, in the DSM-5, there are over 250 psychiatric diagnoses. And most of those can be the result of some form of traumatic exposure.

And so oftentimes, what we see in response to trauma are depressed mood and affect, ruminative thoughts, alterations in concentration, or anxiety, fear over what might happen next, or somatic symptoms. Somatic symptoms are things like chronic headaches, gastrointestinal distress, genital pain for survivors of sexual trauma. The body bears the burden. And there's an excellent book by Bessel van der Kolk, titled The Body Keeps the Score, where, in a very accessible language, he describes how trauma affects people on such a broad scale. And it's really a wonderful illustration of the total dynamics of trauma, not limiting it to the scope of a single diagnostic category, like post-traumatic stress disorder.

And then, of course, substance use. We heard a colleague this morning talk about the prevalence of traumatic stress in the lives of substance users. And so when we consider the consequences of trauma, it's important that we really keep an open mind to what that might look like. And it's not limited to a single diagnostic category, and it's not limited to the diagnoses in the DSM-5, either. Problematic consequences of trauma can be extremely wide and it's up to the individual to really help us define what the impact was for him or her.

So let's consider how we go from something being a stressor to being a trauma. And we can think about demand as existing on a y-axis and our response to the demand as existing on the x-axis. And there are basically two types of responses that I'm categorizing everything into. There are the thoughtful responses and there are the impulsive, or emotion-driven responses.

And when we're encountering a mild stressor, something well within our capacity to cope, we typically will just engage an independent problem-solving. We can manage it on our own. It's not so significant that it throws us off. But then if, for whatever reason, the stressor exacerbates and we need a little bit of perspective, then typically what we do is we reach out to a trusted other, someone who has influence over us to help us work through the problem. And these are our thoughtful responses to stress.

But what happens if during the traumatic experience, or during the stressful experience, our constitution feels threatened? We feel unsafe. Well, that's where we begin to have the more impulsive responses. And I'm using the word impulsive, and I know that it oftentimes carries somewhat of a pejorative tone. Impulsive equates to thoughtlessness. It equates to problems. But really, what we're talking about here when we're talking about impulsivity is, again, the person's self-preservation, their interest in keeping themselves safe. And it's not conscious, but it's the brain saying, threat exists and we need to do something now.

And the first stress response is fight or flight. This is what we first respond with, unconsciously, when we feel unsafe or threatened. We either fight back or we get out of there. Like the individual that I was interviewing that I referenced before. My instinctual stress response mechanism would be to flee, to remove myself from that scene as quickly as possible. But in that moment, escape was impossible for me, and that's when the freeze mechanism kicks in.

The freeze mechanism we can also think of as dissociation. One of our colleagues was commenting to the earlier panel about the relevance of dissociation and dissociative identity disorder in justice-involved individuals. And it is so relevant to our work and often misunderstood. We could spend a day talking about it together. But I'm going to try to make an illustration of it as succinctly as possible.

But the dissociative, or freeze, mechanism is like that surge protector into which we plug all of our most valuable electronics. We plug our computer, our stereo system, our television into that surge protector in the off chance that there's an electrical spike. Perhaps lightning hit our building and caused this surge of electricity, and the surge protector cuts off all power to our valuable electronics, so as not to leave them irreparably damaged.

And our brains operate in a very similar way. When stress is threatening to our sense of selves and escape is impossible, our brain shuts down certain mechanisms so that we don't process them. And it may manifest in interviewing a survivor of sexual assault who can't detail her attacker, or who can't talk about exactly how the attacker assaulted him or her. It may manifest in a child who, in detailing the abuses perpetrated upon him or her by their father, talks about it in such a matter of fact way that you're left wondering whether or not it really happened.

Well, they disconnected themselves from the overwhelming experience, and what's left is only this narrative, disconnected from the emotion and the physical pain that was left from the trauma. That's our brain's and our body's way of dealing with the past and managing it in the present through whatever mechanisms we have available. And we're at risk, particularly when we see people having these freeze mechanisms, to think negatively about their experience, to ask questions like, did this actually happen? Or if it did happen, how is the individual being so matter of fact about it?

And we have to really keep an open mind, recognizing that in response to stressors, we have a number of different mechanisms that we employ. And the last of those mechanisms, when we feel most threatened, is the freeze response, or dissociative mechanism, that leaves us disconnected in many ways from the experience, from the memories, from the physical sensations sometimes, and from the emotions.

And so another way that we can look at this is by going back to our comfort zone slide. And I'm not sure how well those colors are showing up on the PowerPoint. But when something is well within our comfort zone, the gray circle being our comfort zone, we're typically able to manage it independently. But as it gets out to the periphery of our comfort zone, or even extends beyond it, that's when we're more likely to reach out for support from others.

It's not that the situation isn't manageable. It's that it, perhaps, just isn't manageable alone. And it's not until we get outside of that comfort zone by a very significant degree that we start to run in to that stress response system. As threat increases, that's where we have fight, flight, and finally, freeze.

And so we've heard a little bit about the ACE study already today. But it was so fundamental in my understanding of trauma, and it really had the potential to send shock waves through the behavioral health care industry, the criminal justice system, and primary care as well. But in many ways, we're still waiting for those shock waves to hit. But hopefully, we can bridge that gap a little bit today.

So the Adverse Childhood Experiences Study was conducted by a primary care physician out in California. He was operating a weight loss clinic, and the treatment was successful. Virtually every patient going through his weight loss protocol-- and these were individuals who were classified as morbidly obese and were confronting really significant health consequences as a result of the weight-- virtually all of the patients were losing weight. But nonetheless, about half of them were dropping out of treatment.

So he asked that all-important question of, why? Why, if my treatment is successful, are so many people leaving? And he began to interview those who left. And he found one near universality amongst all of the dropouts, and that was a history of childhood sexual molestation. And so once again, he asked the question, why? Why are people who are confronting obesity in adulthood with a history of sexual molestation in their childhood leaving treatment?

And once again, there was almost a universal response amongst the folks that he interviewed. For them, the weight wasn't a pathology. It was a resilience factor. If I lose weight-- this is the perspective of the people he interviewed-- if I lose weight, I may become more attractive. And if I'm more attractive, I may be assaulted again. And so what was being seen as a pathology that needed intervention was, in turn, a source of strength and resilience for the individual.

That's why it's so important that we shift away from the pathology model, when we talk about being trauma-informed, towards the resiliency model. Rather than approaching those patients from the perspective of, you have a problem that needs solving, I'm the doctor and here is what you should do, we shift to a perspective of, how did you make it this far? What were you able to do in your life to keep yourself safe? And how can we build on those strengths now to create ways that you feel adaptive and promote your health?

And having that minimally judgmental and open-minded approach is really essential to being trauma-informed. In that situation, the original approach was, what's wrong with you? And what Dr. Felitti, the architect of the ACE Study learned is that it was really about, what happened to you? And so from that angle, he sent out over 17,000 surveys to individuals within California's Kaiser Permanente Health plan. And at the time, it was an exclusively employer-based health plan.

So we were talking about 17,000, primarily white, primarily well-educated, well employed, middle class Californians. By the way, does that sound like our New York City court-involved folks? Not quite, right? Not quite. And in those surveys, he asked 10 questions about the presence of physical, sexual, emotional abuse, neglect, and household dysfunction.

Emotional abuse being things that made the child feel unloved in the home, being told things like they're worthless and incapable. Neglect being things like not having food in the pantry. And household dysfunction being things like having an incarcerated caregiver, having domestic violence in the home, having a suicidal caregiver, or having a substance using caregiver.

And so even just by looking at those three categories of adverse childhood experiences, which really, is just another way of saying trauma, and that's another way of saying toxic stress. So you'll hear me interchange those words throughout. Looking at those three categories, we can see that there are a lot of things that he didn't ask about. For example, he didn't ask about the presence of community violence. He didn't ask about housing instability. These are things that a lot of the people who are justice-involved confront, and confronted throughout the duration of their lives. And there are things that we know are also sources of toxic stress.

Yet, even with the limited scope of his study, and even within the relatively privileged population, it was incredible what he found. What he found was that 2/3 reported exposure to at least one type of adverse childhood experience. And one in eight reported exposure to four or more. And there have been a lot of studies that have subsequently followed, and the percentage of folks in subsequent studies reporting four or more has gone all the way up to one in five. And then when we look at special populations, like justice-involved, it goes much, much higher.

But he found that there was a tipping point, and that tipping point was exposure to four adverse childhood experiences. And so that would mean like having been exposed to domestic violence in the home, having been physically abused yourself, having an incarcerated caregiver, and having been made to feel unloved. About one in eight reported at least four types, and that's just one example of four potential types.

And what he learned was that there was this dose response relationship. And what that means is that the more you're exposed to, the greater the potential risks. And it went along this very smooth continuum. If you were exposed to one adverse childhood experience, chances are you had enough resiliency to make it through.

But if you were exposed to four adverse childhood experiences, you had a 12-fold increase of attempting suicide, a tenfold increase of using injectable drugs, which has a tremendous potential consequence for intersection with the criminal justice system. You had a sevenfold increase of considering yourself an alcoholic, and a two-fold increase of having a stroke, developing cancer, or of having heart disease. And so four ACES really was shown to be tremendously impactful on someone's health.

But it wasn't just limited to health. There are also social implications for exposure to childhood trauma. We know that adverse childhood experiences increase the likelihood of having behavioral problems by age nine, and that adolescents risk of engaging in violent behavior increases exponentially with each successive trauma they experienced, and that survivors of abuse and neglect are 60% more likely to be arrested as juveniles.

And for those who were arrested, your ACE score is correlated to a higher risk for re-arrest. The more ACES that you experienced during your childhood, the greater the risk for re-arrest. And so there really is a direct link between not just health consequences of traumatic stress, but social consequences as well. And of course, these two overlap. And we know that the rate of chronic disease is much higher in incarcerated populations than within the general population.

And so what are the mechanisms by which traumatic stress causes impairment? Well, we know that toxic stress changes the way the brain develops. We'll talk a little bit about exactly how that plays out. But that disrupted neurodevelopment impairs the way the person feels, thinks, and relates to the world, which consequently results in engaging in high-risk behaviors, like injectable drug use, like interpersonal provocation, criminal behavior, gang activity, sexual promiscuity, which has the potential to result in disease, disability, and social problems, like incarceration.

And what we know is that for individuals who have been exposed to six or more types of ACES-- so we would be talking about emotional neglect, a domestic violent home, an incarcerated caregiver, a suicidal caregiver, having been sexually abused, and having been physically abused. That's six possible adverse childhood experiences. If you've been exposed to six or more, your lifespan is 20 years shorter than the average. The average American today lives to be about 80. The average American with six or more adverse childhood experiences prior to their 18th birthday lives to be 60.

And there was a study done among juvenile detainees within the Florida system. And they found that those detainees who were in the moderate to high-risk for re-offense had an average ACE score of six. So here we are with children in a juvenile detention center, right from the get-go, being able to predict a 20 year reduction in lifespan. That is absolutely incredible, and really highlights the impact that trauma has socially and across the lifespan, not just during the time of the traumatic event.

And so the social, emotional, cognitive impairment, high-risk behaviors, that's probably where most of our interest lies for the folks in this room. So let's take a look at how we get from that to some of the behaviors that we see for court-involved folks.

CHRISTINE EDWARDS: Anthony, can I interrupt you for a minute?

ANTHONY WATERS: Yeah, absolutely.

CHRISTINE EDWARDS: We've heard a lot about ACE this morning. Other than ACE, can you suggest another screening instrument that folks should use?

ANTHONY WATERS: Sure. So there are a lot of screaming instruments that are out there. Most are designed for mental health practitioners. There's something called a trauma screening questionnaire. It's another 10 item questionnaire. There's something called the primary care PTSD screen. That's really for primary care settings. There's something called the SPAN, which is really designed to identify trauma-relevant symptoms that are consistent with the DSM-5 diagnosis of post-traumatic stress disorder.

But the most important thing that we can do is be curious. Be curious and genuine with the person that we're sitting across from. And that means being open to the potential for traumatization and allowing them to articulate what their past was, what happened to them or did not happen to them. And not being presumptive as well, not directly linking a behavior and saying it must be because of trauma.

There's also a really excellent video series that was published by the International Society for the Study of Trauma and Dissociation. It's really geared towards interviewing practices for the legal community, both prosecutors and defense attorneys. It's a three-part video series and part 1 is on the behavioral impacts of trauma. Part 2 is on the issues for interviewers. And part 3 is a guideline for prosecutors. So that's really a comprehensive look at how folks who intersect with the legal system, legal professionals, can be informed to be more trauma aware.

And so going back to the role of categorization, there was an amazing study done out of the University of Wisconsin by Dr. Pollak and his colleague, [? Kessler. ?] They looked at the role of categorizing facial expressions and how that is impacted by the presence of physical abuse in children. So what they did is they showed physically abused children-- we're talking about those who were exposed to serious physical abuse-- and controls who had not been abused, a series of faces that evolved from nonthreatening to angry.

And they asked the children, at what point do you see anger? At what image do you first see anger? And their hypothesis was that the children exposed to serious physical abuse would identify anger much earlier than the controls. And unsurprisingly, they were absolutely right. And that's really done, for these children, as a means of protection. I'm a bit of a broken record when I talk about the role of protection.

But it's so important, because these children who are exposed to chronic physical abuse oftentimes within the home, they needed to be able to see those emerging signs of anger. They needed to be able to know if dad was drunk when he came home, because if he's drunk, that means I'm going to get beat. Or they needed to be able to identify the moment anger started to emerge in that abuser because that meant that I had to get out of there or I had to prepare to fight back. And so it was really about self-protection. And for the non traumatized individuals, they didn't need to identify those early signs of anger, and so they would wait much longer until the faces evolved into something really dramatic to really say, anger.

And so let's consider a common example, and this is the example of Tom. Tom grew up in a physically abusive home. His father was an alcoholic and Tom's father would beat him with instruments like belts or cords. And for Tom, he needed to know when his father would look angry. It was the furrow of his brow or the pursing of his lips. And at those early signs of anger, Tom would know that he needed to get his brother out and that he would have to prepare to fight his dad. And so it was really about keeping himself safe.

But unsurprisingly, Tom had problems when he got into school. He fought with his peers. He was seen as oppositional to the teachers. And ultimately, he was taken out of a mainstream educational setting because of his behaviors. And unsurprisingly, Tom was arrested as a juvenile. Because what was adaptive in the home for Tom, seeing those emerging signs of anger, became problematic outside the home, because it may have been miscategorized at times.

And that brings us into a discussion of another phenomenon known as stimulus generalization. And for those of you who are familiar with Pavlov and his dogs, some of this may sound familiar. Before we go back to the story of Tom, let's start with a fairly innocuous example. I grew up with chocolate labs. One of my charcoal labs was named Jasmine. He was an adorable animal. And Jasmine knew that we kept the treats in the pantry right off the kitchen.

And when we opened the pantry door, it made a characteristic creak. And so when Jasmine would hear that pantry door open, she would come running, her little toes Flintstoning across the hardwood floor, moving too fast for her ability to gain traction. But right next to that pantry door was the laundry room. And when the laundry room door opened, it made a similar, albeit noticeably different, sound.

But for Jasmine, even when she would hear that laundry door open, her enthusiasm would kick in. She would think that maybe she was getting a treat, and she would come running. She had generalized the sound of the pantry door to the sound of the laundry room door. And that's symptom generalization has the potential to create a generalization of how we categorize faces, particularly for traumatized individuals.

So let's go back to our example of Tom. Tom would see the furrowing of a brow, the pursing of the lips, the squinting of the eyes. And those characteristics, to him, meant anger. But let's think about confusion. A lot of really similar facial characteristics occur in a confused face. And so Tom would miscategorize anger. He would see it where it didn't exist, and he would start to instinctively act with his fight or flight mechanisms to keep himself safe.

And as I mentioned before, Tom's primary mechanism was fight. And so he was seen as provocative and threatening and dangerous. But really what this was self-protection as a result of the way he categorized faces and the generalization of facial categorization.

And so with that, hopefully we can begin to create a conceptualization of how this may create problems for the people that we intersect with within the court systems. When we see an outsized reaction to what appears like a relatively benign stressor, maybe what's happening for the individual is that they've generalized the response to something threatening. And it's not a conscious process, either. It's an unconsciously processed mechanism.

And so that threat detection meter is really governed by a process within our autonomic nervous system. And so we're going to talk a little bit about what neurobiologically is happening within traumatization individuals that leads to these impulsive reactions. But first, why is it important to talk about neurobiology? And maybe just by a show of nods or hands, who's heard of the willpower trap? All right. Not many folks, great.

So the willpower trap is the belief that the will to change is enough to actually make change happen. And if that were the case, we'd still be in the gym after we made that New Year's resolution, right? But the reality is willpower is not enough. It takes much more, particularly when we're talking about changing the orientation of the threat detection meter. Because this does happen outside of conscious awareness, the assessment of threat is not a thoughtfully mediated process. It's an emotionally mediated process.

And so the will to change is not enough because will is oriented through our thinking brain and trauma responses are mediated by our feeling brain. And that's a part of our autonomic nervous system. And so we could think about the autonomic nervous system as having two primary divisions, the parasympathetic and the sympathetic. And these divisions operate in opposition to one another.

The parasympathetic nervous system manages our rest and digest and the sympathetic nervous system manages our fight and our flight. And so they don't operate concurrently. They operate in opposition. And what we know with traumatized individuals is that the sympathetic nervous system is hyperactivated.

And so what exactly is happening in response to a potentially traumatizing experience? Well, first, we have to sense the experience, and we do that through our sensory organs. So let's say, for this example, that we've seen something in our environment that may be potentially threatening. It goes from our eyes to our processing center of our brain and from there, the pathways bifurcate. There's the local track, which, as we know, takes a little bit longer, and then there's the express lane, which we know skips multiple stops along the way to get to that destination more quickly.

And at our express lane, we have our amygdala. This is our fear center of the brain. This is what drives our response to threats in the environment. And if our amygdala determines that a threat does exist, it triggers a series of events that overwhelms the capacity for the thinking part of our brain, that local track, to take over.

It triggers our sympathetic nervous system, down our spinal cord, into a nerve, and into our adrenal gland to release adrenaline. And it triggers something called the hypothalamic pituitary adrenal axis, to, again, go down into our adrenal glands and trigger the release of adrenaline, and also cortisol.

And as many of us probably know, adrenaline is the thing that shoots the blood out to our skeletal muscles to prepare us to run or fight. It causes our pupils to dilate so that we can see better. It causes our heart to race so that that blood can shoot out to our skeletal muscles. Our capillaries in our lungs expand so that we can take on more air. And all of this happens unconsciously and instantaneously in response to the threat, as determined by our amygdala.

And as I mentioned, this is a separate pathway from the local track that goes to our thinking brain, which is mediated by our prefrontal cortex. And we know, in traumatized individuals, through brain imaging studies, that the prefrontal cortex is less active. And we know that, just like any muscle in traumatized individuals where the amygdala is overworked, there are brain imaging studies that show that the amygdala is actually larger in volume.

And that's what we call when we have amygdala-driven reactions. That's called bottom-up processing. And we have thoughtfully mediated actions. That's called top-down processing. And in individuals who have been traumatized, that threat detection meter is altered, and bottom-up processing becomes dominant and the top-down processing that's mediated by thoughtfulness is quieted.

And so what you have is an imbalance between our emotional side and our thoughtful side. The thoughtful side is not active and the emotional, impulsive threat response side is overactive. Again, this is not a consciously mediated process. It's triggered by any event that the individual senses that's outside of their comfort zone, and the brain kicks in this automatic sequence of events that is designed at its base to keep the person safe. This is survival-based behavior. And a similar process, as I mentioned before, exists in every mammal on our planet, because safety and survival is the most basic instinct in humans, just as it is in every other mammal.

And so individuals get caught in this cycle of bottom-up processing that, for healing to occur, has to be altered. And there's this wonderful parable attributed to the Native American tradition about two wolves. Anybody heard of the parable of the two wolves? OK, just a couple of folks. Great.

So a grandfather is walking with his grandson. And the grandfather tells his grandson, I have two wolves fighting inside of me. One wolf is angry, vengeful, reactive, and filled with hate. And the other wolf is loving, empathic, patient, and optimistic. And the grandson asked his grandfather, which wolf will win? And the grandfather responds, the one that I feed. I love that parable, and I think it's so relevant for the treatment of trauma disorders.

Because for these individuals, the reactive wolf is the one that becomes dominant in their life. And it's not about starving out that wolf. It's not about repressing it and forgetting its existence. But it's about feeding the loving wolf so that it can look at the other part of the self and say, it's OK. Thank you for keeping me safe. Thank you for protecting me when I felt scared. And finding the way to self-empathize is so critical, and I think this parable is a lovely illustration of that.

Another way to conceptualize it is a quote from Einstein that says that, "No problem can be solved at the same level of consciousness that created it." And for traumatized individuals, that level of consciousness is unconscious, as we've talked about. It's happening from the threat detection system. But in order to be able to recalibrate that threat detection meter to be more appropriate, to be more discriminate, and to not generalize the way that it did for Tom, we need to look at the problem from another perspective.

We need to, instead of seeing it as reactive, impulsive, and problematic, we need to look at it from the perspective of self-preservation and resilience. Every behavior that that individual did lead them to this point in time, which means that, despite the trauma, they've survived. They found a way to make it through, which suggests strength and resiliency. And so by engaging top-down processes and helping the person learn ways to activate their parasympathetic nervous system, to feel more in control of their emotions, to feel more connected to their bodily sensations, is essential in being able to treat trauma disorders.

CHRISTINE EDWARDS: Anthony?

ANTHONY WATERS: Yeah?

CHRISTINE EDWARDS: Is there a correlation between being unmotivated to participate or follow instructions and trauma-exposed individuals?

ANTHONY WATERS: So I'm trying to avoid responding, unequivocally, yes. Because it's always important that we are curious about why a behavior is occurring. And so it's important to understand that every behavior has a purpose, and it's up to us to try to understand what the purpose of that behavior was.

And by asking those questions and understanding that reality, hopefully we can come to a much better appreciation of why the person did what they did, which positions us best, as members of the behavioral health community and as members of the legal community, to craft the best path forward. We need to know what's happening beneath the surface.

Like an iceberg. Only 10% of the iceberg floats above the water's surface. Well, the behavior that we see people engaging in is only the surface, and we have to look at what's happening underneath it. And by doing so, and by asking the right questions of what happened to the individual, and understanding that every behavior does have a purpose, we can begin to understand what we need to do to help the person heal, and to keep communities safer.

So as I mentioned, in treatment, we need to activate the conscious part of the brain to initiate top-down processing. And there are a number of empirically-supported, trauma-focused therapies. That means evidence-based, trauma-focused therapies. And what I've listed on the board is just a couple of handfuls of them. There are more.

And so I think it's more meaningful to consider, what about these therapies? What do these therapies have in common? Because every patient requires a different approach, tailored to their own unique needs. Yet within empirically-supported approaches, there are a number of commonalities that I think are more important to focus on when we consider the prospect of healing.

And so there was a wonderful article published by the International Society for the Study of Traumatic Stress that boiled down the commonalities between psychotherapeutic interventions for trauma, traumatized individuals, into three primary phases. And most empirically-supported treatments share these three components.

The first is that the realization that chronic defense-- that traumatization is a chronic defense against the present. And so we have to help the person manage the present. And that treatment also involves reconciling the past. And so we first have to be able to deal with the present, and then we can go back and consider the past and how best to safely reconcile it.

So phase 1 of treatment is all about stabilization in skill building. How do we help this individual, who's come in to treatment in a moment of desperation, feel more at equilibrium, feel safer? So it's about reducing symptom acuity. And this can be done through any number of interventions, psychoeducation, helping the person understand that what their experience is is common for folks who've been through extremely traumatizing events. Psychiatric medications can be an important part, typically only in as much as it helps the person tolerate what they are experiencing enough that they can then proceed on to phase 2 of treatment.

And it helps the person reestablish a sense of agency by building skills to manage emotions and to manage sensations surrounding what they experience to be fretful stimuli. And skill building can be things like understanding what emotions feel like in the body. Because in the wake of trauma, there's a major disconnect between the thoughtful self, the narrative of the experience, our emotional self, and our bodily sensations.

So while we're skill building with patients in trauma therapy, we're helping them draw a link between what they're thinking, what their emotions are, and what their bodily sensations are. That helps the individual begin to craft a narrative that's meaningful for their experience. Because oftentimes, traumatized individuals have flashes, flashes of powerful emotion, flashes of images of the past trauma, flashes of physically painful sensations that are really difficult to make sense of in isolation. And in phase 1 of treatment, we're helping to connect all of those things together into a meaningful experience in the here and now.

And none of this can happen unless the person feels safe in the treatment environment, unless they feel like they trust their provider enough to go down this pathway. Because remember, traumatization results in a fear over novelty, and a new person is representative of novelty. And until that person starts to feel like a safe and trusted other does the traumatized individual feel comfortable enough going further in treatment. So the alliance between practitioner and patient is essential.

And so in phase 2 of treatment, we move on to resolving the traumatic memories and developing a meaningful narrative of the past. It's about safely connecting with the past without being overwhelmed by it. So if we think about phase 1 as being able to tolerate the present, phase 2 is about being able to tolerate the past. And that comes with it all of the emotions and sensations. And this is where the parable of the two wolves really becomes relevant again.

Because oftentimes, traumatized individuals feel a lot of shame and guilt and anger over what happened to them, and those feelings served a purpose for that person. But what we want to do in phase 2 of treatment is help the individual, from a little bit of distance, look back on all of those feelings of shame, hurt, guilt, and empathize with themselves to help them appreciate that it's OK to feel hurt, that it's OK to be angry, and then it's OK to even feel ashamed because something was done to you without you asking. Those feelings are understandable and they served a purpose for you. They helped you be resilient and make it to today.

And so how do we look back and find empathy for that part of yourself? That's a big part of phase 2. It's not about going into the nitty-gritty details of the past trauma. It's about helping the person connect to it in whatever way is most meaningful and safe for them. And because we are going into the past in phase 2, it requires a really fine attunement between the patient and the therapist. Because if we rocket too fast into the past, that's going to trigger that stress response system and threaten the person from leaving treatment, or engaging in what we would call enactments, like substance use behavior or sexual promiscuity.

And we see this a lot for justice-involved individuals as well. Remember, trauma results in a loss of control. And so what we need to do in treatment is help people to feel like they have some sense of control and agency over what's happening to them. If we do things to that individual that strips them of that sense of control, we're triggering their unconscious stress response system, which is going to create behaviors, which, to us, look anti-therapeutic, or like they're violating probation or parole, or not meeting the expectations of the court. And then we end up responding to it with greater constriction and control over the individual, which furthers the traumatization and results in a downward spiral for that person. And so there really needs to be a lot of attunement.

And then the third phase of treatment is about consolidating gains, helping the individual now expand out of the treatment into the real world to feel safe engaging with others, trying new things, establishing appropriate supports in the community. And a lot of community-based treatment programs employ what are called WRAPs, or Wellness Recovery Action Plans. And these are really wonderful ways to help guide people towards the identifications of their risk factors for relapse, what a relapse might look like.

What do I need to be tuned into emotionally and in my external world that threatens retraumatization and all of the negative consequences that can happen thereafter? And so the WRAPs really help people establish a structured plan to stay healthy. And they're implemented quite widely within community treatment programs and they're often cited by folks who've gone through treatment, to me, as really instrumental in their healing process.

And so when we're also talking about establishing supports and engagement in the wider world, it helps to consider Bronfenbrenner's social ecological model. This has been adapted by the CDC to look like the image you see on your slide, where, when we really are focused on helping people heal, it's not just about the individual and it's not just about psychotherapy. There are all sorts of processes that can help them get better, particularly those that help activate the parasympathetic nervous system that's focused on rest and digest.

And things like yoga, mindful meditation, creative arts therapy, drama therapy, all of these activities and other adjunctive therapies can be instrumental in the healing process. And some can even be primary treatment interventions, particularly for people who really struggled to verbalize what their experience has been. And then moving out into the interpersonal world, it's about having social supports, people that you can trust and turn to when you're feeling stressed or overwhelmed.

And then going out even further, it's about having things in the community that the person can turn to, services, good schools that offer counseling, community programs that foster healthy engagement, sports, whatever it is that's meaningful for that individual. And then we can move out further and further to the way our society structures laws and helps to protect people and foster healing.

I like to think about it, again, using a metaphor, like a very, very blistering and sunny day. On that sunny day, you look for shade. And we can think of individual resources as one tree that offers shade. And then we can think about interpersonal resources as a second tree that's grown to offer additional shade. And community resources, that's a third tree. And social resources as a fourth tree, until eventually, we have enough trees up, so that when that individual is out walking on that hot, sunny day, they're not exposed to that blistering sun.

And in traumatized individuals, that's what we want to do, is create services as fully encompassing the individual's needs as possible. It's not just about psychotherapy. It's not just about court interventions, but it's about the full constellation. That's essential.

And so I'd like to wrap up just by, once again, thanking everyone for being here. The criminal justice system and the court system requires ideational engagement, thoughtful engagement, the ability to appropriately weigh pros and cons and engage in consequential thinking. And for traumatized individuals, particularly within the context of an adversarial system, which the courts are adversarial, it becomes increasingly difficult to do that.

Because conflict triggers the stress response because the person feels the need to remain safe on an unconscious level, and it makes it very difficult to engage ideationally in that process. And so I'm so heartened by the presence of everybody here, and I hope this is one part in your evolution towards being trauma-informed legal practitioners. And I hope this had some impact.

[APPLAUSE]

CHRISTINE EDWARDS: Anthony, would you suggest that the majority of the participants that we encounter in our mental health courts, as well as in many of our other problem-solving courts, have experienced traumatic events?

ANTHONY WATERS: So I think that a very safe, basic assumption is that everybody that we engage with in the court system has been exposed to some form of trauma. And traumatic exposure doesn't necessarily result in traumatization. Remember, like I referenced that rubber band that can stretch, even under extreme stress, even in an event that we may identify as a trauma, it doesn't necessarily result in the individual having those lasting consequences. And so it's safe to assume that an individual has been exposed to trauma. And it's really up to us to be curious and appropriate and genuine investigators to understand whether that traumatic exposure resulted in traumatization.

CHRISTINE EDWARDS: And what does someone do if they inadvertently trigger a traumatized person into a stress response?

ANTHONY WATERS: Ah. Well, in those moments, when somebody has been triggered, we're looking at an imbalance between their thoughtful self and their emotional self. Their stress response system has been activated. And it's important for us, when we see that powerful affect coming from that individual, that we don't respond by thinking, oh, it's an outsized reaction. Get that person away from me, or call in the security personnel, or whatever.

Instead, what we want to think of is, what's making this person feel unsafe right now? What's making them feel out of control right now? And what we want to do is begin by focusing on the emotions. Actively listen and empathize with the individual and allow the space for them to vent, so long that's safe. Because if we try to impose control on them in that moment, that's going to trigger their stress response up to the next level and things are going to escalate.

And what we want is to safely deescalate the individual out of this stress response system. And it begins with addressing the emotion, helping them feel safe enough with you and that they have the room to be able to vent. And by doing that, it's an unbelievable thing to see. Just by allowing the person to vent, sometimes you can see that the emotion goes down and the thoughtful side of themselves comes back up.

And then, once we see the thoughtful side emerge, we can begin to engage in problem-solving, but ideally, not until that point. Because if we try to engage in problem-solving, well, that's a thoughtfully mediated process and the person is emotionally mediated in that moment. And so we have to first start with the emotions.

CHRISTINE EDWARDS: And what suggestions would you have for us to become more trauma-informed?

ANTHONY WATERS: So we've heard a few times, and at least a couple of those were from me, that it's first about asking the question, what happened to you? Moving away from the, what's wrong with you, into the question of, what happened to you? And there are three main buckets that occur within trauma-informed care systems. They're about realizing the ubiquity of trauma, recognizing how trauma affects behavior, and then coming up with ways to respond to traumatized individuals that are trauma-informed and help the person feel safer in their environment.

There's a concept within the legal community called therapeutic jurisprudence, which shares a lot of commonalities with trauma-informed care models within the behavioral health system. And therapeutic jurisprudence identifies three V's, and those are voice, validation, and voluntariness. And what it means is that you allow the person to have a voice. It doesn't mean that they get to dictate what they do, but it means that they get to articulate what they're experiencing.

And validation is about validating that their experience is very real. And it doesn't mean that we necessarily validate bad behavior, but we can certainly validate the emotional experiences of the individual. And voluntariness means that we look for opportunities to give the person choice whenever possible.

A great way that that happens within the mental health field is, during a de-escalation when somebody is agitated and needs a psychotropic medication intervention, which we try to make as limited as possible, we can ask them, do you want to take the medication or would you like some other form, which might be injection? But you look for choice wherever you can, because choice gives that person a sense of control, power, and agency, and that's what we really try to build on within trauma-informed models.

CHRISTINE EDWARDS: We have time for a couple more questions.

AUDIENCE: If a veteran has been diagnosed with PTSD, would they be treated more fairly in a veteran's court or a mental health court? Which would be more appropriate?

ANTHONY WATERS: Boy, that's a-- yeah, so the question was, if a veteran has been diagnosed with PTSD, is the right place for them within the veteran's court or the mental health court? And that's a fantastic question. And I don't want to talk outside of my expertise, but I'll go back to something that judge Hirsch said this morning, which is that it's about advocacy and making the connections, making the direct advocacy to the various courts, and hopefully understanding, through that advocacy, what the best approach is for that particular client.

Everybody's means are going to be a little bit different. And it's about, from my perspective as a mental health practitioner, understanding what needs are primary for that individual and crafting interventions around those. So a question to ask might be, is the exposure to experiences in the military the primary driver of behavior, or is it something else?

CHRISTINE EDWARDS: Any other questions?

AUDIENCE: I just wanted to ask, is there any effort to bring families together, as far as investigating trauma that the whole family experiences, as a whole? Because I have criminal clients who may be 19 years old, adults in the system, but in the household, that they get out of jail, they get back to their home, and they have that experiences that are still going on in the home.

Or mother's affected, siblings are affected. It might lead him back out to the streets, or whatever. Have you seen a trend toward getting the family involved into addressing the trauma of that family at home?

ANTHONY WATERS: That's a great question. The question was, have there been efforts to incorporate families into interventions, rather than just the individual? Because it's often not just the individual that's in a traumatizing environment, but it might be really related to the family dynamics as well.

And there's a wonderful article in The New York Times from several months ago called "A Gun to His Head as a Child. In Prison as an Adult." And it really shows the intergenerational transmission of trauma. In the video-- in the article, there's a video that accompanies the article-- you can see how this man, who has been through the revolving door of the criminal justice system over and over again, but has a daughter who he loves very much, but because of his trauma history, she is being traumatized as well.

And so there is a need to make sure that we're addressing all of the systems that intersect with the individual to try to create improved outcomes. Within the behavioral health system, historically, we did a great job understanding the relevancy of trauma. And then we moved away from it and began focusing much more on the person's symptoms, and that's really based on the pathology model.

And then in recent years, the pendulum has begun swinging back in the other direction and we've become more and more aware of the relevancy of trauma in all aspects of life and the importance of creating systems and treatment interventions for the various aspects of that person's life that they intersect with, most prominently the family.

CHRISTINE EDWARDS: Are there any other questions?

AUDIENCE: I actually have a comment. I think, in my experience of volunteering and working with children, I have seen that trauma doesn't have to be the result of something negative. It can also be from something very positive. For example, someone can be a young adolescent and her mom gives birth to multiples, and the whole house becomes a complete different house, and her needs aren't addressed anymore, and she experiences a certain level of trauma, just as someone else who may have been someone neglected. And sometimes people don't realize that. They overlook trauma, thinking, oh, that's a great, stable home. There's no trauma over there.

CHRISTINE EDWARDS: So our colleague's comment was a wonderful illustration of how it's up to a person to determine whether or not an event is traumatizing. And what she talked about was how sometimes even positive events, at least events that look on the surface to be positive, can be experienced by somebody as traumatizing. And she gave the example of a child within a home where a parent just had multiple births.

And the child stopped getting the attention that he or she needed, and it was having consequences on that child's thoughts and behaviors and feelings. And so that really just hearkens back to our earlier discussion about how, in our definition of trauma, there were no events. And that's intentional, because it's up to the individual to determine what's traumatizing for them. What in their life had a lasting experience on their ability to cope?

CHRISTINE EDWARDS: You had a quick question?

AUDIENCE: I don't know if you have [INAUDIBLE] comment on, do you think there's enough training on de-escalation techniques in court personnel, corrections personnel? And if not, what do you think should be done? Because to me, the system is about control. So the exact thing that's triggering people is inherent [INAUDIBLE]

ANTHONY WATERS: So a colleague asked the question whether or not there is enough training within the court system around verbal de-escalation of emotional and behavioral crises. And I would say that, historically, the answer is no. There's been a recent movement to institute crisis intervention teams into law enforcement, both within policing and within corrections. And that's all about training folks on understanding mental illness and how to verbally de-escalate emotional crises.

And then about the question of other personnel within the legal system, that would be a little tougher for me to answer. But I would ask amongst the folks here, do you feel equipped to be able to imagine-- not imagine-- respond appropriately to an emotional crisis? And if the answer is no, then there probably hasn't been enough training.

CHRISTINE EDWARDS: Please join me in thanking Dr. Waters for his wonderful [INAUDIBLE]

[APPLAUSE]

ANTHONY WATERS: Thank you.

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