30. 11. 2018 1 Psychotrauma and Intellectual Disabilities Thomas Spaett Psychologist, Psychogerontologist, Paramedic International Aspects on Special Education Masarikova Univerzita Brno 08.11.2018 Lehrstuhl für Sonderpädagogik IV Pädagogik bei geistiger Behinderung 30. 11. 2018 2 Intellectual Disabilities and (traumatic) stress Part 1 Psychological Trauma A vital experience of discrepancy between threatening situational factors and individual coping strategies, which is related to feelings like helplessness and unprotected abandonment and therefore causes a permanent destabilization of the way somebody sees himself and the world. (Fischer & Riedesser 2009) 30. 11. 2018 3 Multifactorial model Event Severity of the trauma, unexpectedness, controllability Posttraumatic psychological processes Intrusions, hyperarousal, avoidance/ freezing dissociation Disorder Acute distress, PTSD … Restabilization Recreation, posttraumatic growth Positive Sense for coherence, social support, coping strategies Negative Age, experiences, psychological disorders, socioeconomic status time Traumatic situations People with ID have a very high risk of experiencing traumatic situations because of • (emotional) neglect • Abuse and experience of violence • Sexual abuse (especially in institutional care) • social exclusion, isolation and stigmatization • In connection with medical treatments (psychological and sensory factors) • Experience of ID as trauma People with ID are more sensitive to stress in daily life and changes. They experience multiple traumata far more often. 30. 11. 2018 4 Personal Risk factors People with ID have a more limited spectrum of coping strategies • Limited linguistic skills (e.g. describing symptoms, pushing through wishes) • Limited abstraction capability (e.g. in or to new situations) • Problems ad distress in situations, which seems little complex for people without ID • People with ID have difficulties to express – especially strong - emotions • Introspection is often connected to negative emotions • Often additional physical, psychiatric or sensory disabilities Environmental risk factors Often there is a „being hindered“ next to „being disabled“ because of e.g. • Unfavorable social environment (e.g. few close friendships, often changing caregivers) • Unfavorable living environment (e.g. living in an institution, overprotection); supports passivity and dependence • Few material resources (e.g. limited/no income, difficult availability of existing resources) • Failure of professional supporting systems (e.g. wrong interpretation of traumatic symptoms, bad medical care) 30. 11. 2018 5 Posttraumatic changes 1. constriction: avoidance/ freezing 2. Intrusion: remembering 3. Hyperarousal 4. Others like – Dissociation – Disorder of regulating affects Traumatic stress disorder and ID • Similar symptoms, but often subsyndromal • Seldom conscious remembering of the traumatic situation • Traumatic situations are seldom reported to others • Mostly there can be observed changes in the behavior (e.g. sleeping or leisure behavior, Recognition of triggering situation) • Often no connection between a traumatic situation and the psychological consequences recognizable Often the structure of personal and objective conditions is too complex to be perceived consistently 30. 11. 2018 6 Challenging behavior • Aggressions • Auto aggressions • Depressive behavior • Autistic behavior • Disturbed attachment behavior • … Many behavioral problems must not be seen just as specific for the disability. Often they may be or are the consequence of an earlier traumatization. Intervention Part 2 30. 11. 2018 7 General • Generally there are no other rules for intervention on people with ID • More individualized course of action is needed • Stronger cooperation and inclusion of attachment persons is necessary, e.g. through: – Consultation – Psychoeducation – Clarification of the living environment • Attachment persons are part of the social net, but as well part of the (burdened) system with own perception and interests Acute intervention • Have an eye on the different rules of communication with people with ID, take complete situation into consideration • Avoid paternalism (more giving impulses to think about or do something) • Observe problematic behavior, arrange therapeutical intervention in a hospital in case of danger or severe hyperarousal • Inform important persons and come to agreements concerning collaboration, consider external support • Plan help on a long-term perspective • Maybe acting vicarious 30. 11. 2018 8 Excursus: Pyramid of safety safety stability process event, cope place in biography time Long-term intervention (1) • Stabilization (fundamental) – Creation of the relationship – Lead to comfortable, positive, relief environmental conditions – Physical stabilization • Special trauma therapy – Psychotherapeutic processes – Close collaboration between therapist and attachment persons necessary • Rehabilitation and reintegration 30. 11. 2018 9 Long-term Intervention (2) • Protection from and avoidance of trigger situations; prevention of retraumatization • Reduce of stress in case of poor or missing individual coping and regulation strategies • Reframing: „reinterpreting“ of situations • Biography work Sources (selection) Weber Germain & Rojahn Johannes (2009). Intellektuelle Beeinträchtigung. In: Schneider Silvia & Margraf Jürgen. Lehrbuch der Verhaltenstherapie. Berlin: Springer. Meyer Hermann (2003). Geistige Behinderung – Terminologie und Begriffsverständnis. In: Irblich Dieter & Stahl Burkhard (Hrsg.). Menschen mit geistiger Behinderung. Göttingen: Hogrefe. Irblich Dieter (2006). Posttraumatische Belastungsstörungen bei Menschen mit geistiger Behinderung. In: Geistige Behinderung 45, 1/2006, 112-123. Senckel Barbara (2008). Wunden, die die Zeit nicht heilt. Trauma und geistige Behinderung. In: Geistige Behinderung 47, 3/2008, 245-256 Stahl Sabine (2012). So und so. Beratung für Erwachsene mit so genannter geistiger Behinderung. Marburg: Lebenshilfe. Wüllenweber Ernst (2009): Krisen und Behinderung – Entwicklung einer praxisbezogenen Theorie zum Verstehen von Krisen und eines Handlungskonzeptes für die Krisenintervention bei Menschen mit geistiger Behinderung und bei Autismus. Hamburg: Elbe Werkstätten Verlag: