By Maggie Bennington-Davis, MD

1. Maggie Bennington-Davis MD
The Neurobiology of Kindness

3. Care that is grounded in and directed by a
thorough understanding of the neurological,
biological, psychological and social effects of
trauma and violence on humans and is informed by
knowledge of the prevalence of these experiences in
persons who receive mental health services.
(NASMHPD, 2004)

4. 4
Effects of experience on the brain
Depend on:
 Single vs. repeated experience
 Age when experiences occurred
or began
 Agent – natural vs. human
 Nature of the experience –
accidental vs. purposeful
 Environmental supports
 Innate resilience
 Practice!

5. A responsive environment will
 Facilitate physiologic calm
 Avoid triggering the
fight/flight/freeze
response
 Encourage thinking,
problem-solving, decision-
making, flexibility
 KEEP EVERYONE SAFE
 These things apply to both
staff and those they are
serving

6. Neurobiology of Exposure to
Trauma and Violence
Neurobiology
of Thinking

7. What have we used the brain for?
100,000 years:
Homo Sapiens
Hunter/Gatherer
5,000 years:
Recorded history
Building civilization
250 years:
“Modern” civilization

8. Prefrontal Cortex (Thinking Part)
 Newest brain region in human development
 Thin outermost layer, behind your forehead
 4-5% of total brain mass
 Sets goals, plans ahead
 Controls impulses
 Solves complex problems
 Visualizes situations/images - creativity
 Helps with focus
 Can be strengthened (take your brain to the gym)

9. Here’s How the Brain Develops
 The brain needs safe experiences to live.
 It grows,
is “pruned”
and learns
 It forms
connectomes
50 trillion 1000 trillion 500 trillion

10. Here’s how it works and breaks:

11. Life and coping can affect
genes

12. “What's wrong with you?"
TO
“What happened to you?”
Change the question from…

13. The people we serve
 Have tremendous exposure to events (trauma)
especially as children
 that cause a wash of threat detection all the time
Those of us who serve them
 Have created ways of thinking about and perceiving
the people we serve and their behaviors and our
environments
 These patterns of thinking sometimes get in our way
 We must begin with ourselves!

15. The Adverse Childhood Experiences Study
(ACES)
 Largest study ever done examining effects of
adverse childhood experiences over one’s lifespan
(>17,000 people)
 Majority were >50 yo, white, and attended college
 Original study done in California
 www.acestudy.org

16. ACES Categories
 Recurrent physical abuse
 Recurrent emotional abuse
 Contact sexual abuse
 An alcohol and/or drug abuser in the
household
 An incarcerated household member
 Someone who is chronically depressed,
mentally ill, institutionalized, or suicidal
 Mother is treated violently
 One or no parents
 Emotional or physical neglect

17. ACES Results
Abuse:
 Emotional 10%
 Physical 26%
 Sexual 21%
Neglect:
 Emotional 15%
 Physical 10%
 Two-thirds had at least one ACE
 ACEs tend to occur in clumps
Household Dysfunction
 Mother treated
violently 13%
 Mental illness 20%
 Substance abuse 28%
 Parental separation or
 divorce 24%
 Household member
 imprisoned 6%

18. ACES Deadly Outcomes
 ACEs influence the likelihood of the 10 most common
causes of death in the U.S.
 With an ACE score of “0”, the majority of adults have
few, often none, of the risk factors for these diseases
 With an ACE score of 4 or more, the majority of adults
have multiple risk factors for these diseases or the
diseases themselves

19. Positive, linear correlation between ACEs
and health problems
 Smoking
 COPD
 Hepatitis
 Cardiac disease
 Diabetes
 Fractures
 Obesity
 Alcoholism
 Other substance abuse
 Depression
 Attempted suicide
 Teen pregnancy and teen
paternity
 Sexually transmitted
diseases
 Occupational health
 Poor job performance
Health
problems
# ACEs

20. Positive, linear correlation between ACEs
and Alcoholism
 High ACE score
predicts alcohol
abuse
 Higher yet
in people whose
parents abused
alcohol
 Self-perpetuating cycle
over generations
 The presence of alcohol
abuse in the family
increases the likelihood
of sexual and physical
abuse
Alcohol abuse &
dependence
# ACEs

21. Positive, linear correlation between ACEs
and suicide
 Depression affects
19 million Americans
 <25% have access to
treatment
 Depression is the leading
cause of disability in the
US
 Depression is the 4th
leading contributor to
“global burden of disease”;
by 2020, it will be the 2nd
leading contributor
 ACE score of 7
correlated with 51
fold increase in suicide
attempts in children and
adolescents
 ACE score of 7 correlated
with 30 fold increase in
suicide attempts in
adults
 Presence of emotional
abuse in the home is the
strongest correlate with
later depression
Suicide
# ACEs

23. Epinephrine (adrenalin)
Cortisol
Beta-endorphins
Hypervigilance
Action, not thought
Cognitive diminishment
Increased aggression
Loss of impulse control
Speechless terror

24. Stress Response to RECURRENT
THREAT
 Reset CNS: the hallmark is
HYPERVIGILANCE
 Brain awash in cortisol
 Traumatic re-enactment
 Aggression become chronic
 Dissociation is common
 Chronic hyperarousal interferes with cognitive clarity
 Loss of (or failure to develop) affect modulation
 Injury or inhibition of prefrontal cortex and
hippocampus Bloom, 2001

25. HYPERVIGILANCE…
 Changes the way you view the world – literally and
neurologically
Hypervigilance is an
enhanced state of sensory
sensitivity accompanied by
an exaggerated intensity of
behaviors whose purpose is
to detect threats.

26. Emotional Brain
(Restak, 1988)

27. Between Stimulus and Response
S Stimulus
Sensory Thalamus
(LeDoux, 1996)

28. Between Stimulus and Response
S Stimulus
Sensory Thalamus Amygdala
Very Fast
(LeDoux, 1996)

29. Your Brain Decides
 Your brain decides what it is going to do before the
signal gets to the “thinking” part of your brain
 Once you do become aware of what you are about to
do… you have very little time to change the impulse
 Your prefrontal cortex is responsible for impulse
control… “Cognitive Wedge”
 Impulse control furthermore requires language…
which becomes important later on, so hold that
thought!

30. Between Stimulus and Response
S Stimulus
Sensory Thalamus Amygdala
Cortex
Very Fast
SlowerHippocampus
Response
(LeDoux, 1996)

31. Once you are in threat status…
 The prefrontal cortex bows out quickly – and blood
flow and hormones make sure that it does (“thinking
can kill you”)
 Then you are in the hands of your limbic system:
amygdala, hippocampus, cingulate gyrus, orbital
frontal cortex, and insula: these then drive your
behavior
 The limbic system wants you to MOVE – away from
the threat and TOWARD safety (but mostly AWAY)

32. Threat
 Easily triggered (what triggers you…?)
 Diverts brain energy to the limbic system
 Activity at this point becomes primitive (F/F/F)
 Difficult in this moment to be self-aware
 Very likely in this moment to interpret things as
dangerous or bad – you will not take risks
 Hypervigilance is the poster child for
misinterpretation
 Constant threat causes allostatic load, and you
experience a chronic sense of threat and a lower
threshold for additional threat

33. Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
SlowerHippocampus
Response
Cortex
(LeDoux,
1996)

34. Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
Slower
Response
Cortex
Hippocampus
(LeDoux,
1996)

35. Play
In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and
Animal Emotions,
Oxford, New York

36. Play and Fear
In Panksepp JP (1998): Affective Neuroscience: The Foundation of Human and Animal Emotions,
Oxford, New York

37. Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
Slower
Response
Cortex
Hippocampus
Neuroregulatory
Intervention
Cognitive engagement
Psychopharmacology
Social /
Environmental
Intervention
(LeDoux,
1996)

38. What we see
 Disengagement
 Aggression and loss of impulse control in the face
of novel situations
 Immediate deterioration into power and control
struggles
 Aggression and fear in the context
of rule enforcement
 “Minor” events precipitating
catastrophic reactions

39. Cognitive Wedge: making the most
before emotions set in
Trigger Response
cognitive wedge
social/
environmental neuroregulatory
Intervention intervention

40. Taking your brain to the gym
Increase blood flow & use of the “thinking” brain
Strengthen pathways to the neocortex
Decrease reliance on the “primitive” brain
Hard wire new “habits”
Change predictions in novel situations

41. Working out the Brain – How?
Mindfulness and Meditation
Cognitive enhancement therapies
Cognitive behavioral therapies
Cognitive exercises
Physical exercises and body
movement
What works for YOU?

42. Changing gears a little…
 Physiologic changes during F/F/F…
 Increased heart rate
 Increased BP
 Increased respiration
 Do you run because you are afraid or are you afraid
because you run… (Kohut)

43. Stress Research from Jerusalem
 Ariah Shalev at Hadassah Medical School
 Survivors of suicide bombers
 Following ER treatment
 Those that do not develop stress symptoms are able
to decrease heart rate, calm, quiet their bodies
 Those that do develop stress symptoms still have
hyperarousal, high heart rates, high blood pressure
 Regulated states appear to be correlated with
decreased likelihood to develop stress
syndromes

44. How do you “center”
yourself?  Deep breath
 Notice internal
signals
 Think positive
thoughts
 Pay close attention to
the present
 Be aware of your own
experience as it
occurs
 Find your cognitive
wedge…

45. Goals of Treatment
•Maintain Regulating State; notice
the present
•Prevent Re-experiencing States:
stay in the thinking brain
•Use strategies to employ the
cognitive wedge
Saxe, 2001

46. Do you believe in Recovery?
 People will live up to your expectations
 Situations will unfold according to your expectations
 Your brain is very invested in your predictions coming
true – so you will do things unconsciously to ensure
that happens

47. Language and Vocabulary
claims
denies
refuses
noncompliant
alleges
failed

48. Physical Environments
 Have an impact on attitude, mood, and behavior
 Physical environment is the program as much as groups,
routines, and therapy
 Its manipulation by skilled staff becomes an essential
aspect of the educational process
 Strong link between physiologic state, emotional state, and
the physical environment
 Natural environment promotes increased dopamine, faster
healing, and less pain in surgical patients
 ACES have less impact if child is in natural environment
 Kids with ADD are more relaxed and focused in “green”
environments

49. Color matters (UBC, 2009) (Drunk Tank Pink – 1970s)
Creativity
Attention to
detail

50. What does YOUR environment say?

51. Triggers for violent events in mental health
treatment settings
 Enforcement of agency rules
 Perception of unfair treatment
 Waiting
 Anger about past experience in mental health
system
 Controlling, restrictive environment
 Shame and humiliation
 Crowding
 Boredom

52. Alternatives to Coercion
 Choices (choice relax the threat alarm)
 Prediction/routine (information and no surprises)
 Navigators with lived experience
 Individual Safety Plans
 Triggers
 Early Warning signs
 Strategies
 Preferences
 Practice!

53. Lived Experience – Been There,
Done That
 Learning from those who
have been through the
system
 System navigators
 Role models
 Glimpse of what could be
 Hope!

54. Coercion… overt and covert
Microaggressions
 Visible or audible keys on staff
 Rules, rules, rules
 Strip searches
 Directive staff language
 Taking personal property
 Privileges
 Invasive security checks and level checks
 Demanding explanations
 Insisting on participation
 Asking intimate questions without context of
relationship

55. On Stage:
Treating each other well
 How staff treat each other is not a secret
 How staff treat each other has an impact on those they
serve
 How staff treat each other sets the cultural norm
 Respect is contagious

56. Parallel Process
 Collective disturbance
 We do unto others as is done to us
 Coercion is infectious
 So is respect
 Response to organizational trauma
 Hypervigilance
 Easily triggered
 Sense of community
 Cultural norms
 Deep democracy: having a voice

57. SAFE!
Control
Respect
Influence
Information
Reassurance
Inclusion
Hopefulness

58. Celebration and Support:
Engagement of staff members
 Discover small victories
 Public recognition
 Celebrate milestones
 Set people free to be creative
 Leaders accountable for challenges
 Promote interactions among staff
 Staff credited with successes
 Create a culture of giving

59. Five Squirrels
 Donald Geisler 2005. “Meaning from Media: the Power
of Organizational Culture”. Organization
Development Journal 23 (1): 81-83.

60. Suggestions for further
reading
 www.sanctuaryweb.com (Sandra Bloom’s website)
 “Creating Sanctuary”, “Destroying Sanctuary”, and “Restoring
Sanctuary” by Sandra Bloom
 “Restraint and Seclusion: the Model for Elimination of their Use in
Healthcare”
 Murphy and Bennington-Davis
 “The boy who was raised as a dog” & “Born for Love”
 Bruce Perry & Maia Szalavitz
 “Trauma systems theory”
 Glenn Saxe
 Anything by Bessel Van der Kolk
 SAMHSA website “trauma informed care”
 “Your Brain At Work” – David Rock