Transcript Trauma-Informed Care

Trauma-Informed Care
Elizabeth Hudson, LCSW
Consultant to the Dept. of Health Services,
Division of Mental Health and Substance Abuse Services
[email protected]
Have you ever had a patient who was…
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irritable or hostile?
avoidant of medical appointments?
chronically poor in self-care health habits?
exhibiting confusion or poor memory when being interviewed about
health?
stoic and reluctant to admit to health problems, or extremely needy
and/or demanding?
more likely to present in emergency than for regularly scheduled
appointments?
presenting with a history of alcohol/substance abuse, depressive
symptoms, chronic relationship difficulties and/or intermittent
employment history?
problems with pain perception, pain tolerance and chronic pain
syndrome?
You Are Not Alone!
 Patients with histories of trauma are likely to present to primary care
with some (or many) of these characteristics.
 Their behavior can interfere with patient-provider communication,
impede compliance with treatment regimens, and generally, frustrate
the practitioner.
 More importantly, these patients are at high risk for deteriorating health.
Most people who have experienced traumas do
not seek mental health services. Instead, they
look for assistance and care in the primary care
setting.
(Adapted from Dept.of Veteran Affairs, PTSD: Implications for Primary Care)
Take Home Message
 Trauma is pervasive
 Trauma’s impact is broad, diverse and often life-shaping
 Health educators and providers can prevent retraumatization:
Do No Harm
 Health educators and providers can have a healing effect:
Healing Happens in Relationship
Trauma-Informed Services…
 incorporate knowledge about trauma – prevalence, impact,
and recovery – in all aspects of service delivery
 minimize re-victimization
 facilitate recovery and empowerment
Roger Fallot, Wisconsin Trauma Summit, 2007
Trauma
 Overwhelming experience
 Involves threat
 Results in vulnerability and loss of control
 Leaves people feeling helpless and fearful
 Interferes with relationships and fundamental beliefs
(Herman, 1992)
Unresolved Trauma is Common
 Abuse: intentional /
patterned
 Accident: things happen
 Contagion: impacted by
others’ hurts
 Oppression: institutional,
systematic mistreatment of one
group by another
Trauma
Psychological
Complex
Historical
Sanctuary
Vicarious
Psychological Trauma
Refers to the individual’s (or family’s) perception of
significant events or circumstances, past or present.
These events or circumstances may result in a cluster
of symptoms, adaptations, and reactions that
interfere with the individual’s functioning.
(Modified from Report from Wisconsin Trauma Summit, 2007)
Psychological Trauma - Examples
 Violence in the home, personal relationships, workplace,
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school, systems/institutions, or community
Maltreatment or abuse: emotional, verbal, physical, sexual,
or spiritual
Exploitation: sexual, financial or psychological
Change in living situation such as eviction or move to nursing
home
Neglect and deprivation
War or armed conflict
Natural or human caused disaster
Complex Trauma
Result of traumatic experiences that are interpersonal, intentional,
prolonged and repeated. Often leads to immediate and long-term
difficulties in many areas of functioning.
Historical Trauma
Historical trauma is the
cumulative emotional and
psychological wounding over the
life span and across generations,
resulting from trauma experienced by
the individual’s social group.
Historical trauma generates such
responses as survivor guilt,
depression, low self-esteem,
psychic numbing, anger, victim
identity, preoccupation with
trauma, and physical symptoms.
(Brave Heart, 2005)
Sanctuary Trauma
The overt and covert traumatic
events that occur in mental
health and other human service
settings.
These events are distressing,
frightening, or humiliating.
People (consumers and staff)
who are exposed to sanctuary
trauma may experience a cluster
of symptoms and reactions that
interfere with functioning.
Trauma occurs in layers, with each layer affecting every
other layer. Current trauma is one layer. Former traumas in
one’s life are more fundamental layers. Underlying one’s
own individual trauma history is one’s group identity or
identities and the historical trauma with which they are
associated.
--- Bonnie Burstow
Statistics, or “How bad is it, really?”
 Domestic violence is the #1 cause of death for African-
American women aged 15-34
 In the US, approximately 1.5 million women and 834,700
men are raped and/or physically assaulted by an intimate
partner each year
 56% of adult sample reported at least one event (Kessler et
al., 1995)
 In 2005, Wisconsin’s CPS reported 8,148 substantiated
cases of child maltreatment and an additional 2,590
cases that were likely to have occurred.
Adverse Childhood Experiences (ACE) Study
The ACE Study identifies ‘adverse childhood experiences’ as growing
up (prior to 18 years of age) in a household with:
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Recurrent physical abuse
Recurrent emotional abuse
Sexual abuse
An alcohol abuser
An incarcerated household member
Someone who is chronically depressed, suicidal, institutionalized or mentally ill
Mother being treated violently
One or no parents
(Felitti et al., 1998)
ACEs are common in this middle class
 Substance Abuse 27%
 Parental Separation/Divorce 23%
 Mental Illness 17%
 Battered Mother 13%
 Criminal Behavior 6%
 Psychological Abuse 11%
 Physical Abuse 28%
 Sexual Abuse 21%
 Emotional Neglect 15%
 Physical Neglect 10%
ACEs Increase Risk
Heart Disease
Leading causes
of death
Substance
abuse
Chronic Lung
Disease
Adverse Childhood
Experiences
Liver Disease
Suicide
HIV and STIs
Injuries
Impact of Trauma Over the Life Span
ACE Study - effects are neurological,
biological, psychological and social in
nature, including:
 Changes in neurobiology
 Social, emotional and cognitive
impairment
 Adoption of health-risk behaviors as
coping mechanisms
 Severe and persistent behavioral
health, physical health, social
problems, and early death
(Felitti)
The Stress Response
 If there is no danger, the
doing brain goes back to
normal functioning.
 If there is danger the
thinking brain shuts down,
allowing the doing brain to
act.
Massive Release of Stress Hormones
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Increase HR and blood pressure
Blood sugar increases
Increased blood clotting
Tunnel vision
Event recorded in “high definition”
Increased cholesterol
Pain sensation dulled – natural morphine (endorphins)
Increased alertness, increased focus
Insulin increases
Memory loss from parts of the event
Increased strength, energy, aggression
Hearing may shut down
Time slows down or speeds up
(Susan A. Storti, 2008)
Trauma Complexity Continuum
Simple Trauma
Complex Trauma
 Adult-onset
 Early onset
 Single-incident
 Multiple
 Adequate child
 Extended
development
 No comorbid psychological
disorders
 Highly invasive
 Interpersonal
 Significant amount of
stigma
 Vulnerability
(Bloom, 2009)
What is a Trigger?
This
A conditioned response
that happens
automatically when faced
with a stimuli associated
with traumatic
experiences
Not This
Triggers
Simple Trauma
Complex Trauma
 Seeing, feeling, hearing,
 More reminders of past
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smelling something that
reminds us of past trauma
Activate the alarm system
The response is as if there is
current danger
Thinking brain automatically
shuts off in the face of
triggers
Past and present danger
become confused
danger
 Brain is more sensitive to
danger
 Interactions with others
often serve as triggers
Common Triggers
 Reminders of past events
 Lack of power/control
 Separation or loss
 Transitions and routine/schedule disruption
 Feelings of vulnerability and rejection
 Feeling threatened or attacked
 Sensory overload
Acting out
 External defense
vs.
Acting in
 Internal defense
 Anger
 Denial, repression
 Violence towards others
 Substance use
 Truancy
 Eating Disorders
 Criminal acts
 Violence to self
 Dissociation
Impact of Trauma on World View
 The world is unsafe place to live in
 Other people are unsafe and cannot be trusted
 My own thoughts and feelings are unsafe
 I expect crisis, danger and loss
 I have no self-worth and no abilities
Trauma-Informed Services…
 incorporate knowledge about trauma – prevalence, impact,
and recovery – in all aspects of service delivery
 minimize re-victimization
 facilitate recovery and empowerment
Roger Fallot, Wisconsin Trauma Summit, 2007
Guiding Values of Trauma-Informed Care
“Healing Happens in Relationship”
Understanding of Service Relationship
Traditional
 Heirarchical staff / patient relationship
 The patient is seen as passive recipient
of services
 The patient’s feelings of safety and trust
are taken for granted
Trauma-Informed
 A collaborative relationship between
the patient and the provider of her / his
choice
 Both the patient and the provider are
assumed to have valid and valuable
knowledge bases
 The patient is an active planner and
participant services
 The patient’s safety must be guaranteed
and trust must be developed over time
Importance of Boundaries
 Being a friend
“Thank you very much for your concern for my family, but my priority is to care forYOU.”
 Being a rescuer
“It sounds like there are several issues that we need to address. Because we only have 20
minutes for our visit today, we will not be able to address them all in one visit. Let’s identify
the two highest priority items that you want to be sure we cover today, and then schedule a
follow-up visit so we can continue working through this list of important issues.”
 Seeking a sexual relationship
“My code of ethics does not allow me to enter into a romantic relationship with a patient. It
is a very strict rule. However, I would like to continue working with you professionally
around your medical problems.Will you be comfortable with that?”
Remember that the patient is coping in the best way he/she knows how,
and may need the clinician’s help to begin to learn new patterns of
interaction.
Complex trauma presentation in
primary care - Example
 Significant emotional distress
 Health risk behaviors
 Substance abuse, high risk sexual behavior
 Chronic pain and increased risk of physical injury and difficulty with pain
management
 Poor medical treatment compliance
The person discloses she was recently in a car accident and she is
having nightmares about familial abuse growing up as a child.
What do you do?
 Relax
 Appreciate she trusted you enough to disclose emotionally
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painful material
Provide psychoeducational materials (see end of presentation
for resources)
Encourage activities that are self-soothing – meditation,
yoga, vigorous exercise, writing
Promote as much mastery and self-help as possible
Write down any medical instructions – assume that under
stress people are not talking in all the information they need
General Tips
 Think about the possibility of trauma as underlying problem – helps to
diminish frustration
 History of physical violations may create hypersensitivity about physical
exams and being at the doctor’s office– involve the patient, help them
feel in control
 Recognize issue of trust and betrayed trust will be a major, ongoing issue
 If you cannot understand why someone does or doesn’t do something
that seems to be common sense, be curious
(Bloom, 2009)
More Tips
 Consider saying something like this when asking about a
trauma history, “At some point in their lives, many people have
experienced extremely distressing events such as combat, physical or
sexual assault, or a bad accident. Have you ever had any experiences
like that?”
 Make no assumptions about how a person has been affected
by what seems to be a traumatic event – ask
 If you learn about a trauma history, it doesn’t mean you have
to fix it
Intervention Goals
 Break silence about trauma and abuse
 Shift blame from survivor
 If relevant, establish short term safety plan
 Patient given control and choice
 Contextualize and normalize the experience
 Validate coping strategies
 Integrate trauma factors in how you conceptualize and
address problems
 Maintain positive relationship
 Offer referrals for services
Professional Resources
 ACE Study. The Centers for Disease Control and Prevention reports on the
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Adverse Childhood Experiences (ACE) Study - one of the largest investigations
ever conducted on the links between childhood maltreatment and later-life
health and well-being. www.cdc.gov/nccdphp/ace
National Center for Posttraumatic Stress Disorder, http://www.ncptsd.org
National Child Traumatic Stress Network, http://www.nctsn.org
The National Working Group on Evidence-Based Health
Care. www.evidencebasedhealthcare.org.
Linda Weinreb, M.D., Vice Chair and Professor Dept. of Family Medicine and
Community Health University of Massachusetts Medical School/UMass
Memorial Health Care, [email protected]. Dr. Weinreb has experience
developing trauma-informed primary health care settings.
Resources for Patients
 Gift from Within. A site for survivors of trauma and victimization.
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www.giftfromwithin.org
Healing Self Injury provides information about self-inflicted violence
and a newsletter for people living with SIV– The Cutting
Edge. www.healingselfinjury.org
National Center for Posttraumatic Stress Disorder,
http://www.ncptsd.org
National Child Traumatic Stress Network, http://www.nctsn.org
Sidran Institute. For Survivors and Loved Ones – printable handouts.
http://www.sidran.org/index.cfm
WCADV. Works to prevent and eliminate domestic violence.
http://www.wcadv.org
WCASA. Works to ensure that every sexual assault victim in Wisconsin
gets the support and care they need. http://www.wcasa.org
References
 Bloom, Sandra. Presentation for Center for Nonviolence and Social
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Justice, School of Public Health, Drexel University. February, 2009.
Burstow, Bonnie. The Trauma Healing Project,
www.healingatttention.org.
Department of Veterans Affairs, Post-Traumatic Stress Disorder:
Implications for Primary Care, Independent Study Course, March
2002.
Fallot, Roger. Community Connections.
The National Center on Family Homelessness.