Trauma-Informed Care

1. Elizabeth Hudson, LCSW Consultant to the Dept. of Health Services, Division of Mental Health and Substance Abuse Services Elizabeth.Hudson@wisconsin.gov Trauma-Informed Care

2. Have you ever had a patient who was… • 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?

3. 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)

4. 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

5. 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

6. 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)

7. Unresolved Trauma is Common • Abuse: intentional / patterned • Accident: things happen • Contagion: impacted by others’ hurts • Oppression: institutional, systematic mistreatment of one group by another

8. Trauma Psychological Complex Historical Sanctuary Vicarious

9. 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)

10. Psychological Trauma - Examples • Violence in the home, personal relationships, workplace, 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

11. 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.

12. 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)

13. 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.

14. 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

15. 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.

16. 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: • 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)

17. 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%

18. ACEs Increase Risk Heart Disease Leading causes of death Chronic Lung Disease Liver Disease Substance abuse Adverse Childhood Experiences Suicide HIV and STIs Injuries

19. 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)

20. 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.

21. Massive Release of Stress Hormones • 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)

22. Simple Trauma Complex Trauma Trauma Complexity Continuum Adult-onset Single-incident Adequate child development No comorbid psychological disorders • Early onset • Multiple • Extended • Highly invasive • Interpersonal • Significant amount of stigma • Vulnerability (Bloom, 2009)

23. What is a Trigger? This Not This A conditioned response that happens automatically when faced with a stimuli associated with traumatic experiences

24. Triggers Simple Trauma Complex Trauma Seeing, feeling, hearing, 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 More reminders of past danger Brain is more sensitive to danger Interactions with others often serve as triggers

25. 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

26. Acting out vs. Acting in • External defense • Anger • Violence towards others • Truancy • Criminal acts • Internal defense • Denial, repression • Substance use • Eating Disorders • Violence to self • Dissociation

27. 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

28. 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

29. Guiding Values of Trauma-Informed Care“Healing Happens in Relationship”

30. 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

31. Importance of Boundaries • Being a friend “Thank you very much for your concern for my family, but my priority is to care for YOU.” • 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.

32. 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.

33. What do you do? • Relax • Appreciate she trusted you enough to disclose emotionally 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

34. 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)

35. 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

36. 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

37. Professional Resources • ACE Study.  The Centers for Disease Control and Prevention reports on the 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, weinrebl@ummhc.org. Dr. Weinreb has experience developing trauma-informed primary health care settings.

38. Resources for Patients • Gift from Within. A site for survivors of trauma and victimization. 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

39. References • Bloom, Sandra. Presentation for Center for Nonviolence and Social 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.