Goals of Presentati on

1. The Psychological Effects of Trauma: Implications for Working with Homeless PopulationsBrian E. Lozano, Ph.D.Contributing Collaborator: Peter Tuerk, Ph.D.Ralph H. Johnson VA Medical CenterHomeless Outreach MeetingColumbia, SCJuly 23, 2014

2. Goals of Presentation To facilitate trauma-informed care with homeless populations through better understanding of: • Normal reactions to trauma • Genesis and maintenance of PTSD • Relation of trauma to homelessness • Barriers to service utilization • Approaches for overcoming barriers to service utilization • Effective treatment of PTSD

3. Psychological Trauma • What is your understanding of trauma and PTSD? • Psychological trauma stems from potentially traumatic events that overwhelm the usual methods of coping that give people a sense of control, connection, and meaning. • Exposure to trauma can severely change the way persons think about themselves and experience the world around them: safety, trust, benevolence, justice, sense of self.

4. NORMAL Post-Trauma Reactions (not pathological: 1-4 weeks) • Most people will experience trauma-related symptoms following exposure to trauma or series of traumas. But most people will get better with simple support, obtained from family, friends, and community. • Just because someone goes through something horrible doesn’t mean they need treatment. • Treatment is appropriate for those who still have problems 4-12 weeks later.

5. Posttraumatic Stress Disorder (PTSD) • PTSD is classified as an Anxiety Disorder in the DSM-IV. • Exposure to traumatic eventinvolving: • Real or perceived threat of life/injury to self/others AND • Intense fear, horror, or hopelessness • It is a complex disorder that can occur following extremely stressful or traumatic events (e.g., MVA, rape, natural disasters, combat exposure).

6. PTSD: DSM-IV Exposure to trauma results in: • Re-experiencing symptoms(at least 1) • Recurring intrusive thoughts, images, nightmares of trauma event • Severe anxiety in response to reminders of the event • Flashbacks • Avoidance symptoms(at least 3) • Avoidance of thoughts, feelings, conversations, or reminders related to event • Inability to recall important aspects of the trauma event • Emotional numbing/detachment, isolation, decreased interest in activities • Hyperarousal symptoms(at least 2) • Physiological reactivity when exposed to trauma reminders • Irritability/angry outbursts, difficulty falling/staying asleep, difficulty concentrating, exaggerated startle • Hypervigilance – constantly scanning people and surroundings

7. Prevalence of PTSD • General population • Men: 2% current; 4% lifetime • Women: 5% current; 10% lifetime (Kessler et al., 2005 -National Comorbidity Survey-Replication) • Veteran populations • US/Vietnam: 9% current; 19% lifetime (Dohrenwend, 2006) • US/Gulf War: 3-16% (Sutker et al., 1993; Wolfe et al., 1999) • US/Iraq & Afghanistan: 12-13% (Hoge et al., 2004)

8. Time Course of Post-trauma Reactions Trauma 1month 3months 6months 20years 40years Acute stress reaction Acute stress reaction Acute stress disorder Acute PTSD Chronic PTSD Delayed-onset PTSD

9. Rate of Recovery After Rape 94% 47% 42% 30 % 25%-15% % with PTSD Symptoms ? 3m Years W 9m 12m Data from Rothbaum et al., 1992

10. One Year Course: Type of Assault and PTSD *Month duration not met Foa, Hembree, and Dancu (2003)

11. Comorbidity with PTSD Anxiety • Nervousness (racing heart, muscle tension) • GI upset & other Physical Problems • Impaired Concentration & Memory that imitate organic problems • Sexual Dysfunction • Avoidance of previously enjoyable activities Panic Disorder • 3-4x more likely among persons with PTSD (Kessler et al., 1995)

12. Comorbidity with PTSD • Depression • Guilt / Self-Blame • Feelings of Worthlessness / low self-esteem • Loss of confidence • Problems with memory/concentration • Eating and Sleep Difficulties • Exacerbation of Physical Problems • Lack of Energy and Motivation • Isolation / withdrawal • Substance Abuse • Increased risk of alcohol and drug abuse/dependence • 2-4x more likely among persons with PTSD

13. Summary of Reactions to Trauma The majority of trauma victims recover with time. PTSD represents a failure of natural recovery. After one year, PTSD does not remit without treatment. PTSD is highly distressing and debilitating disorder.

14. Trauma, PTSD, and Homelessness • Among veterans, presence of a mental health disorder is the strongest predictor of homelessness following military discharge (Department of Veterans Affairs Office of the Inspector General, 2012). • PTSD was associated with 85% increased risk of recurrent homelessness among formerly homeless veterans (O’Connell et al., 2008). • Among women, those who served in the military were 3x more likely to experience homelessness (Gamache et al., 2003). • Homeless female veterans were 3x more likely to have received treatment for MST (Washington et al., 2011).

15. Trauma, PTSD, and Homelessness • In general population, trauma exposure and subsequent development of PTSD often occurs prior to becoming homeless (Goodman et al., 1991; North & Smith, 1992). • Homelessness presents increased risk of exposure to trauma (Perron et al., 2008; Williams & Hall, 2009). • Increased risk of criminal violence and nonviolent crime • Detachment from support systems • Along with comorbidity with substance use disorders there can be an increased tendency to engage in high-risk behaviors making one susceptible to trauma exposure (Fischer & Breakey, 1991).

16. Barriers to Service Utilization What are the most frequent barriers to service utilization that you have noticed? • Lack of awareness of resources • Overwhelmed by multiple comorbidities • Limited insight re: symptoms • Hopeless that situation can improve • Disagreement about target for intervention • Negative reporting experiences (particularly for sexual assault) • Guilt, shame, mistrust • Minimization of symptoms • FEAR • Ambivalence • Lack of awareness of resources • Limited resources available • Limited understanding re: trauma • Not enough time to address trauma • Disagreement about target for intervention • Difficulty coordinating across services • Discomfort with assessment of trauma Patient BarriersProvider / System Barriers

17. Overcoming Barriers to Service Utilization As health care providers, it is important for us to… • Maintain awareness of and routinely screen for trauma and related symptoms • Ensure privacy and confidentiality re: communications • Convey confidence in assessment and discussion re: trauma • Understand our own emotional state • Be able to tolerate emotional distress (within self and patients) • Focus on establishing positive rapport and trust • Be empathic and non-judgmental • Normalize reactions to trauma • Be mindful of physical space, body language, tone/volume of voice, and potential trauma-related triggers

18. Overcoming Barriers to Service Utilization As health care providers, it is important for us to… • Actively elicit patient’s concerns and perspective on symptoms • Communicate understanding through reflective listening • Respect and promote patient autonomy • Align with and emphasize patient’s values and strengths • Recognize that avoidance is normal – it’s a symptom and therefore expected! • Accept that repeated efforts at engagement will likely be needed • Communicate hope and confidence re: capacity to overcome challenges through treatment • At the very least, we can keep the door open!

19. Effective Therapy for PTSD • Prolonged Exposure(PE; Foa et al., 2007)and Cognitive Processing Therapy(CPT; Resick & Schnicke, 1996)– identified as front-line treatments (VA/DoD, 2010). • Institute of Medicine (2007) identifies exposure therapy as the only effective treatment for combat-related PTSD. • Randomized controlled trials demonstrate slightly more favorable outcomes for veterans in PE as compared with CPT (Steenkamp & Litz (2013).

20. What is Prolonged Exposure Therapy? Prolonged Exposure is a manualized, 90-min, weekly, treatment protocol that consists of the following major components: • Education regarding common reactions to trauma & detailed rationale for treatment. • Self-assessment of anxiety using subjective units of distress (SUDs). • Repeated in vivo exposure to situations avoided due to distress. • Repeated, prolonged imaginal exposure to traumatic memories followed by processing or discussion of the memories.

21. Clinical Outcomes: Prolonged Exposure for PTSD Self-rated PTSD Symptoms Self-rated Depression Symptoms PTSD Checklist (PCL) and Beck Depression Inventory-II (BDI) outcomes over the course of treatment (N = 65 OEF/OIF Veterans with PTSD).

22. Clinical Outcomes: Prolonged Exposure for PTSD Self-rated PTSD Symptoms Self-rated Depression Symptoms OEF/OIF Veterans

23. Clinical Outcomes: Prolonged Exposure for PTSD A quarter (25%) of treatment completers used mental health services once or not at all in the year following treatment. The need for mental health service utilization decreases by 50% for Veterans completing PE treatment (N=60)