Elizabeth Hudson, LCSW

1
Trauma-Informed Care

• Elizabeth Hudson, LCSW
• Consultant to the Dept. of Health Services,
• Division of Mental Health and Substance Abuse
  Services
• Elizabeth.Hudson_at_wisconsin.gov

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
• Traumas 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 individuals (or familys)
  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 individuals 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 individuals 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 ones life are more
  fundamental layers. Underlying ones own
  individual trauma history is ones 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, Wisconsins 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
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
Trauma Complexity Continuum

• Simple Trauma

• Complex Trauma

• 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 CareHealing
Happens in Relationship
30
Understanding of Service Relationship

• Traditional
• Heirarchical staff / patient relationship
• The patient is seen as passive recipient of
  services
• The patients 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 patients 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. Lets 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
  clinicians 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 doctors 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
  doesnt 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 doesnt
  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_at_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.c
  fm
• 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.