Trauma Informed Care An Overview Nurse Educator MHAID

Trauma Informed Care An Over-view Nurse Educator MHAID Service Southern DHB

Over-view • • Definitions Prevalence Impact of Trauma Informed Care Resiliency References Resources

What is trauma A traumatic event is one in which a person experiences (witnesses or is confronted with): • Actual or threatened death • Serious injury • Threat to the physical integrity of self or another

What is trauma “Prolonged exposure to repetitive or severe events such as child abuse, is likely to cause the most severe and lasting effects. ” “Traumatisation can also occur from neglect, which is the absence of essential physical or emotional care, soothing and restorative experiences from significant others, particularly in children. ” (International society for the study of Trauma and Dissociation, 2009)

Responses to a traumatic event may include • • Intense fear Helplessness Horror Attachment

Interpersonal trauma? • Interpersonal violence tends to be more traumatic than natural disasters because it is more disruptive to our fundamental sense of trust and attachment, and is typically experienced as intentional rather than as “an accident of nature. ” (International society for the study of trauma and dissociation, 2009)

Attachment • Genes have little to do with Attachment • Temperament and attachment are independent! • Attachment patterns are solely built by experience L. Alan Sroufe, et al “The Development of the Person, ” 2005. • In every culture, healthy relationships are contingent on relational interactions

ACE Study (Adverse Childhood Events) 2010 • CDC and Kaiser Permanente Collaboration (USA). • Over a decade long. 17, 000 people involved. • Looked at effects of adverse childhood experiences over the lifespan. • Largest study ever done on this subject

HMO Members in ACE Study • 80% White, including Hispanic • About 50% men, 50% women • 10% Black • 74% had attended college • 10% Asian • 62% age 50 or older

Adverse Childhood Experience* Categories (Birth to 18) ACE Abuse of Child • Emotional abuse • Physical abuse • Contact Sexual abuse Trauma in Child’s Household Environment • Alcohol and/or Drug User • Chronically depressed, emotionally disturbed or suicidal household member • Mother treated violently • Imprisoned household member • Not raised by both biological parents (Loss of parent – best by death unless suicide, - Worst by abandonment) • • Neglect of Child Physical neglect Emotional neglect * Above types of ACEs are the “heavy end” of abuse. *1 type = Impact of Trauma and Health Risk Behaviors to Ease the Pain Long-Term Consequences of Unaddressed Trauma (ACEs) Neurobiologic Effects of Trauma Disease and Disability • • • Disrupted neuro-development Difficulty controlling anger-rage Hallucinations Depression - other MH Disorders Panic reactions Anxiety Multiple (6+) somatic problems Sleep problems Impaired memory Flashbacks Dissociation Health Risk Behaviors • • • Smoking Severe obesity Physical inactivity Suicide attempts Alcoholism Drug abuse 50+ sex partners Repetition of original trauma Self Injury Eating disorders Perpetrate interpersonal violence • • • Ischemic heart disease Cancer Chronic lung disease Chronic emphysema Asthma Liver disease Skeletal fractures Poor self rated health Sexually transmitted disease HIV/AIDS Serious Social Problems • • Homelessness Prostitution Delinquency, violence, criminal Inability to sustain employment Re-victimization: rape, DV, bullying Compromised ability to parent Negative alterations in self perceptions and relationships with others • Altered systems of meaning • Intergenerational trauma • Long-term use of multiple human service systems

Adverse Childhood Experiences ACE Categories (Birth – 18) Abuse of Child • Emotional Abuse • Physical Abuse • Contact Sexual Abuse Neglect of Child • Physical Neglect • Emotional Neglect Trauma in Child’s Household/Environment • Alcohol and/or Drug user • Chronically depressed, emotionally disturbed or suicidal household member • Mother treated violently • Not raised by both biological parents. (Loss of parent – best by death, unless suicide. – Worst by abandonment)

Adverse Childhood Experiences are Common Of the 17, 000 HMO Members: • 1 in 4 exposed to 2 categories of ACEs • 1 in 16 was exposed to 4 categories. • 22% were sexually abused as children. • 66% of the women experienced abuse, violence or family strife in childhood. • Women were 50% more likely than men to have experienced 5 or more ACEs

ACE Study Findings • Childhood experiences are powerful determinants of who we become as adults.

Impact of Trauma and Health Risk Behaviours to Ease the Pain Neurobiologic Effects of Trauma • • • Disrupted neuro-development Difficulty controlling anger-rage Hallucinations Depression – other MH disorders Panic reactions Anxiety Multiple (6 +) somatic problems Sleep problems Impaired memory Flashbacks Dissociation Health Risk Behaviours • Smoking • Severe obesity • Physical inactivity • Suicide attempts • Alcoholism • Drug abuse • 50 + sex partners • Repetition of original trauma • Self injury

Long-term Consequences of Unaddressed Trauma (ACEs)_ Disease and disability • Ischemic heart disease • Cancer • Chronic lung disease • Chronic emphysema • Asthma • Liver disease • Skeletal Fracture • Poor self rated health • Sexually transmitted disease • HIV/AIDS Serious Social Problems • Homelessness • Prostitution • Delinquency, violence, criminal • Inability to sustain employment • Re-victimisation: rape, violence • Compromised ability to parent • Negative alterations in self perceptions and relationships with others • Altered systems of meaning

The higher the ACE Score, the greater the likelihood of : • • • Severe and persistent emotional problems Health risk behaviors Serious social problems Adult disease and disability High health, behavioral health, correctional and social service costs • Poor life expectancy

Health Consequences of Early Life Trauma Vincent Felitti, M. D. , • Health in all domains is related to childhood experience • Health risks: – Stroke – Heart disease – Depression and suicide – Substance abuse – Smoking

Childhood Experiences vs. Adult Alcoholism 4+ 3 2 1 0

Childhood Experiences Underlie Chronic Depression

Childhood Experiences Underlie Suicide 4+ 3 2 0 1

Emotional Problems • Childhood experiences underlie Chronic depression • Childhood experiences underlie suicide § 2/3 rd (67%) of all suicide attempts § 64% of adult suicide attempts § 80% of child/adolescent suicide attempts Are attributable to Childhood Adverse Experiences

Positive Stress • Moderate, short-lived physiological response – Increased heart rate, higher blood pressure – Mild elevation of stress hormone, cortisol , levels • Activated by: – Dealing with frustration, meeting new people (National Scientific Council on the Developing Brain, Harvard University 2006)

Tolerable Stress • Physiological responses large enough to disrupt brain architecture • Relieved by supportive relationships: – that facilitate coping, – restore heart rate and stress hormone levels – reduce child’s sense of being overwhelmed Activated by: – Death of loved one, divorce, natural disasters (National Scientific Council on the Developing Brain, Harvard University 2006)

Toxic Stress • Strong & prolonged activation of stress response systems in the absence of buffering protection of adult support – Recurrent abuse, neglect, severe maternal depression, substance abuse, family violence – Increased susceptibility to cardiovascular disease, hypertension, obesity, diabetes and mental health problems

Institutionalization and Neglect of Young Children Disrupts Their Body Chemistry 35% Percent of Children with Abnormal Stress Hormone Levels 30% 25% 20% 15% 10% 5% Middle Class US Toddlers in Birth Families Source: Gunnar & Fisher (2006) Neglected/Maltreated Toddlers Arriving from Orphanages Overseas

PTSD • PTSD is the only diagnostic category in the DSM that is based on etiology. • In order for a person to be diagnosed with PTSD, there had to be a traumatic event. • Because most diagnoses are descriptive and not explanatory they focus on symptoms or behaviours without a context: they do not explain how or why a person may have developed those behaviours (e. g. to COPE with traumatic stress).

TRAUMA For the purposes of identifying trauma and its adaptive symptoms, it is much more useful to ask “What HAPPENED to this person” rather than “What is WRONG with this person”.

Types of Trauma: Acute Trauma • Acute trauma is a single traumatic event that is limited in time. Examples include: • Serious accidents • Community violence • Natural disasters (earthquakes, wildfires, floods) • Sudden or violent loss of a loved one • Physical or sexual assault (e. g. , being shot or raped) • During an acute event, people go through a variety of feelings, thoughts, and physical reactions that are frightening in and of themselves and contribute to a sense of being overwhelmed.

Acute Response To Trauma Terror Normal with supports Fear Vulnerable “with supports” Alarm Vigilance Vulnerable few supports Dissociation or Resilient Calm Traumatic Event

Types of Trauma: Chronic • Chronic trauma refers to the experience of multiple traumatic events. • These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war. • The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact.

Types of Trauma: Complex • Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child. • Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age. • Complex trauma has profound effects on nearly every aspect of a child’s development and functioning.

Additional Sources of Stress • Children in the child welfare system frequently face other sources of ongoing stress that can challenge workers’ ability to intervene. Some of these sources of stress include: • Poverty • Discrimination • Separations from parent/siblings • Frequent moves • School problems • Traumatic grief and loss • Refugee or immigrant experiences

The impact of a potentially traumatic event depends on several factors, including: – The child’s age and developmental stage – The child’s perception of the danger faced – Whether the child was the victim or a witness – The child’s relationship to the victim or perpetrator – The child’s past experience with trauma – The adversities the child faces following the trauma – The presence/availability of adults who can offer help and protection

Impact of Trauma on Child Development • Physical and Neurodevelopment • Psychosocial and Relational Development

Developmental Factors • Chronic early trauma – starting when the individual’s personality is forming – shapes a child’s (and later adult’s) perceptions and beliefs about everything. • Severe trauma can have major impacts on the course of life. • Childhood trauma can cause the disruption of basic developmental tasks.

Disruption of Developmental Tasks Survivors of childhood trauma can have mild – several deficits in abilities such as: • Self soothing • Seeing the world as a safe place • Trusting others • Organised thinking for decision making • Avoiding exploitation Disruption of these tasks in childhood can result in adapted behaviour, which may be interpreted as “symptoms: ” • Disrupted self-soothing can be labelled as agitation • The disrupted ability to see the world as a safe place looks like paranoia • Distrust of others can be interpreted as paranoia (even when based on experience) • Disruptions' in organised thinking for decision making appears as psychosis • Avoiding pre-empting exploitation is called selfsabotage.

Exposure to Trauma – General Population • Until fairly recently, trauma exposure was thought to be unilaterally rare (combat violence, disaster trauma) (Kessler et al, 1995) • More recent research has changed this and studies completed indicate that trauma exposure is common across all demographics • 56% of a general population adult sample reported at least one event (National Executive Training Institute NETI 2005)

Prevalence of Trauma – Mental Health Population • 90% of mental health clients have been exposed (Muesar et al. , 1998) • Most have multiple experiences of trauma • 34 – 53% report childhood sexual or physical abuse (kessler et al. , 1995) • 43 – 81% report some form of victimisation

Prevalence of Trauma – Mental Health Population • 97% of homeless women with SMI have experienced severe physical and sexual abuse – 87% experience this abuse both as child and adult (Goodman et al. , 1997) • Current rates of PTSD in people with SMI range from 29 – 43% (Jennings & Ralph, 1997) • Whilst research needs to continue, studies are increasingly showing that trauma appears to be epidemic among the population in mental health services

Prevalence of Trauma What this means……. • A majority of adult and children in inpatient psychiatric treatment settings present with trauma histories (Lipschitz et. Al. , 1999) “ Many providers may assume that abuse experiences are additional problems for the person, rather than the central problem…. ” (Hodas 2004)

Impact of Trauma • Hyperarousal: nervousness', jumpiness, quickness to startle • Re-experiencing: intrusive images, sensations, dreams, memories • Avoidance and withdrawal; feeling numb, shutdown or separated from normal life, pulling away from relationships and/or activities • Avoiding things that trigger memories of trauma/s

Definition of Trauma Informed Care • Mental Health Treatment that is directed by: ü A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual and, ü An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services. (Jennings 2004)

Symptoms as Adaptations • The traumatic event is over, but the person’s reaction to it is not. • The intrusion of the past into the present is one of the main problems confronting the trauma survivor. • Often referred to as re-experiencing, this is the key to many psychological symptoms and psychiatric disorders that RESULT from traumatic experiences. • This intrusion may present as distressing intrusive memories, flashbacks, nightmares, or overwhelming emotional states.

Trauma “symptoms” as adaptations It is useful to think of all trauma “symptoms” as adaptations. • Symptoms represent the clients’ attempt to cope the best way they can with overwhelming feelings. • When we see “symptoms” in a trauma survivor, it is always significant to ask ourselves: what purpose does this behaviour serve? • Every symptom helped the survivor cope at some point in the past and is still in the present – in some way. • As humans we are incredibly adaptive creatures. If we help the survivor explore how behaviours are an adaptation, we can help them learn to substitute a less problematic behaviour.

The use of Adaptive Coping Strategies • Survivors of repetitive early trauma are likely to instinctively continue to use the same selfprotective coping strategies that they employed to shield themselves from psychic harm at the time of the traumatic experience. • Hypervigilance, dissociation, avoidance and numbing are examples of coping strategies that may have been effective at some time, but later interfere with the persons' ability to live the life s/he wants

A model of treatment • Safety and stabilization • Processing of traumatic material • Reconnection and reintegration

Phase one; Safety and stabilization • Attention to basic needs including; connection to resources, self care, identification of support system • Focus on regulation of emotion and develop capacity to self soothe. • Education on trauma and treatment process

Phase two: Processing and Grieving of Traumatic Memories • “The primary goal of this phase is to have the patient acknowledge, experience and normalise the emotions and cognitions associated with the trauma at a pace that is safe and manageable. ” (Luxenberg, Spinazzola, Hildago, Hunt and van der Kolk, 2001)

Phase Three- Reconnection • Development of a firm or a new sense of self • Development of healthy and supportive: § Friendships § Intimacy § Spirituality

Trauma informed Care • Aims to avoid re-victimisation • Appreciates many problem behaviours began as understandable attempts to cope • Strives to maximise choices for the survivor and control over the healing process • Seeks to be culturally competent • Understands each survivor in the context of life experiences and cultural background (Alvarez and Sloan, 2010)

Resiliency • “Resilience is the capability of individuals to cope successfully in the face of significant change, adversity, or risk. The capacity changes over time and is enhanced by protective factors in the individual and environment. ” (Stewart et al. , 1991 as cited by Greene and Conrad, 2002)

Protective Factors • There are behaviours, characteristics and qualities inherent in some personalities that will assist in recovery after exposure to a traumatic event, these are called protective factors.

Environment • A reliable support system (friends, family) • Access to safe and stable housing • Timely and appropriate care from first responders

Behaviours • Good self-care such as sleeping at least eight hours a night • Eating a well balanced diet • Exercise • Practising good boundaries • Using positive coping mechanisms verses negative coping mechanisms

Resiliency as a trait • • A vigorous approach to life A sense of meaningfulness An internal locus of control (vs. external) A way to conceptualise this is the “ability of a person to bounce back from challenges through feelings of control, commitment and the ability to see change as a challenge. ” Phelps et al. , 2009)

Post-traumatic Growth • “Resilient survivors continue therefore, to grow and even thrive in spite of, and quite often because of their histories. ” (Armour 2007) • Survivors of trauma who strengthen their abilities to find wisdom that allow them emotional growth in relationship with others are often referred to as experiencing posttraumatic growth. • Post-traumatic growth is reflected in the following: ü Strengthening of relationships/sense of connection ü Increased sense of personal strengths ü Awareness of increased possibilities in life

References • Centers for Disease control and prevention (CDC). Adverse Childhood experiences (ACE) study. Available at http: //www. cdc. gov/ace/ • Alvarez, G. and Sloan, R. , Trauma: Considering Behaviour Through a Trauma Lens, (2012). Powerpoint Presentation: Everly Ball – Westminster house, 1 – 49 • Armour, M. (2007). Violent Death. Journal of Human Behaviour in the Social Environment, 14(4), 53 – 90. • Child Welfare information Gateway (2006). Long term Consequences of Child Abuse and Neglect. Retrieved from: http: //www. childwelfare. gov/pubs/factsheets/longterm-consequences. cfm

References • Child Welfare Information Gateway (2012), The Risk and Prevention of Maltreatment of Children with Disabilities. Bulletins for Professionals, (1 – 20). • Childhelp, National Child Abuse Statistics: Child Abuse in America, (1), Available at www. childhelp. org/pages/statistics • Greene, R. R. (Ed), (2002). Resiliency: An Integrated approach to practice, policy and research. Washington, D. C. : NASW Press. • International Society for the study of Trauma and Dissociation, FAQs Trauma (1 – 8) Retrieved: http: //isstd. org/education/faq-trauma. htm

References • Marcenich, L. , (2010) Trauma Informed Care, Powerpoint Presentation, available at: http: //smhealth. org/sites/default/files/docs/LMarcenich. Pw rpt/pdf • James, R. K (2008). Crises intervention strategies (6 th ed. ) Pacific Grove, CA: Brooks/Cole Pub. • Phelps, A. , Lloyd, D. , Creamer, M. , & Forbes, D. (2009). Caring for Carers in the aftermath of Trauma. Journal of Aggression, Maltreatment and trauma, 18(3), 313 -330.

Resources • International Society for Traumatic Stress Studies http: //www. istss. org/Home. htm An international collection of studies, research and education regarding trauma. Also provides guidelines for treatment of trauma. • National Child Traumatic Stress Network http: //www. nctsn. org/ Programme works to educate professionals and non professionals about trauma and evidence based practices for trauma interventions. Site provides definitions of different types of trauma and evidence based practice resources. • Sidran Institute: Traumatic Stress Education and Advocacy http: //www. sidran. org/index. cfm