Trauma Informed Care

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Trauma Informed Care

• An Over-view
• Nurse Educator
• MHAID Service Southern DHB

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Over-view

• Definitions
• Prevalence
• Impact of Trauma
• Trauma Informed Care
• Resiliency
• References
• Resources

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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

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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)

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Responses to a traumatic event may include

• Intense fear
• Helplessness
• Horror
• Attachment

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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)

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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

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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

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HMO Members in ACE Study

• 80 White, including Hispanic
• 10 Black
• 10 Asian

• About 50 men, 50 women
• 74 had attended college
• 62 age 50 or older

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Adverse Childhood Experience ACE Categories (Birth to 18) Abuse of Child Emotional abuse Physical abuse Contact Sexual abuse Trauma in Childs 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 ACE score of 1 Impact of Trauma and Health Risk Behaviors 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 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 Long-Term Consequences of Unaddressed Trauma (ACEs) Disease and Disability 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 percep- tions and relationships with others Altered systems of meaning Intergenerational trauma Long-term use of multiple human service systems
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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 Childs 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)

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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

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ACE Study Findings

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

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Impact of Trauma and Health Risk Behaviours to
Ease the Pain

• Health Risk Behaviours
• Smoking
• Severe obesity
• Physical inactivity
• Suicide attempts
• Alcoholism
• Drug abuse
• 50 sex partners
• Repetition of original trauma
• Self injury

• 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

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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

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• 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

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Health Consequences of Early Life TraumaVincent
Felitti, M.D.,

• Health in all domains is related to
• childhood experience
• Health risks
• Stroke
• Heart disease
• Depression and suicide
• Substance abuse
• Smoking

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Childhood Experiences vs. Adult Alcoholism
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3
2
1
0
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Childhood Experiences Underlie Chronic Depression
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Childhood Experiences Underlie Suicide
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3
2
1
0
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Emotional Problems

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

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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)

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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 childs sense of being overwhelmed
• Activated by
• Death of loved one, divorce, natural disasters
• (National Scientific Council
  on the Developing Brain, Harvard University 2006)

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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

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Institutionalization and Neglect of Young
Children Disrupts Their Body Chemistry
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Percent of Childrenwith Abnormal Stress Hormone
Levels
30
25
20
15
10
5
Middle Class US Toddlersin Birth Families
Neglected/Maltreated ToddlersArriving from
Orphanages Overseas
Source Gunnar Fisher (2006)
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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).

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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.

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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.

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Acute Response To Trauma
Terror
Vulnerable few supports
Normal with supports
Fear
Vulnerable with supports
Alarm
Dissociation or Resilient
Vigilance
Calm
Traumatic Event
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Types of Trauma Chronic

• Chronic trauma refers to the experience of
  multiple traumatic events.
• These may be multiple and varied eventssuch as a
  child who is exposed to domestic violence, is
  involved in a serious car accident, and then
  becomes a victim of community violenceor
  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.

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Types of Trauma Complex

• Complex trauma describes both exposure to chronic
  traumausually caused by adults entrusted with
  the childs careand 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 childs development and
  functioning.

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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

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The impact of a potentially traumatic event
depends on several factors, including

• The childs age and developmental stage
• The childs perception of the danger faced
• Whether the child was the victim or a witness
• The childs relationship to the victim or
  perpetrator
• The childs past experience with trauma
• The adversities the child faces following the
  trauma
• The presence/availability of adults who can offer
  help and protection

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Impact of Trauma on Child Development

• Physical and Neurodevelopment
• Psychosocial and Relational Development

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Developmental Factors

• Chronic early trauma starting when the
  individuals personality is forming shapes a
  childs (and later adults) 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.

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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
  self-sabotage.

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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)

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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

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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

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Prevalence of TraumaWhat 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)

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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

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Definition of Trauma Informed Care

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

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Symptoms as Adaptations

• The traumatic event is over, but the persons
  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.

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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.

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The use of Adaptive Coping Strategies

• Survivors of repetitive early trauma are likely
  to instinctively continue to use the same
  self-protective 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

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A model of treatment

• Safety and stabilization
• Processing of traumatic material
• Reconnection and reintegration

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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

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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)

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Phase Three- Reconnection

• Development of a firm or a new sense of self
• Development of healthy and supportive
• Friendships
• Intimacy
• Spirituality

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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)

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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)

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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.

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Environment

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

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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

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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)

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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 post-traumatic
  growth.
• Post-traumatic growth is reflected in the
  following
• Strengthening of relationships/sense of
  connection
• Increased sense of personal strengths
• Awareness of increased possibilities in life

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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/f
  actsheets/long-term-consequences.cfm

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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//isst-d.org/education/faq-trauma.htm

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References

• Marcenich, L., (2010) Trauma Informed Care,
  Powerpoint Presentation, available at
  http//smhealth.org/sites/default/files/docs/LMarc
  enichPwrpt/pdf
• James, R.K (2008). Crises intervention strategies
  (6th 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.

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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