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S A R A P H I L L I P S , P S Y D

O R E G O N S T A T E H O S P I T A L

S A R A . N . P H I L L I P S @ D H S O H A . S T A T E . O R . U S

A Trauma-Informed Approach to Aging and Elder Care

I HAVE NO CONFLICTS OF INTEREST

Objectives

Recognize the widespread impact of trauma across the lifespan

Identify lifelong behavioral risk factors and long-term health complications associated with childhood adversity

Apply SAMHSA’s six key principles of a trauma-informed approach to working with older adults

Inspire

Shifting the Lens

WRONG

HAPPENED

MEANING

“The way in which we grow old

and experience this process, our

health and functional ability, all

depend not only on our genetic

makeup but also on what we

have done during our lives;

what sort of things we have

encountered in the course of our

lifetime, on how and where we

have lived our lives.”

(Heikkinen, 1998).

What is Trauma?

Individual trauma results from an event, or series of

events, or set of circumstances that is experienced by

an individual as physically or emotionally harmful or

life threatening and that has lasting adverse effects

on the individual’s functioning and mental, physical,

social, emotional, or spiritual well-being.

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ACE Study

Collaboration between CDC and Kaiser Permanente

Over 17,000 HMO members

Relationship between childhood maltreatment and later-life health

and well-being

10 Types of Trauma Measured

The ACE Study: Main Findings

o ACEs are common

• 1:8 ≥ 4 ACEs

o ACEs occur in clusters

o More ACEs = Increased risk

ACES Among Adults in Oregon, 2016

31.20%

22.30%

14.50%

9.40%

22.60%

4+ 0

1 2

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Many chronic diseases of adults are determined

decades earlier, in childhood.

Not by disease, but by life experiences.

Four or More ACEs

160% increased risk of severe

obesity

190% increased risk of ANY

cancer

220% increased risk of heart

disease (1 in 6)

240% increased risk of

hepatitis

390% increased risk of COPD

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Four or More ACEs

7x increase in alcoholism

4.5x increase in perpetrating

intimate partner abuse

5x increase risk

of being raped

4.5x increase in depression

10x increase in IV drug use

12x increase in attempted

suicide “What happens to children, plays out powerfully, decades later, and turns

out to be the main force for the ten most common causes of death in the United States.”

~Dr. Vincent Felitti

Elder-Specific Traumatic Experiences

Loss of spouses, family members, and peers

Chronic and life-threatening diagnoses

Physiological changes, limitations and disability

Cognitive and memory loss

Loss of roles and resources

Increased dependence on caregivers

How does having a trauma history compound these later-

in-life traumas?

Past Victimization Predicts Future Victimization

Elder abuse affects at least 1 in 10 older Americans

Underreported (1 out of 24 cases)

Experience of previous traumatic events increases risk of victimization

“Older adults who suffered from physical neglect and abuse in childhood may be more likely to tolerate

poor care later in life.” (Fulmer, et al, 2005)

National Center on Elder Abuse

Impact of Trauma on Engagement in Healthcare

Missed/Cancelled appointments

Avoiding preventative care

Poor adherence to medical

recommendations

Chronic, unexplained pain

Anxiety about certain medical

procedures

Labeled as “uncooperative” or having poor coping ability

Trauma and Terminal Prognoses

“The threat to life inherent in a terminal illness may mimic the original trauma, exacerbating previously mild PTSD symptoms and leading to significant distress;

When key memories are trauma-related, the normal process of life review can lead to intense anxiety, sadness, guilt or anger;

Avoidance symptoms and distrust of authority figures can lead to poor medical adherence and strained communication with one’s medical team; and

Patients with PTSD may lack caregivers because of a history of social isolation and avoidance.”

(Feldman & Periyakoil, 2006)

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A Trauma-Informed Approach (4 R’s)

• Realizes the widespread impact of trauma and understands potential paths for recovery REALIZES

• Recognizes signs and symptoms of trauma in clients, families, staff, (myself) RECOGNIZES

• Responds by integrating knowledge into practices, policies, and procedures RESPONDS

• Seeks to actively Resist re-traumatization RESISTS

REALIZES

Behaviors are understood in the context of

coping strategies designed to survive adversity

and overwhelming circumstances, whether these

occurred in the past, whether they are currently

manifesting, or whether they are related to the

emotional distress that results from caring for

another

Pathology or Adaptation?

FIGHT

• “Non-compliant, combative” or • Struggling to regain or hold onto personal power

FLIGHT

• “Treatment resistive, uncooperative” or • Disengaging, withdrawing, avoiding

FREEZE

• “Passive, unmotivated” or • Submitting to establish safety

RECOGNIZES

People recognize the signs of trauma.

These signs may be gender, age, or

setting-specific and may be manifested

by individuals seeking or providing

services in these settings.

Trauma or Dementia?

The interconnection between PTSD and dementia can be complex and is often unrecognized

“Behaviors” associated with dementia may also be symptoms of PTSD – difficulty differentiating what is driving such behaviors

Sundowning

Susceptibility to environmental triggers

Hyperarousal / Hyperreactivity

Agitation

Impaired social attunement

RESPONDS

Staff in every part of the organization

change their language, behaviors,

and policies to take into consideration

of the impact of trauma among service

recipients and among staff providing

the services.

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RESISTS RE-TRAUMATIZATION

Staff who work within a trauma-informed

environment are taught to recognize how

organizational practices may trigger

painful memories and re-traumatize

clients and staff with trauma histories

Potential Triggers in Healthcare

Invasive procedures

Removal of clothing

Physical touch

Vulnerable physical position

Loss of and lack of privacy

Personal questions that may be embarrassing or distressing

Power dynamics of the relationship

Gender of the healthcare provider

SAMHSA’S TIA KEY PRINCIPLES

SAFETY TRUSTWORTHINESS & TRANSPARENCY

COLLABORATION & MUTUALITY

EMPOWERMENT, VOICE & CHOICE

CULTURAL, HISTORICAL, &

GENDER LENSES

PEER SUPPORT & MUTUAL SELF-

HELP

A way of being…

SAFETY

Defined by those served and those

providing services

PHYSICALLY

EMOTIONALLY

PSYCHOLOGICALLY SPIRITUALLY

CULTURALLY

TRUSTWORTHINESS AND TRANSPARENCY

“Creating a trauma-informed community is not about getting

it right all the time; it’s about how consistently and

forthrightly you handle situations with a client {and staff}

when circumstances provoke feelings of being vulnerable or

unsafe. Honest and compassionate communication

that conveys a sense of handling the situation

together generates healing.”

~SAMHSA Tip 57

“Whenever I adopt a sharp tone with one of my clients, display indifference, or attempt some well-meant coercion for her benefit, I unwittingly take on the features of the powerful ones who first wounded and frightened her decades ago. Whatever my intentions, I end up evoking pain and fear.” ~Gabor Mate, M.D.

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COLLABORATION & MUTUALITY

Mutuality is the recognition, acknowledgement, and valuing of each person’s expertise.

Partnering and leveling of power differences between staff and people served demonstrates that

healing happens in safe relationships.

One does not have to be a therapist to be therapeutic

“Don’t ever take a fence down until you know why it was put

up.”

~Robert Frost

EMPOWERMENT, VOICE & CHOICE

Individual strengths are recognized, built on, and validated.

A trauma-informed approach aims to strengthen the staffs’, clients’, and family members’ experience of choice and recognize that every person’s experience is unique and requires an individual approach.

Seeks to avoid coercive treatment by supporting and cultivating self-advocacy

"If we know that you have sugar in your coffee, we will still ask you every day, 'Do you want sugar in your coffee?' so you can make that choice every

day. That you can still decide what you put in your coffee is important.”

~Eloy van Hal, Hogeweyk Facility Manager

CULTURAL, HISTORICAL, AND GENDER

LENSES

A trauma-informed approach:

Moves past cultural stereotypes and biases (including ageism)

Offers access to gender responsive services

Incorporates policies, protocols, and processes that are responsive to the racial, ethnic, and cultural needs of the individuals served

Honors the healing value of traditional cultural connections

Recognizes and addresses historical and intergenerational trauma

PEER SUPPORT & MUTUAL SELF-HELP

Peer support and mutual self-help are key vehicles for establishing safety and hope, building trust, enhancing collaboration, and utilizing

stories and lived experience to promote recovery and healing, for both those served and service providers

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Vicarious Trauma

Compassion Fatigue

Burnout

Secondary Traumatic Stress

DO DON’T Inquire in a physically

private & safe setting

Echo/reflect

Normalize, don’t minimize

Validate

Honor their experience

Know mandated reporting laws

Appear to doubt or disbelieve

Inquire about details of the trauma episode at this time

Use language that projects blame

Trauma Screening

Red Flags for Prior Abuse

Re-victimization (DV, elder abuse)

Suicidal/Self-injurious behaviors

Depression

Self-neglect, poor self-care

Insomnia

Multiple, chronic, complex illnesses

Eating disturbances

Helplessness, hopelessness, pessimism

Medication/ tx non-adherence

Isolation

Create a safe, secure environment

Early screening and comprehensive

assessment of trauma

Consumer-driven care and services

Trauma-informed, educated and

responsive workforce

Provision of trauma-informed, evidence-based and emerging

best practices

Engage in community outreach

and partnership building

On-going performance improvement

What can we do to promote

a Trauma-Informed culture?

Who Benefits?

A trauma-informed organization:

Increases safety for all

Cares for the caregivers

Improves the quality of services

Reduces negative encounters and events

Creates a community of hope, wellness, and recovery

Increases success and satisfaction at work

Promotes organizational wellness

Improves the bottom line

Shifting the Lens

“It is not that something different is seen, but that one sees

differently…

It is as though the spatial act of seeing were changed by a new dimension.”

~Carl Jung

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RESOURCES

NATIONAL CENTER FOR TRAUMA INFORMED CARE

http://www.samhsa.gov/nctic

NATIONAL COUNCIL FOR BEHAVIORAL HEALTH

http://www.thenationalcouncil.org/topics/trauma-informed-care/

ACES CONNECTION NETWORK

http://www.acesconnection.com/

ACES TOO HIGH

http://acestoohigh.com/

NATIONAL REGISTRY OF EVIDENCE-BASED PROGRAMS AND PRACTICES (NREPP)

http://www.samhsa.gov/nrepp

TRAUMA-INFORMED OREGON

http://www.traumainformedoregon.org/

RECOMMENDED READING LIST

The Body Keeps the Score Bessel van der Kolk

Creating Sanctuary Sandra Bloom

The Deepest Well Nadine Burke Harris

Trauma Stewardship Laura van Dernoot Lipsky

Waking the Tiger Peter Levine

Trauma and Recovery Judith L. Herman

The Boy Who Was Raised as a Dog Bruce Perry

In the Realm of Hungry Ghosts Gabor Mate

Why Zebras Don’t Get Ulcers Robert Sapolsky