Elizabeth Hudson, LCSW

Consultant to the Dept. of Health Services,

Division of Mental Health and Substance Abuse Services

Elizabeth.Hudson@wisconsin.gov

Trauma-Informed Care

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?

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)

Take Home Message

Trauma is pervasive

Trauma’s 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

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

Trauma

Overwhelming experienceInvolves threatResults in vulnerability and loss of controlLeaves people feeling helpless and fearfulInterferes with relationships and fundamental

beliefs

(Herman, 1992)

Unresolved Trauma is Common

Abuse: intentional / patterned

Accident: things happen

Contagion: impacted by others’ hurts

Oppression: institutional, systematic mistreatment of one group by another

Trauma

Psychological

Complex

Historical

Sanctuary

Vicarious

Psychological Trauma

Refers to the individual’s (or family’s) 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 individual’s functioning.

(Modified from Report from Wisconsin Trauma Summit, 2007)

Psychological Trauma - ExamplesViolence in the home, personal relationships,

workplace, school, systems/institutions, or community

Maltreatment or abuse: emotional, verbal, physical, sexual, or spiritual

Exploitation: sexual, financial or psychologicalChange in living situation such as eviction or

move to nursing homeNeglect and deprivationWar or armed conflictNatural or human caused disaster

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.

Historical Trauma

Historical trauma is the cumulative emotional and psychological wounding over the life span and across generations, resulting from trauma experienced by the individual’s 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)

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.

Trauma occurs in layers, with each layer affecting every other layer. Current trauma is one layer. Former traumas in one’s life are more fundamental layers. Underlying one’s own individual trauma history is one’s group identity or identities and the historical trauma with which they are associated.

--- Bonnie Burstow

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, Wisconsin’s CPS reported 8,148 substantiated cases of child maltreatment and an additional 2,590 cases that were likely to have occurred.

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 abuseRecurrent emotional abuseSexual abuseAn alcohol abuserAn incarcerated household memberSomeone who is chronically depressed, suicidal,

institutionalized or mentally illMother being treated violentlyOne or no parents

(Felitti et al., 1998)

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%

ACEs Increase Risk

Leading causesof death

Substance abuse

HIV and STIs

Injuries

Suicide

Liver Disease

Chronic LungDisease

Heart Disease

Adverse ChildhoodExperiences

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)

The Stress ResponseIf 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.

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)

Trauma Complexity Continuum

Adult-onsetSingle-incidentAdequate child

developmentNo comorbid

psychological disorders

Early onsetMultipleExtendedHighly invasiveInterpersonalSignificant amount

of stigmaVulnerability

(Bloom, 2009)

Simple Trauma Complex Trauma

What is a Trigger?

This Not This

A conditioned response that happens automatically when faced with a stimuli associated with traumatic experiences

TriggersSimple Trauma Complex TraumaSeeing, 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

Common TriggersReminders of past eventsLack of power/controlSeparation or lossTransitions and routine/schedule

disruptionFeelings of vulnerability and rejectionFeeling threatened or attackedSensory overload

Acting out vs. Acting inExternal defense

AngerViolence towards

othersTruancyCriminal acts

Internal defenseDenial, repressionSubstance useEating DisordersViolence to selfDissociation

Impact of Trauma on World View

The world is unsafe place to live inOther people are unsafe and cannot be

trustedMy own thoughts and feelings are unsafeI expect crisis, danger and lossI have no self-worth and no abilities

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

Guiding Values of Trauma-Informed Care

“Healing Happens in Relationship”

Understanding of Service Relationship

Traditional

Heirarchical staff / patient relationship

The patient is seen as passive recipient of services

The patient’s 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 patient’s safety must be guaranteed and trust must be developed over time

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. Let’s 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 clinician’s help to begin to learn new patterns of interaction.

Complex trauma presentation in primary care - Example Significant emotional distress

Health risk behaviorsSubstance 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.

What do you do?RelaxAppreciate she trusted you enough to disclose

emotionally painful materialProvide psychoeducational materials (see end of

presentation for resources)Encourage activities that are self-soothing –

meditation, yoga, vigorous exercise, writingPromote as much mastery and self-help as

possibleWrite down any medical instructions – assume

that under stress people are not talking in all the information they need

General TipsThink about the possibility of trauma as underlying

problem – helps to diminish frustrationHistory of physical violations may create

hypersensitivity about physical exams and being at the doctor’s 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 doesn’t do something that seems to be common sense, be curious

(Bloom, 2009)

More TipsConsider 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 doesn’t mean you have to fix it

Intervention GoalsBreak silence about trauma and abuseShift blame from survivorIf relevant, establish short term safety plan

Patient given control and choice Contextualize and normalize the experienceValidate coping strategiesIntegrate trauma factors in how you

conceptualize and address problemsMaintain positive relationshipOffer referrals for services

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 HealthCare. 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@ummhc.org. Dr. Weinreb has experience developing trauma-informed primary health care settings.

Resources for PatientsGift 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.cfm

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

ReferencesBloom, 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.