WELCOME – Person Centered Trauma Informed Care

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Accreditation and CreditsAccreditation: Sharp HealthCare is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME Credit: Sharp HealthCare designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Educational ObjectivesFollowing this knowledge activity, participants should be able to:

1. Define Trauma and trauma-informed care as it relates to older adults.2. Identity and begin to utilize two trauma-related screening tools3. Identify one organizational and one clinical practice change that will aid in

addressing the long-lasting impact of trauma on mental health4. Identify two tools to obtain the information of an older adult’s traumatic

experience(s) without re-traumatization.5. Recognize two ways that older adults with trauma history may be triggered

and how certain behaviors may be misunderstood and misdiagnosed. 6. Increase awareness and understanding of how trauma may present in a

Holocaust Survivor.

Panelists

Lisa McJunkin, LMFT CHTPLead Therapist Trauma IOPSharp Mesa Vista Hospital

Caroline Atterton, LCSWLead Therapist Senior IOP Sharp Mesa Vista Hospital

Hedy Dalin, MSSWDirector of Care Management

Jewish Family Service of San Diego

Margarita FerdmanGeriatric Care Manager

Jewish Family Service of San Diego

Disclosure

The speakers and planning committee have no relevant financial relationships to disclose.

This activity is a collaboration of the following organizations:

Evidence Based

&

Integrative Treatment for

Trauma Informed Care

Understanding the Demographics of the Population

Single Event Developmental Trauma Multiple Events

Relational/Historical

TraumaWar/Combat 

Trauma

Single Event: A trauma can be a one-time or isolated event as in a car accident, a natural disaster, and even a sexual assault. This is an event that occurs one time and might be interpreted as being an exceptional circumstance.

Developmental Trauma: May involve physical, sexual and emotional abuse while a minor, as well as neglect. It can also involve witnessing violence between caregivers.

Multiple Events: A series of difficult life events that interfere with healthy attachment in relationships and threaten the development in the following life domains: emotional, cognitive, language, intimacy, physical, and/or social.

Understanding the Demographics of the Population

Relational/Historical Trauma: Defined as “a collective complex trauma inflicted on a group of people who share a specific group identity or affiliation/ethnicity, nationality and religious affiliation. It is the legacy of numerous traumatic events a community experiences over generations and encompasses the psychological and social responses to such events” (Evans-Campbell, 2008). The Holocaust would be an example of a historical trauma.

War/Combat Trauma: For some people they are born into a culture where war is apart of their daily existence, others are sent into war as military personnel or contractors.

Understanding the Demographics of the Population

Traumatic Stress

Moral Injury PTSD Delayed 

PTSDComplex PTSD

Traumatic Stress: An individual may have a traumatic stress response to a traumatic event but not go on to develop Post Traumatic Stress Disorder (PTSD). A traumatic stress response may include an involuntary reaction to a situation that is experienced as highly stressful, but the body is able to quickly regulate itself after the stressful event.

Moral Injury: Refers to an injury to an individual's moral conscience resulting from an act of perceived moral transgression which produces profound emotional shame. The concept of moral injury emphasizes the psychological, cultural, and spiritual aspects of trauma.

Understanding the Demographics of the PopulationPost-Traumatic Stress Disorder (PTSD): A more significant intrusive response to a traumatic event. This would include the ongoing experience of 1) Reliving of the traumatic events, 2) Avoidance of the reminders of the event and, 3) Increased arousal as a result of the event.

Delayed Post Traumatic Stress Disorder: Includes all the symptoms and experiences listed in the PTSD response but the symptoms may occur much later after the traumatic event has occurred. This can be very confusing and frightening for people who experience a traumatic event and months or maybe even years later begin to develop symptoms of a PTSD response.

Complex PTSD: This would be considered the most severe form of PTSD and is characterized by a history of severe, long-term trauma that usually includes exposure to caregivers who were cruel, inconsistent, exploitive, unresponsive or violent. It is usually directly connected to trauma that occurred and was experienced at an early age in development.

Feeling Unsafe

Low Self-Esteem – Lack of Trust – Hopelessness

Acting Out Behaviors (Internalizing and Externalizing)

Impact of Trauma

Traditional Stress ResponsesBody signals

•Heart pounding•Rapid breathing•Muscle tense up•Fight or Flight

Feelings•Excited or worried•Frustrated, determined•Angry or scared•Feel in control•Feel good yourself

Unresolved Stress and Trauma Responses Body signals

•Heart feels like bursting•Gasping, feeling smothered•Muscles feel like exploding•Overreacting or freezing

Feelings•Terrified or panicked•Enraged or aggressive•Hopeless or doomed•Helpless or out of control•Worthless, like a failure

Trauma and Effect on Physiological Functioning

What Is Trauma Informed Care?

Trauma-informed care (TIC): is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, Bassuk, & Olivet, 2010, p. 82). It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services. (SAMHSA, 2014, p 19).

How Do I Provide Trauma Informed Care Services?SAMHSA TIP 57:1) Clarify to the client what to expect in the service being provided.2) Approach the client in a matter-of-fact, yet supportive, manner.3) Respect the client’s personal space.4) Adjust tone and volume of speech to suit the client’s level of engagement and degree of

comfort in the service being provided. 5) Provide culturally appropriate symbols of safe in the physical environment. (including

use of preferred name and pronoun)6) Overcome linguistic barriers by using an interpreter.7) Only elicit information necessary to determine a history of trauma and the possible

existence/extent of traumatic stress symptoms and related disorders.8) If the client is emotionally responsive when recalling or acknowledging trauma give

the client time to become calm and orient to the present.9) Provide feedback from the service provided.10) Be aware of possible implications of the service (abuse reporting guidelines).

Addressing Emotional Flooding

– Important to note that emotional “flooding” can happen when a client is requested to share their trauma narrative when they are not emotionally ready or able to self-sooth the emotions that may arise during their processing of information.

– Emotional “flooding” can appear (and is not limited to) the following expressions/behaviors: tearfulness to sobbing, increased psychomotor agitation, sudden or increased restricted affect, panic attack symptoms, reporting sudden sensations of pain (i.e. headache or chronic pain flare up), engagement in angered/verbally aggressive responses, physical posturing to elicit intimidation, refusal to answer questions asked, and/or abruptly leaving the room.

Grounding Techniques

References

Department of Health and Human Services- Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. (2014). Trauma-Informed Care in Behavioral Health Services. [PDF file]. Rockville, MD. Author retrieved from https://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14-4816Guarino, Kathleen. American Institutes for Research. (2016). How Trauma-Informed Are We?. Retrieved August 10, 2020 from http://www.schoolmentalhealth.org/media/SOM/Microsites/NCSMH/Documents/Archives/CS-4.1-Trauma.pdfHopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the Storm: Trauma Informed Care in Homeless Service Settings. The Open Health Services and Policy Journal, 3, 82.Van der Kolk, Bessel. (2015). The Body Keeps the Score. New York, NY: Penguin Books.

Trauma

and the Older Adult

Educational Objectives

Recognize examples of trauma

1

Identify manifestations of trauma in older adults

2

Apply skills to use with older adults

3

Employ principles of Trauma Informed Care

4

“Time doesn’t heal, time conceals.”

Prevalence

Trauma likely underreported in older adults

70-90% over 65 years old exposed

What about…

Women, LGBTQ, racial and ethnic minorities, the oldest old (85+), the cognitively impaired?

How Aging Can Affect Trauma

SELF‐REFLECTION

RETIREMENT LOSS PHYSICAL ABILITY 

How Aging Can Affect Trauma

A change in environment Reduced income Increased screen 

time

Medical problems/decreased sensory abilities

Cognitive impairment

Ageist Beliefs

– Stigma 

– Masking and coping

– Disempowerment 

– Resource Reduction 

– Differential treatment

– Docility

Comorbidity

– Obesity – Alcoholism – Heart disease – Cancer– Stroke – COPD – Diabetes – Depression– Suicide

Implications of Trauma for Older Adults

Physical Social

Psychological Spiritual

Assessment

– Clinician Administered assessment measures have been used validly with older adults

– Self-Report Measures

– Assess for Suicide

Past victimization predicts future victimization!

Behaviors

Multiple layers of clothesHypervigilanceAnonymity of large sheltersNot bathingLack of medical & dental attentionGuarded/defensive

AggressivenessNot taking medicationsUse of drugs and alcoholHoardingIsolating

“What’s wrong?” versus

“What’s happened?”

Paradigm Shift

• Know the history • Understand • Use that understanding• Allow services to be delivered to

facilitate consumer participation in treatment

• NO WRONG DOOR

Trauma is when people live with more fear than hope.

Recovery is when people live with more hope than fear.

References

– Cook, J. M. (2001). Post‐Traumatic Stress Disorder In Older Adults. PTSD Research Quarterly, 12, 1‐7.

– Covington, S. (2003). Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelden.

– Felitti, V.J., et al. (1998). Adverse Childhood Experiences (ACE) Study. cdc.gov/ace. 

– Grant, G. California at the Center of Excellence for Trauma Informed Care.

– https://www.psychiatrictimes.com/view/ptsd‐late‐life‐special‐issues

– https://www.psychologytoday.com/us/blog/the‐aftermath‐trauma/201610/the‐golden‐years‐traumatic‐stress‐and‐aging

– M. Harris & R. D. Fallot (Eds.). (2001). New Directions for Mental Health Services. Using Trauma Theory to Design Service Systems. Jossey‐Bass/Wiley.

– Ogle, C.M., Rubin, D.C., & Siegler, I.C. (2013). Cumulative Exposure to Traumatic Events in Older Adults. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3944195/

– Mohit P. Chopra. (2018). PTSD in Late Life: Special Issues. https://www.psychiatrictimes.com/view/ptsd‐late‐life‐special‐issues

– Hermann, B., et al. PTSD Assessment and Treatment in Older Adults https://www.ptsd.va.gov/professional/treat/specific/assess_tx_older_adults.asp

– The Golden Years: Traumatic Stress and Aging An interview with Joan Cook https://www.psychiatrictimes.com/view/ptsd‐late‐ life‐special‐issues

– Trauma‐Informed Approach and Trauma‐Specific Interventions. Retrieved 08/14/2015 from http://www.samhsa.gov /nctic/trauma‐interventions. 

Questions & AnswerPart I

Holocaust Survivors & Trauma

Questions & AnswerPart II

Thank you all for joining us today. We hope you enjoyed the presentation!

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Jewish Family Service, please contact (858) 637‐3210

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