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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
3
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
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