2/9/2015
Trauma-Informed Care
Dr Annabel Mead
MBBS FAChAM dipABAM
Overview
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Defining trauma and its’ effects
Providing Trauma Informed Care
Trauma in the Workplace
Developing Trauma Informed Services
F lourish
....
Taken from me was my childhood, my youth
Finally I am able to tell the truth
My soul aches with anxiety and despair
I was so lost
I thought nobody cared
The hole inside of me is like a chasm
Whenever I think of it, my heart does spasm
What he did took over my being...
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What’s the big deal about trauma?
Pervasiveness of Trauma
Effects:
Mental health
: access to treatment
Substance use
Physical health
: retention in treatment
: recovery
Canadian Reports on HIV & Trauma
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Canadian Aboriginal AIDS Network
AW dx at younger age, later in their disease, IDU
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The Cedar Project
[Pearce et al, 2008]
HIV in Aboriginal street youth and female sex workers
[Duncan et al , AIDS and Behavior, 2011]
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Childhood trauma among HIV+ IDUs : 42-52% prev.
[Walton G et al, AIDS Care, 2011]
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‘Our Search For Safe Spaces’
A qualitative study of the role of sexual violence in the
lives of aboriginal women living with HIV/AIDS
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Exposure to violence
Violence-related exposure to HIV (direct & indirect)
HIV-related exposure to violence
Experience with health and welfare services
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Racism, sexism, stigma of HIV
Relationship between Trauma & HIV
US data
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High prevalence of trauma in PLHIV cf general population.
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CHASE study:
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Trauma in adulthood and post-HIV dx is higher
2x all-cause death rate
faster progression to OI or AIDS death
Depressive sx increase AIDS, reduce CD4
Recent trauma predicts ARV failure.
30% PTSD rate in HIV+ W (meta-analysis)
What is Trauma Informed Care?
• An organisational structure and treatment framework
• Involves understanding, recognizing and responding to the
effects of all forms of trauma.
• Gives priority to safety, choice and control.
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What is Trauma?
Experience(s) that overwhelm an individual’s
capacity to cope
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Both internal and external resources are inadequate to cope with
[Van der Kolk]
the external threat.
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They are life events that are out of one’s control :
potentially devastating emotional, physical & behavioral
disturbances.
Ability to cope with trauma:
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Context of the trauma
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Single vs repeated
Age of person
Natural vs human
Accidental vs purposeful
Environmental supports
Innate resilience
Types of Trauma
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Single incident trauma
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(an unexpected, overwhelming event)
Complex / repetitive trauma (ongoing abuse, DV, war)
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Developmental trauma
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Intergenerational trauma
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Historical trauma
Sanctuary trauma
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Effects of Trauma
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Psychological
Developmental
Physical
Interpersonal
Spiritual
Behavioural
shame, guilt
emotional numbness,
disconnection
anxiety, terror, shock
Psychological
dreams
memory
helplessness
powerlessness
Developmental effects of trauma
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Childhood abuse
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Attachment / intimate relationships : emotional regulation
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Impulse control
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Cognitive impairment & attention deficits
ACE study
[Felitti & Anda]
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ACE Study
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American Adverse Childhood Events study
[Felitti & Anda]
Includes multiple possible events:
abuse, neglect, witnessing violence, parental divorce,
mental illness, substance abuse, incarceration
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ACE > 4: highly predictive of multiple health problems
ACE of 7: 51 x increase in adolescent suicide attempts
30 x increase in suicide attempts in adulthood.
Neurobiology
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Flight, fight or freeze response to danger
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Activated by the amygdala
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Adrenaline stress response
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Prefrontal cortex activity decreases
Physiological Adaptations
Occur with exposure to chronic stress or recurrent traumas:
• Hyper-arousal :
• Hyper-vigilence :
anxious, jumpy, sleep-disturbed
external focus of attention
• Dissociation
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Behavioural Adaptations
• Self-harm
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reduces tension / downgrades arousal
increases adrenaline and endorphins (dissociative)
Disordered eating
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Alcohol or drug use
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Avoidance of triggers
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Risky behaviours
Effects on Identity and Agency
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Early abuse distorts the core of a person’s identity
Poor internal sense of self
Lack of trust
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frequent conflicts
difficulty establishing/maintaining close relationships
boundaries
Spiritual effects:
Loss of meaning/faith
Loss of connection
Shame, guilt
Self-blame
Self-hate
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Labeling
Symptoms and behaviors subsequent to trauma can be
missed / misdiagnosed if we don’t apply a ‘trauma’ lens.
psychoses
personality disorder
anxiety disorders bipolar
ADHD
Case Scenario
A young homeless woman arrives at your out-patient clinic with
an infected ulcer on her lower leg.
Past history
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HIV infection secondary to IDU.
Polysubstance use.
She is presenting with significant pain, and is irritable and
agitated.
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Change the fundamental question:
“What is wrong with this person?”
to
“What has happened to this person?”
Behaviours (maladaptive)
in a clinical setting
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Disengagement
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Aggression and poor impulse control in new situations
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Quick deterioration
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power and control struggles
Rule enforcement : aggression and fear
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“Minor events” precipitate catastrophic reactions
Trauma-Informed Practice
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Engagement
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Welcoming, friendly environment
Focus on safety
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Attend to immediate needs
Be transparent and predictable
Respect healthy boundaries
Informed consent
Principles of Care
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Avoid retraumatization
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Empowerment :
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Early disclosure, safe pace
Choice and control / Strengths / Skills
Work collaboratively, with flexibility
Safety & trustworthiness
Relating to trauma survivors
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Cultivate safety in every interaction
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Non-judgemental
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Avoid confrontational approaches
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Pay attention to (un)spoken responses
Motivational Interviewing techniques
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Response to upset behavior
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Reinterpret through the lens of trauma exposure
Notice own internal reactions, avoid over-reacting
Validate
Provide safety
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Offer verbal support and grounding
Strengthen empowerment + collaboration
Mindfulness
the intentional, accepting and non-judgmental focus of one’s attention
on the emotions, thoughts and sensations occurring in the present moment
Practice traps
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Fixing and taking over
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Feeling overwhelmed
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Rigidity in practice
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Losing awareness of body language/exp
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Recovery from Trauma
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Work with the relative strengths
Set up resiliency rather than undo the trauma
Moves through four stages
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Victimization: not a failure or damaged, but changed
Safety & self-care: managing symptoms
Integration of trauma: disclosure, integration and self as survivor
Reconnection with others: beyond survivorship to intimacy, trust & meaning
[Glenn Grigg]
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