The Psychological Effects of Trauma:
Implications for Working with Homeless
Populations
Brian E. Lozano, Ph.D.
Contributing Collaborator: Peter Tuerk, Ph.D.
Ralph H. Johnson VA Medical Center
Homeless Outreach Meeting
Columbia, SC
July 23, 2014
Goals of Presentation
To facilitate trauma-informed care with homeless populations through
better understanding of:
• Normal reactions to trauma
• Genesis and maintenance of PTSD
• Relation of trauma to homelessness
• Barriers to service utilization
• Approaches for overcoming barriers to service utilization
• Effective treatment of PTSD
Psychological Trauma
• What is your understanding of trauma and PTSD?
• Psychological trauma stems from potentially traumatic events
that overwhelm the usual methods of coping that give people a
sense of control, connection, and meaning.
• Exposure to trauma can severely change the way persons think
about themselves and experience the world around them:
safety, trust, benevolence, justice, sense of self.
NORMAL Post-Trauma Reactions
(not pathological: 1-4 weeks)
• Most people will experience trauma-related symptoms following
exposure to trauma or series of traumas. But most people will
get better with simple support, obtained from family, friends, and
community.
• Just because someone goes through something horrible doesn’t
mean they need treatment.
• Treatment is appropriate for those who still have problems 4-12
weeks later.
Posttraumatic Stress Disorder (PTSD)
• PTSD is classified as an Anxiety Disorder in the
DSM-IV.
• Exposure to traumatic event involving:
1.
Real or perceived threat of life/injury to
self/others
AND
2.
Intense fear, horror, or hopelessness
• It is a complex disorder that can occur following
extremely stressful or traumatic events (e.g.,
MVA, rape, natural disasters, combat exposure).
PTSD: DSM-IV
Exposure to trauma results in:
1.
Re-experiencing symptoms (at least 1)
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2.
Avoidance symptoms (at least 3)
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3.
Recurring intrusive thoughts, images, nightmares of trauma event
Severe anxiety in response to reminders of the event
Flashbacks
Avoidance of thoughts, feelings, conversations, or reminders related to event
Inability to recall important aspects of the trauma event
Emotional numbing/detachment, isolation, decreased interest in activities
Hyperarousal symptoms (at least 2)
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•
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Physiological reactivity when exposed to trauma reminders
Irritability/angry outbursts, difficulty falling/staying asleep, difficulty
concentrating, exaggerated startle
Hypervigilance – constantly scanning people and surroundings
Prevalence of PTSD
•
General population
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Men: 2% current; 4% lifetime
•
Women: 5% current; 10% lifetime
(Kessler et al., 2005 -National Comorbidity Survey-Replication)
•
Veteran populations
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US/Vietnam: 9% current; 19% lifetime (Dohrenwend, 2006)
•
US/Gulf War: 3-16% (Sutker et al., 1993; Wolfe et al., 1999)
•
US/Iraq & Afghanistan: 12-13% (Hoge et al., 2004)
Time Course of Post-trauma Reactions
Trauma
1
month
3
months
6
months
20
years
40
years
Acute stress reaction
Acute stress disorder
Acute PTSD
Chronic PTSD
Delayed-onset PTSD
Rate of Recovery After Rape
94%
47%
42%
% with PTSD
Symptoms
30 %
25%-15%
?
W
3m
9m12m
Years
Data from Rothbaum et al., 1992
% with PTSD
One Year Course:
Type of Assault and PTSD
100
90
80
70
60
50
40
30
20
10
0
Rape
Non-Sexual
Assault
1 wk* 1 mo
*Month duration not met
2 mo
3 mo
6 mo 12 mo
Foa, Hembree, and Dancu (2003)
Comorbidity with PTSD
Anxiety
• Nervousness (racing heart, muscle tension)
• GI upset & other Physical Problems
• Impaired Concentration & Memory that imitate organic problems
• Sexual Dysfunction
• Avoidance of previously enjoyable activities
Panic Disorder
• 3-4x more likely among persons with PTSD (Kessler et al., 1995)
Comorbidity with PTSD
Depression
• Guilt / Self-Blame
• Feelings of Worthlessness / low self-esteem
• Loss of confidence
• Problems with memory/concentration
• Eating and Sleep Difficulties
• Exacerbation of Physical Problems
• Lack of Energy and Motivation
• Isolation / withdrawal
Substance Abuse
• Increased risk of alcohol and drug abuse/dependence
• 2-4x more likely among persons with PTSD
Summary of Reactions to Trauma
•
The majority of trauma victims recover with time.
•
PTSD represents a failure of natural recovery.
•
After one year, PTSD does not remit without treatment.
•
PTSD is highly distressing and debilitating disorder.
Trauma, PTSD, and Homelessness
•
Among veterans, presence of a mental health disorder is the
strongest predictor of homelessness following military
discharge (Department of Veterans Affairs Office of the Inspector General, 2012).
•
PTSD was associated with 85% increased risk of recurrent
homelessness among formerly homeless veterans (O’Connell et
al., 2008).
•
Among women, those who served in the military were 3x
more likely to experience homelessness (Gamache et al., 2003).
•
Homeless female veterans were 3x more likely to have
received treatment for MST (Washington et al., 2011).
Trauma, PTSD, and Homelessness
•
In general population, trauma exposure and subsequent
development of PTSD often occurs prior to becoming
homeless (Goodman et al., 1991; North & Smith, 1992).
•
Homelessness presents increased risk of exposure to
trauma (Perron et al., 2008; Williams & Hall, 2009).
o
o
•
Increased risk of criminal violence and nonviolent crime
Detachment from support systems
Along with comorbidity with substance use disorders
there can be an increased tendency to engage in high-risk
behaviors making one susceptible to trauma exposure
(Fischer & Breakey, 1991).
Barriers to Service Utilization
What are the most frequent barriers to service utilization that you
have noticed?
Patient Barriers
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Lack of awareness of resources
Overwhelmed by multiple
comorbidities
Limited insight re: symptoms
Hopeless that situation can improve
Disagreement about target for
intervention
Negative reporting experiences
(particularly for sexual assault)
Guilt, shame, mistrust
Minimization of symptoms
FEAR
Ambivalence
Provider / System Barriers
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Lack of awareness of resources
Limited resources available
Limited understanding re: trauma
Not enough time to address trauma
Disagreement about target for
intervention
Difficulty coordinating across
services
Discomfort with assessment of
trauma
Overcoming Barriers to Service Utilization
As health care providers, it is important for us to…
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Maintain awareness of and routinely screen for trauma and related
symptoms
Ensure privacy and confidentiality re: communications
Convey confidence in assessment and discussion re: trauma
Understand our own emotional state
Be able to tolerate emotional distress (within self and patients)
Focus on establishing positive rapport and trust
Be empathic and non-judgmental
Normalize reactions to trauma
Be mindful of physical space, body language, tone/volume of
voice, and potential trauma-related triggers
Overcoming Barriers to Service Utilization
As health care providers, it is important for us to…
•
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Actively elicit patient’s concerns and perspective on symptoms
Communicate understanding through reflective listening
Respect and promote patient autonomy
Align with and emphasize patient’s values and strengths
Recognize that avoidance is normal – it’s a symptom and therefore
expected!
Accept that repeated efforts at engagement will likely be needed
Communicate hope and confidence re: capacity to overcome
challenges through treatment
At the very least, we can keep the door open!
Effective Therapy for PTSD
•
Prolonged Exposure (PE; Foa et al., 2007) and Cognitive Processing
Therapy (CPT; Resick & Schnicke, 1996) – identified as front-line
treatments (VA/DoD, 2010).
•
Institute of Medicine (2007) identifies exposure therapy as the
only effective treatment for combat-related PTSD.
•
Randomized controlled trials demonstrate slightly more
favorable outcomes for veterans in PE as compared with CPT
(Steenkamp & Litz (2013).
What is Prolonged Exposure Therapy?
Prolonged Exposure is a manualized, 90-min, weekly, treatment
protocol that consists of the following major components:
•
Education regarding common reactions to trauma & detailed
rationale for treatment.
•
Self-assessment of anxiety using subjective units of distress
(SUDs).
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Repeated in vivo exposure to situations avoided due to distress.
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Repeated, prolonged imaginal exposure to traumatic memories
followed by processing or discussion of the memories.
Clinical Outcomes:
Prolonged Exposure for PTSD
Self-rated PTSD Symptoms
Self-rated Depression Symptoms
PTSD Checklist (PCL) and Beck Depression Inventory-II (BDI) outcomes over the course of
treatment (N = 65 OEF/OIF Veterans with PTSD).
Clinical Outcomes:
Prolonged Exposure for PTSD
Self-rated PTSD Symptoms
Self-rated Depression Symptoms
OEF/OIF Veterans
Clinical Outcomes:
Prolonged Exposure for PTSD
A quarter (25%) of
treatment completers used
mental health services
once or not at all in the
year following treatment.
The need for mental health service utilization decreases by 50%
for Veterans completing PE treatment (N=60)