Objectives. The Triad. APNA 27th Annual Conference Session 1013: October 9, Grabbe, Amar 1

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1 The Triad of Childhood Trauma, Mental Illness, and Substance Abuse: Applying Trauma-Informed Care Linda Grabbe, PhD, FNP-BC, PMHN-BC Nell Hodgson Woodruff School of Nursing Emory University October 9, 2013 American Psychiatric Nurses Annual Conference The speaker has no conflicts of interest to disclose Objectives Discuss the prevalence of adverse childhood experiences Differentiate among complex, high-betrayal, and low-betrayal trauma Describe the impact of childhood trauma on health Discuss current literature on the relationship of early trauma to mental illness and substance use disorders The Triad Substance abuse Psychological distress Psychiatric disorders Childhood abuse and neglect Grabbe, Amar 1

2 What is childhood trauma? Victimization including sexual/verbal/physical abuse, neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters May involve the intentional infliction of mental anguish or physical harm High-betrayal vs. low-betrayal trauma Complex trauma Childhood vs. adult trauma 4 ACE Pyramid Framework ( Prevalence of Trauma in the General Population the ACE Study Kaiser-CDC study of 17,000 Kaiser patients found 2/3 of patients had experienced trauma in childhood ACE scores: sum of 9 types of trauma 16% have 3 or more Grabbe, Amar 2

3 ACE Study: Prevalence of the 9 categories of trauma recurrent and severe physical abuse (11%) recurrent and severe emotional abuse (11%) contact sexual abuse (men 16%; women 28%) physical neglect (11%) emotional neglect (15%) household trauma (Felitti & Anda, 2010) Behavioral Risk Factor Survey 26,000 adults in 5 states 60% had 1 ACE 9% had 5 or more ACEs Common among all races/ethnicities (MMWR Dec 17, 2010) Higher Prevalence of Trauma in Special Populations Patients in substance abuse treatment Patients with severe mental illness Incarcerated persons Homeless persons 9 Grabbe, Amar 3

4 Childhood life events Childhood trauma Divorce Loss of a parent Placement* Abuse* Neglect* *Predicted anxiety, depression, or both (Hovens 2010) What does childhood trauma do? Trauma shapes a child s basic beliefs about identity, world view, spiritual sense Negative beliefs and views require adaptations Some symptoms and behaviors may be seen as adaptations (Saakvitne, Gamble, Pearlman & Lev, 2000) Health risk behaviors are sometimes used as coping mechanisms or adaptations eating disorders smoking substance abuse self harm, cutting sexual promiscuity (Felitti et al., 1998) 12 Grabbe, Amar 4

5 Trauma: Impact and Expression Psychological/emotional Cognitive Social/behavioral Psychiatric Biologic Depression Anxiety Fear Feeling Worthless Bad Intimacy problems Emotional consequences Guilt and shame Enhanced resilience Anger Neurologic endocrine changes Dysregulated biologic stress response Dissociative experiences Cognitive effects Hypervigilence Intrusive memories and flashbacks Epigenetic effects Grabbe, Amar 5

6 Impulsiveness Poor anger control Substance abuse Self-harm Social/Behavioral Consequences Interrupted education High-risk behaviors Suicidality Victimization PTSD Personality disorders Depression Psychiatric consequences Eating disorders Compulsions Anxiety Somatic complaints Somatic disturbances Pulmonary /heart/liver disease Heavy use of health care Prescriptions Biologic impacts Cancer Diabetes Pain/Sexual dysfunction Increased ACTH and HPA axis activity Grabbe, Amar 6

7 Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD (R), Compared with a Healthy, Non-Maltreated Matched Control (L) (De Bellis et al., 1999) Between Stimulus and Response Social Environmental Intervention Cortex Psychotherapy Neuroregulatory Intervention Hippocampus Slower Psychopharmacology Sensory Thalamus Very Fast Amygdala Stimulus Response (LeDoux, 1996) Trauma, PTSD and AUD Childhood trauma or PTSD predicted alcohol use disorder Those with childhood trauma without PTSD more likely to have alcohol use disorder PTSD Alcohol use disorder Childhood trauma (34,000 US adults: Fetzner et al 2011) Grabbe, Amar 7

8 Trauma, psychological distress, and AUD Alcohol problems associated with Psychological distress Alcohol use disorder adverse childhood experiences were mediated by psychological distress Childhood trauma (7,279 adult Kaiser patients: Strine et al 2012) Trauma, anxiety, and AUD Anxiety Alcohol dependence Childhood trauma Anxiety disorders precede alcohol dependence Stronger associations in women with trauma history (7,076 in general population: Marquenie et al, 2007) Case example: Deanna Physically and emotionally abused by parents Sexually abused by uncle Only help from school nurse Her1 st drink : It felt like the depression went away (age 14) I ve spent most of my life feeling dirty Bipolar, PTSD, GAD Addictions: cocaine, MJ, PCP, ETOH Grabbe, Amar 8

9 Trauma and depression/ptsd (564 young adults: Teicher 2009) 29 with childhood sexual abuse exclusively 62% of these developed MDD Time between abuse and onset of depression = 9.2 years onset of PTSD = 8 years Need to screen adolescents for depression and monitor abused children through puberty Trauma, self-compassion, psychological distress, and suicide Low self compassion Anxiety, drinking, depression, suicide attempts Childhood trauma Emotional abuse was most significantly associated with reduced selfcompassion Low self-compassion associated with psychological distress, problem alcohol use, and serious suicide attempt (117 youth in child protection services: Tanaka 2011) Poly vs. Monosubstance abuse and psychiatric disorders Polysubstance Higher childhood trauma scores (emotional/physical neglect) More psychosis, aggression, impulsivity, suicide attempts Monosubstance More Axis I disorders Higher depression scores (752 substance dependent adults: Marinotti 2009) Grabbe, Amar 9

10 Trauma, dissociation, and drug vs. ETOH Dissociation Drugs vs. ETOH Abuse severity More dissociation: Drug addicts vs. ETOH abusers Emotional abuse Female gender, younger age (459 substance dependent adults: Schafer et al. 2010) Case example: Quanda Raised by grandmother Molested by uncle for some years Excellent student Reported molestation Case investigated Drinking at 13 Early sex Pregnant at 14 Anxiety, insomnia, depression Addiction Trauma, dissociation, and SUD More dissociation with trauma-related symptoms emotional abuse and physical neglect High-dissociation group expected that substances could manage their psychiatric symptoms Trauma symptoms or dissociation Substance dependence Childhood trauma (77 women with PTSD and SUD: Najavits & Walsh 2012) Grabbe, Amar 10

11 The Triad Childhood trauma Mental health disorders And distress Substance abuse Individual and family toll; Marginalization; Physical health problems; Losses to society; Recurrent trauma Trauma: loss of safety; betrayal Coping: Substance use Lack of sense of self, compassion; emotional dysregulation Coping: avoidance, dissociation; maladaptive behaviors Depression, anxiety, PTSD; emotional distress Someday, maybe, there will exist a wellinformed, well considered and yet fervent public conviction that the most deadly of all possible sins is the mutilation of a child s spirit; for such mutilation undercuts the life principle of trust (Erik Erikson1958) Grabbe, Amar 11

12 What is Trauma-Informed Care? Nursing care that incorporates: An awareness of the high prevalence of traumatic experiences in persons who receive health services in any setting A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual A trauma framework: the effects of trauma can be addressed and a patient can heal from trauma, mental distress or illness, and substance abuse 34 Prevention Efforts Goals reduce ACE rates improve functioning of persons with high ACE scores Activities 18 states collecting data on ACEs movers: Illinois, Arizona, Maine, Pennsylvania, Washington, Wisconsin, North Carolina Interventions home visits to high-risk mothers by nurses parenting programs Good news Rates of childhood maltreatment are dropping ( ) Declines: physical, sexual assault, bullying, emotional abuse Traumaspecific therapies TAMAR Seeking safety Sanctuary National Organizations SAMHSA Stop it Now Prevent Child Abuse National Child Traumatic Stress Network Grabbe, Amar 12

13 Questions? Thank you! Grabbe, Amar 13

14 Trauma Informed Care ANGELA FREDERICK AMAR, PHD, PMHCNS-BC, FAAN NELL HODGSON WOODRUFF SCHOOL OF NURSING EMORY UNIVERSITY Objectives Describe the basic principles of trauma-informed care Analyze psychiatric systems and treatment facilities for opportunities to implement trauma- informed care Examine barriers to implementing trauma-informed care and possible solutions. The Speaker has no conflicts of interest to disclose 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) What s wrong with you? What has happened to you? Grabbe, Amar 1

15 Basic Principle of Trauma Informed Care 1: Impact of violence & victimization on development & coping 2: Recovery from trauma primary goal 3: empowerment model 4: Maximize woman s choice & control over recovery 5: Based in a relational correlation 6:Create an atmosphere of respect 7: Emphasis on strengths 8: Minimize possibilities of retraumatization 9:Cultural competence 10: Consumer input in designing & evaluating services Basic Principle of Trauma Informed Care 1: Recognize the impact of violence & victimization on development & coping strategies 2: Identify recovery from trauma as a primary goal 3: Employ an empowerment model Basic Principle of Trauma Informed Care 4: Strive to maximize a woman s choice & control over her recovery 5: Based in a relational collaboration 6:Create an atmosphere that is respectful of survivors need for safety, respect, & acceptance 7: Emphasize women s strengths, highlighting adaptation over symptoms, & resilience over pathology Grabbe, Amar 2

16 Basic Principle of Trauma Informed Care 8: Goal is to minimize the possibilities of retraumatization 9:Strive to be culturally competent & to understand each women in the context of her life experiences & cultural background 10: Solicit consumer input and involve consumers in designing & evaluating services 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 Organizational Commitment to Trauma- Informed Care Adoption of a trauma-informed policy to include: Commitment to appropriately assess trauma Avoidance of re-traumatizing practices Key administrators getting on board Resources available for system modifications and performance improvement processes Education of staff prioritized (Fallot & Harris, 2002; Cook et al., 2002) 9 Grabbe, Amar 3

17 Organizational Commitment to Trauma- Informed Care (Cont d) Unit staff can access expert trauma consultation. Unit staff can access trauma-specific treatment if indicated. (Fallot & Harris, 2002; Cook et al., 2002) 10 Organizational Commitment to Trauma- Informed Care (Cont d) 11 Assessment data informs treatment planning in daily clinical work. Advance directives, safety plans, and deescalation preferences are communicated and used. Power and control are minimized by attending constantly to unit culture. (Fallot & Harris, 2002; Cook et al., 2002) Systems Without Trauma Sensitivity- Related Characteristics High rates of staff and recipient assault and injury Lower treatment adherence High rates of adult, child/family complaints Higher rates of staff turnover and low morale Longer lengths of stay/increase in recidivism (Fallot & Harris, 2002; Massachusetts DMH, 2001; Huckshorn, 2001) 12 Grabbe, Amar 4

18 Barriers to a Systemic Understanding of Trauma & Trauma Informed Care Stigma, Social Distance, & lack of familiarity Lack of educational resources Lack of trauma trained sensitive staff Social conventions that support stigma Lack of common experience Lack of empathy Resistance to change Institution Specific Barriers Guiding Values of Trauma-Informed Care Healing Happens in Relationship Grabbe, Amar 5

19 Developing Trauma-Informed Service Systems The Institute for Health and Recovery The Sanctuary Model: An Integrated Theory What is the Sanctuary Model? What is the Sanctuary Model? The Sanctuary Model represents a theory-based, traumainformed, evidence-supported, whole culture approach that has a clear and structured methodology for creating or changing an organizational culture. Grabbe, Amar 6

20 olkit.php Trauma Specific Services Crisis Intervention Trauma Recovery & Empowerment Model (TREM) Trauma Adaptive Recovery Group Education & Therapy (TARGET) TRIAD Women s Group model TAMAR = Trauma, Addictions, Mental Health and Recovery Angela Frederick Amar aamar@emory.edu Grabbe, Amar 7