Trauma Informed Care. Marie Hobart MD Clinical Assistant Professor of Psychiatry

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1 Trauma Informed Care Marie Hobart MD Clinical Assistant Professor of Psychiatry

2 Thanks and Credit No commercial conflicts SAMHSA- Substance Abuse and Mental Health Services Administration The National Council- Center for Integrated Health Solutions- Cheryl Sharp MSW Center for Integrated Primary Care- Alexander Blount EdD, Linda Weinreb MD

3 Overview Data on trauma in the populations we serve Role of trauma in physical and mental health conditions. Trauma history in health care providers Assessment and recognition of trauma Guidelines for trauma informed care Resources and references

4 SAMHSA s Concept of Trauma Trauma: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically and/or emotionally harmful or threatening and that has lasting adverse effects on the individual s functioning and mental, physical, social, emotional, and/or spiritual well-being

5 Why is Understanding Trauma Important? To provide effective services we need to understand the life situations that may be contributing to the persons current problems Many current problems faced by the people we serve may be related to traumatic life experiences People who have experienced traumatic life events are often very sensitive to situations that remind them of the people, places or things involved in their traumatic event These reminders, also known as triggers, may cause a person to relive the trauma and view our setting/organization as a source of distress rather than a place of healing and wellness

6 Traumatic events are common National Comorbidity Study: 61% of men, 51% of women 25 50% report two or more traumas Often underlies chronic pain, irritable bowel, multiple somatic symptoms, contributes to underlying disease mechanism of many conditions.

Prevalence Majority of adults and children in inpatient psychiatric and substance use disorder treatment settings have trauma histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010) 43% to 80%

7 Prevalence Majority of adults and children in inpatient psychiatric and substance use disorder treatment settings have trauma histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010) 43% to 80% of individuals in psychiatric hospitals have experienced physical or sexual abuse 51%-90% public mental health clients exposed to trauma (Goodman et al, 1997; Mueser et al, 2004) 2/3 adults in SUD treatment report child abuse and neglect (SAMHSA, CSAT, 2000) Survey of adolescents in SU treatment > 70% had history of trauma exposure (Suarez, 2008)

8 Examples of Traumatic Life Experiences Physical, emotional and/or sexual abuse in childhood or adulthood In Childhood neglect or abandonment (food insufficiency, lack of money to met basic needs, homelessness) death of a parent divorce family life that includes drug addiction, alcoholism, parental incarceration, violence Rape Serious medical illness or disease (disabling conditions, loss of function, invasive and distressing procedures)

9 The Adverse Childhood Experiences (ACE) Study Center for Disease Control and Kaiser Permanente (an HMO) Collaboration Over a ten year study involving 17,000 people Looked at effects of adverse childhood experiences (trauma) over the lifespan Largest study ever done on this subject

10 ACE Questionnaire Prior to your 18th birthday: 1. Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you; or act in a way that made you afraid that you might be physically hurt? No= 0 Yes=1 2. Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you; or ever hit you so hard that you had marks or were injured? No= 0 Yes= 1 3. Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way; or attempt or actually have oral, anal, or vaginal intercourse with you? No= 0 Yes= 1 4. Did you often or very often feel that no one in your family loved you or thought you were important or special; or your family didn t look out for each other, feel close to each other, or support each other? No= 0 Yes= 1 5. Did you often or very often feel that you didn t have enough to eat, had to wear dirty clothes, and had no one to protect you; or your parents were too drunk or high to take care of you or take you to the doctor if you needed it? No= 0 Yes= 1

11 ACE Questionnaire 6. Was a biological parent ever lost to you through divorce, abandonment, or other reason? No= 0 Yes= 1 7. Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her; or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? No= 0 Yes= 1 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? No= 0 Yes= 1 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? No= 0 Yes= Did a household member go to prison? No= 0 Yes= 1 Now add up your Yes answers. This is your ACE Score

12 Consequences of Adverse Childhood Experiences

13 Impact of Trauma Over the Lifespan Increases the risk of neurological, biological, psychological and/or social difficulties such as: Changes in brain neurobiology; Social, emotional & cognitive impairment; Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence); and Severe and persistent behavioral health, physical health and social problems, early death. (Felitti et al, 1998)

14 Healthcare conditions often associated with a history of adverse childhood experiences: Diabetes COPD 2.6 times greater with an ACE of 4 Heart Disease High Blood Pressure Obesity Headache Cancer = 3X rate with ACE 6 Liver Disease Gynecologic Disorders Sexually Transmitted Diseases Unintended Pregnancies The Hidden Impact of Early Life Trauma On Health and Disease. Chapter 8. in Lanius,. By Felliti and Anda, 2010.

15 Adverse Childhood Experiences and Current Smoking, Alcohol Abuse, Chronic Depression 20% smoke tobacco with ACE of 4 or more 5% with ACE of 0 16% with alcohol abuse ACE of 4 or more 2% with 0 60% of women and 40% of men with ACE 4 or more with lifetime depression

16 ACE and risk of suicide attempt

17 Trauma may negatively influence access to and engagement in primary care: Avoidance of medical and dental services Non-adherence to treatment Postponing medical and dental services until things get very bad Misuse of medical treatment services ex. over use of ER Services and misuse of pain med

18 Why medical settings may be distressing for people with trauma experiences: Invasive procedures Removal of clothing Physical touch Personal questions that may be embarrassing/distressing Power dynamics of relationship Gender of healthcare provider Vulnerable physical position Loss of and lack of privacy

19 Therefore We need to presume those we serve have a history of traumatic stress and exercise universal precautions by creating systems of care that are trauma-informed. (Hodas, 2005 ) Someone finally asked What happened to you? instead of What is wrong with you?

20 Challenges for Primary Care Staff Training of primary care staff doesn t typically include how to explore and identify the role of trauma as an important factor in a persons physical health status and health risk behaviors The pace and culture of primary care settings place considerable time constraints on practitioners Staff often have the misconception that considerable time and expertise is required to address trauma issues in the context of primary care visits

Providers also have trauma histories Study by Candib, Savageau, Weinreb, Reed- Family Practice physicians in Massachusetts 2008. 42.4% of women and 24.

21 Providers also have trauma histories Study by Candib, Savageau, Weinreb, Reed- Family Practice physicians in Massachusetts % of women and 24.3% of men reported some history of lifetime trauma MORE likely to feel confident in screening and less likely to perceive time as a barrier. Surveys of other providers- common in health care in general.

22 Signs that a person may be feeling distressed: Emotional reactions anxiety, fear, powerlessness, helplessness, worry, anger Physical or somatic reactions nausea, light headedness, increase in BP, headaches, stomach aches, increase in heart rate and respiration or holding breath Behavioral reactions crying, uncooperative, argumentative, unresponsive, restlessness Cognitive reactions memory impairment or forgetfulness, inability to give adequate history

23 What Can Be Done To Provide Sensitive Care and Practices? Communicate a sensitivity to trauma issues Create a safe and comfortable environment Provide services in a trauma informed manner

24 Screening for Trauma Make it routine Not intrusive Gives patient the message that you know this is an important part of health history. May not give this information initially, but may over time Example: Many individuals I work with have experienced maltreatment as children or adults, for example sexual or physical trauma. This can impact your health care. Has anything like this ever happened to you? May ask directly about history (current and past) of physical or sexual harm, serious accidents, exposure to war or serious violence, how discipline was/is handled Use of standard questionnaires

25 Primary Care PTSD Screen In your life have you ever had any experience that was so frightening, horrible or upsetting that you: Have had nightmares about it or thought about it when you did not want to? Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings?

26 A brief, empathic, validating response by a healthcare provider to someone who discloses a trauma history may be: I m sorry that that happened to you; no one has the right to hit another person/force another person to have sex Growing up in an environment of violence is so difficult for a child no one should have to face such upsetting and scary situations We know that there is a direct relationship between these experiences and a person s physical health; have you ever had a chance to explore these?

27 Communicating a Sensitivity to Trauma Issues Trauma related materials in waiting areas Posters inviting individuals to talk about trauma and/or needs located in exam rooms Asking questions about trauma and/or needs before and during exams

28 Creating a Safe and Secure Environment Survey service recipients to gain feedback about their experiences, including the physical environment Solicit staff to suggest improvements to care and the environment Insure individuals feel welcome and comfortable from reception through exiting Do no harm prevent re-traumatization Provide trauma sensitive practices and care

29 Trauma Informed Care: Principles of Sensitive Practice 1. Respect 2. Taking Time 3. Rapport 4. Sharing Information 5. Sharing Control 6. Respecting Boundaries 7. Fostering Mutual Learning 8. Understanding Non-linear Healing 9. Demonstrating Awareness and Knowledge of Trauma Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse was researched and written by Candice L. Schachter, Carol A. Stalker, Eli Teram, Gerri C. Lasiuk and Alanna Danilkewich

30 Trauma Informed Care: Practical Tips Engage person, develop rapport and build trust over time Provide calm and soothing office environment Give relaxed, unhurried attention- Talk about concerns and procedures before doing anything (ex. asking patient to disrobe) Give as much control and choice as possible Validate any concerns as understandable and normal Allow a support person or female staff person to be present in the room Explain thoroughly each procedure and get consent

31 Trauma Informed Care: Practical Tips Ask if person is ready to begin and inform them that they can pause or stop procedure at anytime Encourage questions and ask about any worries or concerns and how you can help (ex. leaving door ajar) Maintain a personable, respectful, kind and honest manner Talk to person throughout to let them know what you are doing and why Encourage person to do what feels most comfortable (ex. keeping coat on, listening to music, keeping dental chair upright) Place a high priority on culture; including ethnicity, race, religion, sexual orientation, historical and social trauma such as homelessness and poverty

References/Resources Lucy Candib MD, et al; When the Doctor is a Survivor of Abuse. Family Medicine; 2012 ;44(6) 416-24. Crosby SS.

32 References/Resources Lucy Candib MD, et al; When the Doctor is a Survivor of Abuse. Family Medicine; 2012 ;44(6) Crosby SS. Primary Care Management of Non English-Speaking Refugees Who Have Experienced Trauma: A Clinical Review. JAMA. 2013;310(5): Vincent Filitti MD, et al, Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998; 14(4) Robert J. Ursano, David M. Benedek, Charles C. Engel; Trauma-Informed Care for Primary Care: The Lessons of War. Annals of Internal Medicine Dec;157(12): Linda Weinreb MD, et al; Screening for Childhood Trauma in Adult Primary Care Patients: A Cross Sectional Survey. Primary Care Companion J of Clin Psychiatry 2010; 12(6): e1-e10

33 References/Resources American Psychiatric Association Practice Guidelines for Acute Stress Disorder and PTSD SAMHSA (Substance Abuse and Mental Health Services Administration) Center on Trauma Informed Care in collaboration with the National Council on Behavioral Health: National Association of State Mental Health Program Directors

TRAUMA-INFORMED CARE:

TRAUMA-INFORMED CARE: W H A T I S I T A N D W H Y I S I T I M P O R T A N T? Stephanie Dove, M.A., LCSW MST Coordinator Phoenix VA Medical Center Stephanie.Dove@va.gov OBJECTIVES - Definition of trauma