Trauma-Informed Care: What Health and Social Service Providers Need to Know to Improve Patient Care

Transcription

1 Trauma-Informed Care: What Health and Social Service Providers Need to Know to Improve Patient Care Michelle Hoersch, MS Regional Women s Health Coordinator U.S. Department of Health and Human Services- Office on Women s Health Sheela Raja, PhD Clinical Psychologist and Assistant Professor University of Illinois at Chicago Region V - Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin

2 Office on Women s Health Vision: All women and girls achieve the best possible health Mission: The Office on Women s Health provides national leadership and coordination to improve the health of women and girls through policy, education and model programs. 2

3 Goals The Office on Women s Health provides national leadership to: Inform and advance policies Educate the public Educate professionals Support model programs 3

4 Violence Against Women Violence against women is so pervasive that the United Nations has addressed and defined violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life. (United Nations General Assembly, 1993) 4

5 Region V Focus on Trauma Vision To equip every health and social service provider and institution with the knowledge, resources and support to provide services that are gender responsive and trauma informed so as to provide the best possible care for trauma-affected individuals. 5

6 Collaboration Dr. Sheela Raja Clinical Psychologist and Assistant Professor University of Illinois - Chicago 6

7 My interest in trauma began with a visit to a prison 7

8 Functional definition of trauma Trauma occurs when an external threat overwhelms a person s coping resources 8

9 What is trauma? A practical definition Non-consensual Victim is in discomfort, fear, feels intimidated Bodily integrity, or that of someone else, is threatened 9

10 Prevalence of Trauma in the U.S. Rape and Sexual Assault One out of every 6 American women has been the victim of an attempted or completed rape in her lifetime 17.7 million American women have been victims of attempted or completed rape. 10 Source: RAINN

11 Prevalence of Trauma in the U.S. Child Abuse In 2009, approximately 3.3 million child abuse reports and allegations were made involving an estimated 6 million children. 1 11

12 Prevalence of Trauma in the U.S. Childhood Sexual Abuse Estimated that at least 2 out of every 10 girls 1 out of every 10 boys are sexually abused by the end of their 13 th year 12

13 Prevalence of Trauma in the U.S. Intimate Partner Violence Nearly one in three adult women experience at least one physical assault by a partner during adulthood. Men who have witnessed their parents' domestic violence are twice as likely to abuse their own partners compared to men of non-violent parents. Girls who have witnessed domestic violence are more likely to stay in an abusive relationship as an adult. More than 50% of batterers also abuse their children or their victim s children. Report of the American Psychological Association Presidential Task Force on Violence and the Family, (1996) 13

14 Prevalence of Trauma in the U.S. Elder Abuse Over one million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection. 4 14

15 Prevalence of Trauma in the U.S. Historical Trauma American Indians and Alaska Natives Robbed of culture Boarding schools 15

16 Prevalence of Trauma in the U.S. War and Military Exposure to combat either as soldier or civilian Military Sexual Assault 16

17 Prevalence of Trauma in the U.S. Natural Disasters and Terrorism Hurricanes Tornados 9/11 BP Deep Water Horizon Boston Marathon No one who sees a disaster is untouched by it. 17

18 Prevalence of Trauma in the U.S. Very common that an individual will have exposure to multiple traumatic events during their lives 18

19 The impact of trauma is dramatically underestimated 19

20 Short Term Consequences 20

21 Psychological Aftermath Disbelief, numbness, or shock Shame, guilt, or self-blame Anxiety, sadness, or anger Confusion or helplessness Fear or lack of safety Difficulty concentrating 21

22 Physical Aftermath Appetite changes Sleep changes Aches and pains in the body 22

23 Behavioral aftermath Difficulty trusting others Isolation Missing work, classes, appointments Using alcohol or drugs as a means to cope 23

24 Long- term consequences Emotional Stress High-Risk Behavior Physical and Mental Illness, Disease and Disability 24

25 The Adverse Childhood Experience (ACE) Study Study analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life. On-going collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente Health System. The Co-principal Investigators - Vincent J. Felitti, MD, Kaiser Permanente Robert F. Anda, MD, MS, CDC 25

26 The Adverse Childhood Experience (ACE) Study Over 17,000 Kaiser patients participated in routine health screening volunteered to participate in the study Data continues to be collected and analyzed Study reveals staggering proof of the health, social, and economic risks that result from childhood trauma 26

27 What is an ACE? Growing up experiencing any of the following conditions in the household prior to age 18: Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol/and or drug abuser in the household An incarcerated household member Someone who is chronically depressed, mentally ill or suicidal Institutionalized household member Mother is treated violently One or no parents in home Emotional or physical neglect 27

28 ACE Scores ACE Score Prevalence 0 33% 1 25% 2 15% 3 10% 4 6% 5 or more 11%* *Women are 50% more likely to have a score >5. 28

29 The ACE pyramid 29

30 ACE Study findings Suicide At least 2/3 of all attempted suicides can be attributed to adverse childhood experiences. Sexually Transmitted Diseases There is a 250% increased risk of having a sexually transmitted disease between individuals with an ACE Score of 4 compared to those with an ACE Score of

31 ACE Study findings An Individual with an ACE Score of 4 is: COPD 260% more likely to have COPD than someone with an ACE score of zero. Depression 460% more likely to be suffering from depression than one with an ACE score of zero. 31

32 ACE Study findings IV Drug Use A male child with an ACE score of 6 or more has a 4600% increased likelihood of becoming an IV drug user. 32

33 Relationship between Trauma and Health Risk Behaviors A quote from Dr. Felitti: It s hard to give something up that almost works. 33

34 ACE Study findings As the number of ACEs increase, the risk for health problems increase in a strong and graded fashion. 34

35 In summary, the ACE Study indicates Adverse childhood experiences are the most basic and long lasting determinants of: health risk behaviors mental illness social malfunction disease disability death healthcare costs 35

36 Utilization of Medical Services Trauma survivors: Have higher utilization of medical services Report a greater # of physical health problems 36 Sources: Kartha et al., 2008; Lesserman, et al., 2006; Letourneau, Holmes, & Chasendunn-Roark, 1999; Nicolaidis, et al., 2004; Sadler, et al, 2000; Sledjeski, Speisman & Dierker (2008)

37 Preventive Care Female trauma survivors are less likely to: Obtain regular mammograms Obtain regular cervical cancer screenings Attend regular dental appointments 37 Sources: Farley, Golding, & Minkoff (2002); Farley, Minkoff, & Barkan (2001); Farley & Patsalides (2001)

38 Other Studies of Health and Trauma Chronic pain, GI disorders, Gynecological problems, Fibromyalgia Obesity, Substance abuse, Smoking Multiple traumas have more physical health consequences Depression & PTSD aren t the whole story Neuroendocrine differences when survivors/nonsurvivors deal with stress. 38 Sources: Kartha et al., 2008; Lesserman, et al., 2006; Letourneau, Holmes, & Chasendunn-Roark, 1999; Nicolaidis, et al., 2004; Sadler, et al, 2000; Sledjeski, Speisman & Dierker, 2008

39 Secondary Victimization 39

40 Secondary Victimization Also referred to as re-traumatization : Victimization which occurs, not as a direct result of the traumatic event, but through the response of institutions and individuals to the victim 40 Sources: Campbell & Wasco (2005); Campbell & Raja (2005); Campbell, Wasco, Ahrens, et.al, (2001)

41 The Results of Secondary Victimization Actually increases mental health symptoms Stigmatizing reactions and distraction ( get on with your life, stop talking about it ) have the worst effects 41 Sources: Campbell & Wasco (2005); Campbell & Raja (2005); Campbell, Wasco, Ahrens, et.al, (2001); Ullman & Filipas, 2001

42 Retraumatization - Specific Examples ER visit The forensic rape exam procedure Primary care Disclosure of DV ( you need to leave, NOW ) Disclosure of trauma ( it will all be ok ) A surgical procedure Feeling out of control during sedation 42

43 Retraumatization - Specific Examples Dental settings Supine position Can t speak Psychiatric Settings Restraints Invasive searches 43

44 So what can be done to prevent re-traumatization? 44

45 Trauma-Informed Care 45

46 Trauma-informed care Services that are provided for issues other than trauma but require knowledge about the impact of trauma to improve effectiveness 46

47 Trauma-informed services Take the trauma into account Avoid triggering trauma reactions and/or traumatizing the individual Adjust the behavior of providers, other staff, and the organization to support the individual s coping capacity Allow survivors to manage their trauma symptoms successfully so they are able to access, retain, and benefit from services (Harris and Fallot) 47

48 Trauma-Informed Care Your words, actions, and policies have the ability to hurt or heal Clients remember and truly value what you say and do 48

49 What is Trauma-Informed Care? Every part of an agency or institution Understands the effects of exposure to traumatic events Sensitively interacts with trauma survivors Prevents re-traumatizing Engages in trauma screening only as appropriate and after extensive proper training 49

50 Goal: Universal trauma precautions Keep in Mind You are likely to encounter survivors of trauma who do not disclose Not all survivors are psychologically ready to discuss their experiences Suggestions Assume a trauma history Inform staff of a confirmed history and pass on specific treatment plan recommendations 50 Source:

51 Goal: Screen when appropriate Keep in Mind Tools like the ACE or the Primary Care-PTSD Screen can be used to screen for trauma Specific Suggestions Have a standard procedure to screen and review the results Practice discussing a positive result with clients 51

52 Trauma-Informed Care Paradigm shift from What s wrong with you? to What happened to you? 52

53 What predicts recovery? No prior trauma history Social support A sense of life purpose Intervention A feeling of mastery Religious/Spiritual coping Approach vs. Avoidance Source: Alim, et al., 2008; Frazier, et al,

54 Brief Summary Traumatic events are highly prevalent in our society Trauma has negative physical, psychological and behavioral consequences Survivors sometimes experience secondary victimization when they seek help You can help reduce some of these long-term issues through trauma-informed practices 54

55 Trauma Theory and Interventions Stephanie Covington, PhD. Sandra Bloom, M.D. Mary Harvey, Ph.D. Judith Herman, M.D. Peter Levine, Ph.D. et al. Integrate cognitive-behavioral, expressive arts, guided imagery, and relational therapy approaches 55

56 Substance Abuse Mental Health Services Administration (SAMHSA) SAMHSA's National Center for Trauma-Informed Care (NCTIC) a technical assistance center dedicated to building awareness of trauma-informed care Promotes the implementation of trauma-informed practices, programs and services. 56

57 Webinar Series provided by the Office on Women s Health in partnership with SAMHSA To Register for our upcoming webinars: 57

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59 Contact Info Michelle D. Hoersch, MS Office on Women's Health - Region V U.S. Department of Health and Human Services 233 N. Michigan Ave, Suite 1300 Chicago, IL michelle.hoersch@hhs.gov 59