Didactic Series Trauma-Informed Care David J. Grelotti, MD Director of Mental Health Services, Owen Clinic UC San Diego May 10, 2018 1
Learning Objectives 1) Understand the burden of trauma in HIVaffected persons and its impact on the HIV epidemic 2) Review principals of trauma-informed care how to integrate trauma-informed care in an HIV primary care practice 2
We know how to prevent HIV. We know how to treat HIV. Why do people still get HIV? Why do people still die from HIV? 3
Question 1 Untreated psychiatric disorders among PLWH are risk factors for which of the following: A. Poor linkage to HIV care B. Poor adherence to ART C. Higher healthcare costs D. All of the above 4
Psychosocial comorbidities worsen HIV outcomes Trauma Alcohol Drug use Depression Increase risk of HIV infection Act as barriers to accessing treatment services and delay in initiating antiretroviral therapy Are associated with suboptimal adherence to therapy, treatment failure, poorer viral suppression Are associated with greater HIVrelated morbidity and mortality
What is a syndemic? A syndemic is a set of intertwined and mutually enhancing epidemics involving disease interactions at the biological level that develop and are sustained in a community/ population because of harmful social conditions and injurious social connections. - Singer & Clair 2003
What is syndemics theory? 1. Harmful social conditions: Political, economic, and cultural factors affecting communities leads to disease concentration 2. Disease concentration: Diseases occurring at the same time and in the same location lead to disease interaction 3. Disease interaction: Interactions of diseases lead to mutually reinforcing harmful effects on health 10
What can be done about syndemics? Structural Reform Treat syndemics Trauma- Informed Care Harmful social conditions Early life adversity Psychosocial epidemics HIV vulnerability HIV infection HIV-related morbidity and mortality Promote Targeted prevention resilience Gilbert et al. 2015; O Leary et al. 2014; Pitpitan et al. 2015; Pachankis 2015; Blank et al. 2013; Operario and Nemoto 2010; Rotheram-Borus et al. 2009
Question 2 Which statement about trauma exposure among PLWH is true? A. HIV-infected women have higher rates of trauma exposure than HIV-infected men. B. HIV-infected men have higher rates of trauma exposure than HIV-infected women. C. HIV-infected men have equivalent rates of trauma exposure than HIV-uninfected men. 9
Disparities and HIV Greater exposure to adverse social conditions Poverty Stigma Trauma Higher burden of psychiatric disorders Alcohol use disorder Depression Drug use disorder Post-traumatic Stress Disorder 10
Trauma Trauma is the result of an event, series of events, or set of circumstances that is experienced by an individual as: physically or emotionally harmful or life threatening has lasting adverse effects on the individual s functioning and mental, physical, social, emotional, or spiritual well-being Trauma can have an impact across settings, services, and populations SAMHSA 2014 11
Types of trauma LeGrand et al. 2015 12
Trauma exposure among PLWH Whetten et al. 2006 13
Common reactions to trauma Numbness and detachment Heightened startle reactions, difficulty concentrating, hyperarousal, sleep disturbances, and physical complaints Reexperiencing of the trauma: nightmares, flashbacks, trauma-related hallucinations, intrusive thoughts, and memories Emotional dysregulation, anxiety (including panic attacks), and mood disorders Avoidant behaviors, including self-medication through substance use Cognitive changes regarding beliefs about the future, oneself, and the world 14
Trauma can affect the person Poor (i.e., less active and emotion-focused / emotionally reactive) coping styles Avoidant attachment styles A poor sense of self-efficacy Mistrust in the medical system and medical providers A greater burden of mental health disorders (PTSD, depression, cognitive disorders) Alcohol and drug use Hostility Sexual health problems, Difficulty with risk appraisal Sexual impulsivity 15
Trauma has external mediators Poor social supports Recent stressful life events Poverty High-risk occupations including sex work Infrequent condom use Homelessness 16
Trauma and the HIV risk Dissociation Sexual risk behavior Trauma Stress Interpersonal vulnerability Depression Substance use Barriers to healthcare Forced sex Brezing et al. 2015 17
Trauma and HIV HIV infection 5% of HIV-uninfected MSM who had a history of 1 syndemic (childhood sexual abuse only) seroconverted over a 4-year period 18-25% of HIV-uninfected MSM who had a history of 4 syndemics (including childhood sexual abuse) Adherence Viral suppression Mimiaga et al. 2015; Blashill et al. 2015; Friedman et al. 2015 18
Question 3 True or false: All traumatic events have a long-lasting, negative impact on person s health. A. True B. False 19
Resilience 20
Intervention research Seeking safety: PTSD and substance use to reduce symptoms Individual interventions: Physical and sexual abuse to reduce STI, mental health problems Community interventions: Intimate partner and other forms of interpersonal or community violence Sales et al. 2016; Empson et al. 2017 21
Trauma-Informed Care (TIC) Creating a safe space Context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. Anticipate and avoid institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma. Uphold the importance of consumer participation in the development, delivery, and evaluation of services. SAMHSA 2014 22
The 4 R s Realize the widespread impact of trauma and understands potential paths for recovery Recognize the signs and symptoms of trauma in clients, families, staff, and others involved with the system Respond by fully integrating knowledge about trauma into policies, procedures, and practices Resist retraumatization SAMHSA 2014 23
Treatment principles Promote Trauma Awareness and Understanding Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences View Trauma in the Context of the Client s Environment Minimize the Risk of Retraumatization or Replicating Prior Trauma Create a Safe Environment Identify Recovery From Trauma as a Primary Goal Support Control, Choice, and Autonomy Create Collaborative Relationships and Opportunities for Participation Familiarize the Client With Trauma-Informed Services Incorporate Universal Routine Screenings for Trauma View Trauma Through a Sociocultural Lens Use a Strengths-Focused Perspective: Promote Resilience Foster Trauma-Resistant Skills Show Organizational and Administrative Commitment to Trauma-Informed Care. Develop Strategies To Address Secondary Trauma and Promote Self-Care Provide Hope Recovery Is Possible. SAMHSA 2014 24
Screen for PTSD Primary Care PTSD Screen (PC-PTSD) In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you Have had nightmares about it or thought about it when you did not want to? YES NO Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO Were constantly on guard, watchful, or easily startled? YES NO Felt numb or detached from others, activities, or your surroundings? YES NO Prins et al. 2004 25
Approach to patient Provide Psychoeducation About Trauma, Common Traumatic Stress Reactions, and Treatment. Offer Trauma-Informed Peer Support. Use Strategies To Normalize Symptoms of Traumatic Stress. Identify and Manage Trauma-Related Triggers. Draw Connections Among Clients Histories of Trauma and Subsequent Consequences. Teach Balance. Build Resilience. Address Sleep Disturbances and Disorders. Build Trust. Support Empowerment. Acknowledge Grief and Bereavement. Use Culturally and Gender-Responsive Services. SAMHSA 2014 26
Summary recommendations Create a practice environment that promotes a sense of safety in all patient interactions Screen for and identify trauma, its mediators, posttraumatic sequelae, poor adherence to treatment, and high-risk HIV behaviors. Provide patient education about the relationship between trauma and HIV infection. Become acquainted with resources in the area and make referrals when available for specialized trauma and mediatorspecific treatments Involve patient's social supports in treatment plans whenever possible. SAMHSA 2014; Brezing et al. 2015 27
References National Center for Trauma Informed Care (https://www.samhsa.gov/nctic) Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 28