2/9/2015. F lourish. Trauma-Informed Care. Overview. Dr Annabel Mead MBBS FAChAM dipabam

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1 Trauma-Informed Care Dr Annabel Mead MBBS FAChAM dipabam Overview Defining trauma and its effects Providing Trauma Informed Care Trauma in the Workplace Developing Trauma Informed Services F lourish... Taken from me was my childhood, my youth Finally I am able to tell the truth My soul aches with anxiety and despair I was so lost I thought nobody cared The hole inside of me is like a chasm Whenever I think of it, my heart does spasm What he did took over my being... 1

2 What s the big deal about trauma? Pervasiveness of Trauma Effects: Mental health Substance use Physical health : access to treatment : retention in treatment : recovery Canadian Reports on HIV & Trauma Canadian Aboriginal AIDS Network AW dx at younger age, later in their disease, IDU The Cedar Project [Pearce et al, 2008] HIV in Aboriginal street youth and female sex workers [Duncan et al, AIDS and Behavior, 2011] Childhood trauma among HIV+ IDUs : 42-52% prev. [Walton G et al, AIDS Care, 2011] 2

3 Our Search For Safe Spaces A qualitative study of the role of sexual violence in the lives of aboriginal women living with HIV/AIDS Exposure to violence Violence-related exposure to HIV (direct & indirect) HIV-related exposure to violence Experience with health and welfare services Racism, sexism, stigma of HIV Relationship between Trauma & HIV US data High prevalence of trauma in PLHIV cf general population. Trauma in adulthood and post-hiv dx is higher CHASE study: 2x all-cause death rate faster progression to OI or AIDS death Depressive sx increase AIDS, reduce CD4 Recent trauma predicts ARV failure. 30% PTSD rate in HIV+ W (meta-analysis) What is Trauma Informed Care? An organisational structure and treatment framework Involves understanding, recognizing and responding to the effects of all forms of trauma. Gives priority to safety, choice and control. 3

4 What is Trauma? Experience(s) that overwhelm an individual s capacity to cope Both internal and external resources are inadequate to cope with the external threat. [Van der Kolk] They are life events that are out of one s control : potentially devastating emotional, physical & behavioral disturbances. Ability to cope with trauma: Context of the trauma Single vs repeated Age of person Natural vs human Accidental vs purposeful Environmental supports Innate resilience Types of Trauma Single incident trauma (an unexpected, overwhelming event) Complex / repetitive trauma (ongoing abuse, DV, war) Developmental trauma Intergenerational trauma Historical trauma Sanctuary trauma 4

5 Effects of Trauma Psychological Developmental Physical Interpersonal Spiritual Behavioural shame, guilt anxiety, terror, shock Psychological emotional numbness, disconnection dreams helplessness powerlessness memory Developmental effects of trauma Childhood abuse Attachment / intimate relationships : emotional regulation Impulse control Cognitive impairment & attention deficits ACE study [Felitti & Anda] 5

6 ACE Study American Adverse Childhood Events study [Felitti & Anda] Includes multiple possible events: abuse, neglect, witnessing violence, parental divorce, mental illness, substance abuse, incarceration ACE > 4: highly predictive of multiple health problems ACE of 7: 51 x increase in adolescent suicide attempts 30 x increase in suicide attempts in adulthood. Neurobiology Flight, fight or freeze response to danger Activated by the amygdala Adrenaline stress response Prefrontal cortex activity decreases Physiological Adaptations Occur with exposure to chronic stress or recurrent traumas: Hyper-arousal : anxious, jumpy, sleep-disturbed Hyper-vigilence : external focus of attention Dissociation 6

7 Behavioural Adaptations Self-harm reduces tension / downgrades arousal increases adrenaline and endorphins (dissociative) Disordered eating Alcohol or drug use Avoidance of triggers Risky behaviours Effects on Identity and Agency Early abuse distorts the core of a person s identity Poor internal sense of self Lack of trust frequent conflicts difficulty establishing/maintaining close relationships boundaries Spiritual effects: Loss of meaning/faith Loss of connection Shame, guilt Self-blame Self-hate 7

8 Labeling Symptoms and behaviors subsequent to trauma can be missed / misdiagnosed if we don t apply a trauma lens. psychoses personality disorder anxiety disorders bipolar ADHD Case Scenario A young homeless woman arrives at your out-patient clinic with an infected ulcer on her lower leg. Past history HIV infection secondary to IDU. Polysubstance use. She is presenting with significant pain, and is irritable and agitated. 8

9 Change the fundamental question: What is wrong with this person? to What has happened to this person? Behaviours (maladaptive) in a clinical setting Disengagement Aggression and poor impulse control in new situations Quick deterioration power and control struggles Rule enforcement : aggression and fear Minor events precipitate catastrophic reactions Trauma-Informed Practice 9

10 Engagement Welcoming, friendly environment Focus on safety Attend to immediate needs Be transparent and predictable Respect healthy boundaries Informed consent Principles of Care Avoid retraumatization Early disclosure, safe pace Empowerment : Choice and control / Strengths / Skills Work collaboratively, with flexibility Safety & trustworthiness Relating to trauma survivors Cultivate safety in every interaction Non-judgemental Avoid confrontational approaches Pay attention to (un)spoken responses Motivational Interviewing techniques 10

11 Response to upset behavior Reinterpret through the lens of trauma exposure Notice own internal reactions, avoid over-reacting Validate Provide safety Offer verbal support and grounding Strengthen empowerment + collaboration Mindfulness the intentional, accepting and non-judgmental focus of one s attention on the emotions, thoughts and sensations occurring in the present moment Practice traps Fixing and taking over Feeling overwhelmed Rigidity in practice Losing awareness of body language/exp 11

12 Recovery from Trauma Work with the relative strengths Set up resiliency rather than undo the trauma Moves through four stages Victimization: not a failure or damaged, but changed Safety & self-care: managing symptoms Integration of trauma: disclosure, integration and self as survivor Reconnection with others: beyond survivorship to intimacy, trust & meaning [Glenn Grigg] 12

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