Trauma-Informed Care for Refugee Populations: Building Awareness, Skills, and Knowledge

Transcription

1 Trauma-Informed Care for Refugee Populations: Building Awareness, Skills, and Knowledge Creating Pathways to Wellness: One-Day Seminar on Fostering Mental Health Among Rochester's Refugee Patient Population Nancy Murakami, LCSW Rochester, NY April 10, 2015

2 Refugee someone who fled his or her home and country due to a well-founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group, or political opinion 1951 United Nations Refugee Convention

3 Persons of Concern Country Refugees Asylum Seekers IDPs Globally 13 M 1.3M 26M Afghanistan 2.7M 75, ,000 Somalia 1.1M 40, M Sudan 670,000 33, M Burma 480,000 48, ,000 Iraq 426,000 53, M Nepal 41,000 Bhutan 27,000 Mid-Year Trends 2014, UN High Commissioner for Refugees; 2015 UNHCR Country Operations Profiles

4 Refugees and Trauma 2,511,061 refugees entered the United States ( ) [Office of Refugee Resettlement published in 2005] (recent estimates suggest >3M) 187,000 resettled refugees in NYC ( ) [migrationpolicy.org tabulation of ORR data] Rates of PTSD vary widely within any given refugee population, with prevalence rates ranging from 4% to 86% for PTSD and 5% to 31% for depression [Hollifield, M. et al (2002)]

5 Displaced Persons: Conditions for trauma responses and trauma reminders Pre-Flight Flight Post-Flight War Fear Language/cultural barriers Violence and Torture Lack of access Financial instability Arrests, imprisonment Hiding Housing instability Fear, threats Risks Shock Lack of access Lack of basic needs Change in roles Secrecy Loss Family tension Disrupted daily life Violence Differing rates of acculturation Separation and death Leaving others behind Discrimination More More More

6 What is Trauma? Stressful events are intense or overwhelming in the moment, but the person is able to return to their regular functioning soon after the event has ended An event is traumatic when it is experienced as so destructive or shocking that a person s coping skills are overwhelmed and the normal stress reactions are too intense for the body and mind to return to regular functioning after the event has ended

7 Post-Traumatic Stress Disorder (PTSD) Stressor: Exposure to a traumatic event Intrusion symptoms: Event is re-experienced Avoidance symptoms: Avoiding thoughts, feelings and reminders Negative alterations in cognitions and mood: negative beliefs & emotions, constricted affect, diminished interest Alterations in arousal and reactivity: irritability, hypervigilance, sleep, concentration

8 Trauma Reactions The world is unsafe I am crazy It is my fault Anxious Afraid Depressed Angry Thoughts Emotions Behaviors Sensorimotor Isolating Avoiding Re-enacting Rapid heart rate Rigid body posture Body Pains

9 Trauma Across Systems Individual Family/Friends Community Trauma & Conflict Society Coping & Healing

10 M: Current Functioning M is a 23 year old Karen women who resettled in Rochester 3 months ago. Pre-Flight Flight Post-Flight Limited English, literate in Karen and Burmese Fired from multiple jobs, rent late Misses bus stop often Not attending English classes Misses appointments at resettlement agency Does not answer calls Tired, memory issues, headaches, nightmares, Arguing with sister Sleeps on floor near door

11 A Trauma-Informed Approach Awareness and acknowledgment of: The high rates of traumatic experiences The broad impacts of traumatic experiences The silencing and shame around traumatic experiences Recognition of: The importance of empowerment and safety for the survivor The resilience of someone with a trauma history The impact of the trauma work on service providers

12 Application of a Trauma Approach Clinical Level assessment, intervention, and evaluation levels through questions you ask your case formulation terminology used with clients and colleagues intervention selection collateral work, referral options and processes Agency Level agency materials on-boarding processes supervision professional development and support

13 APPLICATION: Trauma-informed Assessments Explain encounter purpose, duration, expectation, next steps Explain who is present, seeking permission for additional people (including interpreters) Facilitate client s sense of agency and control Use supportive and normalizing language, tone, and presence Ask about history of traumatic events, if appropriate Do risk assessments Identify thoughts and behaviors that were perhaps once adaptive (when threat was still present) but have become maladaptive Assess distress tolerance (window of tolerance)

14 APPLICATION: Trauma-informed Assessments, cont. Assess client s understanding of the symptoms and the client s priorities of care Seek understanding of the symptoms and care from the client s family-, community- and cultural-perspective Identify self-protective skills and coping skills Assess support system and appropriate treatment team Assess and problem-solve potential barriers to care Know that assessment is ongoing and anticipate additional information being disclosed later *View client report and clinical observations through a trauma lens*

15 M: More History Pre-Flight Flight Post-Flight Fled by foot for days with family Received call that her brother had died Fear of Thai police Lived in Mae La Camp, Thailand for 10 years Resettled in Rochester only with sister Unstable housing Limited English, literate in Karen and Burmese Fired from multiple jobs, rent late Misses bus stop often Not attending English classes Misses appointments at resettlement agency Does not answer calls Tired, memory issues, headaches, nightmares, Arguing with sister Sleeps on floor near door

16 APPLICATION: Trauma-Informed Intervention Approaches Promote a clinical relationship of safety, empowerment, respect & hope Establish a predictable and consistent treatment frame Foster a collaborative approach Practice in culturally-informed ways Be clinically curious and nonjudgmental Validate your clients reactions Foster client s curiosity rather than shame and judgment about their own symptoms Acknowledge and praise your clients strengths and resiliency Prepare the client for efforts in and between sessions to self-regulate

17 APPLICATION: Trauma-Informed Interventions Individual, group, family, community, collateral interventions In medical, school, social service, mental health, community program, etc. settings Teach clients to monitor their functioning Provide trauma and symptom psycho-education Identify and teach affect regulation and cognitive coping skills Do and teach safety planning and harm reduction Promote support systems Listen and bear witness to your clients stories of trauma when recounted while in a window of tolerance Encourage practice, practice, practice of new coping strategies

18 M: Trauma-informed Assessment or Intervention Ideas Pre-Flight Flight Post-Flight Village destroyed by military in middle of night Homes burned Fled by foot for days with family Received call that her brother had died Limited English, literate in Karen and Burmese Fired from multiple jobs, rent late Neighbors shot Fear of Thai police Misses bus stop often Knocked unconscious with rifle butt Landmines laid so could not return Lived in Mae La Camp, Thailand for 10 years Resettled in Rochester only with sister Not attending English classes Misses appointments at resettlement agency Education stopped Unstable housing Does not answer calls Brother joined KNU and unheard from since Tired, memory issues, headaches, nightmares Arguing with sister Sleeps on floor near door

19 PRACTICE: Apply a Trauma Lens to these Manifestations of Trauma Report of Somatic Symptoms Missed Appointments Arriving Late Anger at the provider Forgetting things Resistance Checking out Asking multiple providers for the same thing Sharing different information with different providers

20 APPLICATION: Trauma-Informed Referral Approaches Become familiar with other agencies, their services, and their approaches to working with trauma survivors Acknowledge personal and agency s limits and refer out when Other individuals or agencies have greater expertise Specialized treatment is indicated (e.g. substance abuse, high risk behaviors, trauma processing) You cannot meet client s cultural/linguistic needs Expand client support system by referring to additional programs Incorporate client s traditional and spiritual practices into the referral plan Prepare client for the referral, what to expect, potential challenges/barriers, have a planned good-bye Facilitate successful connection with new agency

21 APPLICATION: Trauma-Informed Agency-Level Approaches Discuss what is needed for your agency to conceptualize itself as providing trauma-informed care. Are the necessary changes possible at this time? Review agency training and operations materials and consider integration of trauma constructs, language, and approaches Review agency screening and on-boarding processes for personnel and consider integration of trauma Can trauma-informed supervision be available at all levels of staffing? What individual and agency commitments can be made to professional development and support related to trauma, traumainformed care, and vicarious trauma? Establish a resource guide of trauma-informed services and agencies in the community for referrals, collaboration, joint funding, etc.

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