Traumatized People, Service Delivery Systems, and Learning from 9/11 (NYC) Ryan Edlind MS, MSW, LISW-S April 29, 2015 Traumatized People, Service Delivery Systems, and Learning from 9/11 (NYC) Ryan Edlind MS, MSW, LISW-S April 29, 2015 You observe a lot by watching. -Yogi Berra 1
Our Goals Today o Introduction to trauma theory and PTSD o Secondary traumatic stress and self care for the service provider o Effective professional services and transformational community o Treatment processes and current research based practices o Implications of trauma in case management Trauma Informed Practice o What do you think of when you hear the word trauma or loss? o What types of events are traumatic? 2
What is Trauma Informed Care Paradigm Change for Service Provision Was based on What is wrong with you? Now, What has happened to you? Behaviors & responses (symptoms) expressed by survivors are often directly related to traumatic experiences. Definitions o Traumatic Event - a situation that causes physical or psychological distress o Traumatized Person- someone hurt by a serious injury or shock to the body o Stress- physical or psychological tension o Stress Injury- life threat, loss (death, power, relationship), inner conflict (violation of values), wear & tear (fatigue without rest of recovery) Definitions o Person s response involves intense fear, horror and helplessness, leading to extreme stress that overwhelms the person s capacity to cope. o This includes sexual abuse, physical abuse, severe neglect, loss, domestic violence and the witnessing of violence, terrorism, or disasters. 3
For the Professional Helper: Mental Health Assessment Tools o Psychometrics (CAPS, Beck, etc.) o See www.ptsd.va.gov//professional/pages/asse ssments/all_measures.asp o Interviewing and Narrative Reports For the Professional Helper: DSM IV-TR Classification: 3 symptom clusters DSM V Classification: 4 symptom clusters o Intrusion; avoidance; negative alterations in cognition & mood; alterations in arousal & reactivity o Subtypes: Delayed onset; depersonalization & de-realization; childhood 4
PTSD Symptomology Cluster 1: Intrusion Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s). PTSD Symptomology Cluster 1: Intrusion Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli. PTSD Symptomology Cluster 2: Avoidance Trauma-related thoughts or feelings. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations). 5
PTSD Symptomology Cluster 3: Negative Alternations in Cognition and Mood Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs). Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. PTSD Symptomology Cluster 3: Negative Alternations in Cognition and Mood Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). Constricted affect: persistent inability to experience positive emotions. PTSD Symptomology Cluster 4: Alternations in Arousal and Reactivity Irritable or aggressive behavior Self-destructive or reckless behavior Hyper-vigilance Exaggerated startle response Problems in concentration Sleep disturbance 6
PTSD Symptomology Prevalence of Trauma o National co-morbidity survey Kessler et al., 1995 (benchmark study, 5000 US adults) o 61% of men and 51% of women experience trauma in their lifetime o More than 25% experience multiple traumas as witness, accident, threat, natural disaster, physical attack, combat, abuse/ neglect, molestation, rape. Prevalence of Trauma o Lifetime PTSD prevalence is only 6.8% (9.7% women, 3.6% men) o Like anxiety and depression, women twice as likely to experience PTSD o Currently 3.6% have PTSD (5.2% women, 1.8% men) 7
Combat Exposure In National Co-Morbidity Survey o Lifetime prevalence of PTSD= 39% among male combat veterans o Likely delayed onset and unresolved symptoms o Gulf War: 10% o Afghanistan War (ongoing research): 6-11% o Iraq War (multiple deployments): Army 13-18%, Marines 12-20% by Kang et al., 2003; Hoge et al., 2004 Conditional Risk of PTSD o Women are more likely to develop PTSD than men. 20% of exposed women and 8% exposed men develop PTSD o Men experience more traumatic events than women, possibly by nature of work (fire, police, military, etc.) o Some types of traumatic events are more likely to cause PTSD Conditional Risk of PTSD o Gender differences & PTSD are not easy to explain, and not due to exposure. Possible that women internalize events differently. o Severity of exposure (frequency, duration, intensity) 8
Consequences of PTSD o Elevated risk of mood, other anxiety, and substance abuse disorders o Greater functional impairment o Reduced quality of life o Elevated risk of poor physical health PTSD & Co-Morbidity o Men 88%, Women 79% have another disorder with PTSD o Major Depressive Disorder (men 6x more likely and women 4x more likely) o Dysthymia o GAD, Panic, Simple, Social Phobia, Alcohol Abuse- Kessler et al., 1995 PTSD & Other Problems o o o o Teenage parenthood: 30x more likely Academic failure: 40x more likely Marital problems: 60x more likely Unemployment: 150x more likely 9
Course and Onset of PTSD o Course is variable o Onset usually occurs within 1-2 years of trauma (can be long-delayed) o Relapse is common (likely 3-5 years) o Symptoms common in chronic PTSD o New trauma or life events can reactivate symptoms Risk Factors for PTSD o Pre-trauma risk factors least significant (female, genetics, childhood trauma, previous psych. problems, lower level of education, lower IQ, lower socioeconomic status, & minority race) Brewin, et. al., 2001 o Peri-traumatic (at time of event) a significant predictor of PTSD. Severity of event, danger, perceived threat, unpredictability, and uncontrollability key variables. Risk Factors for PTSD Two greatest post-trauma risk factors are o Lack of social support o Concurrent life stressors 10
9/11 Memorial Hall No day shall erase you from the memory of time. -Virgil Trauma Treatment Updates Peri or Post Trauma Psychological First Aid o Prior to onset of PTSD o Safety, calming, connection, self-efficacy, hope o Least intrusive to most intrusive o Practical, needs focused, problem solving, referrals Trauma Treatment Updates Post Trauma Acute Stress Management o Prior to onset of PTSD o Healing injuries and illness o Con-joint, short term, and long term care o EMDR, CBT, psychotropic medication, medical evaluation 11
PTSD Treatment Treatment Planning and Outcome Foci o Treatment Obstacles o Co-morbidity o Substance Abuse o Resistance to counseling and mental health o Access to services Implications for the Patient Care: o Commitment from administrative staff to determine flow of resources o Ensuring that staff receive training o Hiring practices & identifying trauma champions. o Focus on empowerment vs. management & control Implications for Patient Care: o Build on strengths & promote resilience o Be holistic & use 1 st person language with decreased emphasis on symptoms or behaviors o Consider triggers, sensory stimulation, repetition compulsion, power struggles, and self-protection through the lens of trauma. 12
Implications for Patient Care: o Create an affectively calm place to decrease or mitigate hyper-arousal o Use safety focused & sensory-based interventions o Create Best Practices Guidelines for traumatized patients o Develop and practice coping skills over strictly gaining insight Implications for Provider: o Know signs of compassion fatigue o Watch for isolation and activation of your own traumas o Consider boundaries, burnout, secondary traumatic stress o Prepare a personal coping plan Final Implications for Provider: o Use universal precautions and assume that all people with whom you are working are coping with effects of trauma, and modify your professional practices accordingly. 13
Resources: o Domestic Violence & Child Advocacy Center o Rape Crisis Center of Cleveland o Cornerstone of Hope o Psychologist (EMDR Specialist) Dr. Warren Faber Resources: o US Government www.ptsd.va.gov o International Society for Traumatic Stress Studies www.istss.org o National Center for Trauma Informed Care www.mentalhealth.samhsa.gov/nctic 14