Trauma-informed And Resiliency-promoting Care
Trauma-informed andresiliency-promoting careLeigh Kimberg, MDDivision of General InternalMedicineUCSF/Zuckerberg San FranciscoGeneral Hospital and TraumaCenterDecember 5, 2017Leigh.kimberg@ucsf.edu
DisclosuresI have nothing to disclose
Learning Objectives Define trauma and resilienceReview how childhood trauma results indisease and poor outcomesDefine “trauma-informed care” and describeways of addressing trauma using health careas an exampleEmphasize the importance of caring foryourself as you care for others
Caring for Ourselves:Practice
Define Trauma “an event, series of events, or set ofcircumstances [e.g., childhood and adultphysical, sexual, and emotional abuse;neglect; loss; community violence;structural violence; war] that isexperienced by an individual as physicallyor emotionally harmful or threatening andthat has lasting adverse effects.”– The Substance Abuse and Mental Health ServicesAdministration (SAMHSA)Trauma ruptures Relationships
Trauma and Resilience:Socio-ecological modelTrauma and adversity are SDOH that areinequitably distributed in iew/social-ecologicalmodel.html
How Common Is Trauma? In 2015, 60.8% of children were exposed to atleast 1 form of violence in past year; 10% childrenexposed to 6 or more forms of violence in pastyear.90% of US residents have experienced a serioustraumatic event in their lifetimes253% of all adults are exposed to either physical orsexual interpersonal violence over their lifetimes21. Finkelhor, D., et al. (2015). "Prevalence of childhood exposure to violence, crime, and abuse: Results from thenational survey of children’s exposure to violence." JAMA Pediatr 169(8): 746-7542.2. Kilpatrick, D.G., et al., National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSMIV and DSM-5 Criteria. Journal of Traumatic Stress, 2013. 26(5): p. 537-547.
Trauma affects health:Adverse Childhood Experiences(ACE) study 17,000 predominantly White, college educated KaiserpatientsSurveys asked about 10 categories of childhoodabuse, neglect and family dysfunctionCross-sectional study: compared answers to an arrayof current health behaviors and conditionsConclusion: ACEs are common; and are strongpredictors of later health risks and disease in agraded dose-response relationship– Felitti VJ et al Childhood Experiences (ACE) Study.American journal of preventive medicine. 1998May;14(4):245-58.
ACES Study: Prevalence of childhoodphysical and sexual abuse?1. 5% physical, 2% sexual2. 10% physical, 5% sexual3. 28% physical, 20% sexual4. 60% physical, 40% sexual
ACES: Results
ACE’s: Childhood ExperiencesAffect health across thelifespan Adverse behaviors: Children: behavioral &developmental problems Alcoholism and alcohol abuse Illicit drug use Smoking Early initiation of smoking Early initiation of sexual activity Multiple sexual partnersReproductive outcomes: Unintended pregnancies Adolescent pregnancyFuture violence: Risk for intimate partnerviolenceAdverse health outcomes: Fetal death Childhood asthma & failure tothrive Depression Suicide attempts Sexually transmitted diseases(STDs) Health-related quality of life Obesity Ischemic heart disease (IHD) Liver disease Chronic obstructive pulmonarydisease (COPD)Adverse social outcomes: Homelessness Incarceration
Our experiences andrelationships build our brains,bodies, and behavior Harvard Center on the Developing Child http://developingchild.harvard.edu/Bellis, M. A., et al. (2017). BMC Psychiatry 17: 110.
The Science of Toxic Stresssee: http://developingchild.harvard.edu/
ACE study:
ACE’s: Life Expectancy—adult healthis affected by childhoodexperiences
Adulthood IPV: HealthEffects Injuries and deathPoor mental health (depression, anxiety, PTSD)Increased suicidalityPoor physical health (eg’s)Chronic painDisabilityAsthmaStrokeHeart diseaseSTD’s—risk doubled or tripled, HIV risk increasedUnwanted pregnancy and abortionsSubstance addiction (ETOH) increasedOveruse of health services and missed medical appointments andhigher cost of timatepartnerviolence/consequences.html
Trauma is rooted in oppressionand discrimination Structural Violence Interpersonal Violence Continuum RacismHomophobia/TransphobiaMisogyny/gender-based violenceXenophobiaDiscrimination against people with disabilitiesPolice brutality and violenceMass incarceration/ unnecessary criminalizationBullyingCommunity violence/response to community violenceWar/Genocide/Rape and Torture used in warPoverty/discriminatory economic policiesHousing instability/substandard housing/housing discriminationFood instability/food desserts/racist food advertisingUnemployment/employment discriminationPoor education/education system disparities/school to prison pipelineEnvironmental injustice (local and global) and the list goes on Braveman, P. (2014). "What is Health Equity: And How Does a Life-Course Approach Take Us FurtherToward It?" Maternal and Child Health Journal 18(2): 366-372.
Trauma is “contagious”: transmittedthrough relationships Passed on through individuals, families,communities, systems Passed on through generations Passed on through power dynamics/discrimination Passed on to healthcare providers as vicarioustraumatization
Experience of trauma can bemitigated by resilience The ability of an individual, family, orcommunity to cope with adversity and trauma,and adapt to challenges or change.– The Substance Abuse and Mental Health Services)Administration (SAMHSAResilience is promoted by healthy relationships andsocial connectedness (at every level of socioecological model)
Trauma informed care: Strengths-based service delivery approachGrounded in an understanding of andresponsiveness to the impact of traumaEmphasizes physical, psychological, and emotionalsafety for both providers and survivorsCreates opportunities for survivors to rebuild asense of control and Letter/Volume 22 Number 2/trauma tip/keyterms.html
Trauma Informed Systems Principles:San Francisco DPHA system in which there is a healing space for all (allemployees and all patients) created by continuouscommitment to these “trauma informed principles”: Trauma Understanding Cultural Humility** & Responsiveness Safety & Stability Compassion & Dependability Collaboration & Empowerment Resilience & -Systems-Initative-2014.pdf**Watch: https://www.youtube.com/watch?v LLchs28ANj8 Turvalon, M. and Murray-Garcia, J(1998). "CulturalHumility vs Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in MulticulturalEducation." Journal of Health Care for the Poor and Underserved 9(2): 117-125.
Trauma-informed Care:CALM CalmContainCareCope* Kimberg, L., Trauma and Trauma-Informed Care, in The Medical Managementof Vulnerable and Underserved Patients: Principles, Practice and Populations.Talmadge King and Margaret Wheeler, Editors. McGraw-Hill Companies , 2016.
Ms. Jones:Ms. Jones is 44 y old woman who comes to herfirst primary care visit complaining of pain andinsomnia.She has diabetes and asthma—both are poorlycontrolled. She seeks care frequently in the EDfor pain and shortness of breath where she hasbeen noted to smell strongly of alcohol.She is very upset that you are late for herappointment.
Trauma-informed Care:Calm Calm yourself to help model and promotecalmness for the patient (Co-regulation)
Ms. Jones:HIDDEN Childhood historyMs. Jones’ father was incarcerated for DV whenshe was 10. Her uncle moved in to “help out”but sexually abused her for 3 years. Ms. Jonesbegan drinking at age 10 and did very poorly inschool. She was placed in a group home at age13 when her mother felt she was “out ofcontrol.” She fled a violent relationship with afemale partner five years ago.Ms. Jones remembers a favorite aunt as the onlyperson she ever felt truly loved her.
Trauma-informed Care:Calm ASSUME trauma could be root cause of poorlycontrolled disease processes and alcoholismEXPECT that change will likely be slowGOALS (eg’s): Model a respectful, healthy relationship Prioritize safety, dependability De-stigmatize adverse sequelae of trauma Collaborate on shared agenda setting Empower and focus on resiliency Practice with cultural humility and attentionto power dynamics
Trauma-informed Care:ContainIntroduce or ask about the topic of trauma in away that: will allow the patient to maintain emotionaland physical safety; offers choice and control, respects the time-frame for your interaction; allows you to offer the patient further traumaspecific treatments without disclosureThink: How can patient leave this interaction feelingmore calm and in control than when we started?
Universal Education: Atrauma-informed approach1.2.3.12/5/2017Provide education that is specific andrelevant to the patient’s presentinghealth problems or concernExplicitly mention IPV or trauma andhow it can be related to the patient’shealth problem or concernOffer assistance and interventionswithout requiring IPV or traumadisclosureZuckerberg San Francisco GeneralHospital and Trauma Center28
Universal Education: Atrauma-informed approach Non disclosure basedUniversal education approach success: PlannedParenthood study* Reduced pregnancy coercion in IPV patients by71% “We know that sometimes women’s sexual partners try to forcethem to get pregnant or interfere with their birth control.Sometimes partners break or pull off condoms or hide birthcontrol pills. All women deserve to make their own choicesabout pregnancy. So, we offer all women who come to our clinichidden methods of birth control, like an IUC with the string cutshort or depo-provera injections. Please let us know if youwould like to discuss one of these hidden birth controlmethods.”*(Miller, Elizabeth et al. Contraception, 2011)12/5/2017Zuckerberg San Francisco GeneralHospital and Trauma Center29
Education followed byInquiry:“Our relationships affect our health. I talk to allmy patients with about how ourrelationships affect our health. If your partner orsomeone else is putting you down, hurting you, orthreatening you that can cause a lot of stress andmake your worse. We have help availablefor people who are being hurt by someone. Wecan call an Advocate to come talk to you aboutrelationship stress if that is ever a problem foryou." Has your partner (or anyone else) ever hurt, hit,threatened you or made you feel afraid?Has your partner (or anyone else) forced you tohave sex or do something sexual you didn’t wantto do?Has your partner (or anyone else) tried to forceyou to get pregnant or messed with your birthcontrol?30
Additional questions iftime permits: How does your partner treat you? Emotionaloutcomes abuse alone causes poor healthAre you ever frightened of yourpartner?What happens when you and yourpartner disagree?31
Ms. Jones:Ms. Jones tells you that she fled arelationship with a woman who treatedher very badly and hurt her five yearsago, but that she is currently not in arelationship. ZSFG clinics: (RFPC, FHC, WHC in 2000) 15% in past 12 months 51% in lifetimeBauer, H. M., et al. (2000). J Gen Intern Med 15(11): 811-817.
Lifetime trauma screening:Early onset clues Young age of onset of substance use or mentalhealth problem or first sexual experiences is highlysuggestive of traumaAppropriate clinic staff should always ask age ofonset“How old were you when you first started drinkingalcohol?”“How old do you think you were when you first everbecame depressed?”
Framing lifetime trauma FRAMING: “How we were treated when we werechildren can affect our health later in life.”PCP/BH: So I would like to ask you about yourchildhood” “Who did you grow up with?” (parent(s)?,grandparent?, others?)How did [insert person(s)] treat you?Provide examples if unclear: “Sometimes familymembers cheer you on and support you andsometimes family members criticize you, put youdown, hurt you or hit you?” “How did [insert person]treat you?
Framing lifetime trauma: CHW FRAMING:“How we were treatedwhen we were children can affect ourhealth and our relationships later inlife. Especially if we have been hurt byothers, we may have very goodreasons why we don’t trust othersvery easily. I want to be supportiveto you. I know I need to earn yourtrust. I am going to try very hard tonot promise to do things that I cannotdo.”Under-promise and Over-deliver
Trauma-informed care:ContainSo, for example When Ms. Jones tells me on the veryfirst visit that she first began drinking at age 10, I wouldsay “In my experience, when a patient tells me thatshe began drinking at age 10, it is often becauseshe was experiencing very difficult things duringchildhood. We are just meeting each other forthe first time today, so we don’t need to go intothose details right now. I do want you to knowthat I am open to discussing those things in thefuture or referring you to a counselor whospecializes in trauma treatment if you think thatwould be helpful”.
Trauma-informed care:ContainMs. Jones discloses trauma briefly withoutobvious distress Acknowledge courage: “Thank you for sharingthis information with me”Provide validation and support: “I am so sorrythis happened to you”Inquire re impact: PCP: “How do you feelthis experience has affected you?”
Trauma-informed care:ContainMs. Jones becomes upset, tearful or distressed: CONTAIN: “I am hoping that we will gradually get toknow each other over time. I would like to help makethis clinic a place that feels healing to you. So it is veryimportant that we only discuss the level of detail thatwill allow you to feel as calm as possible when you leavethe appointment.CALM: “Let’s take a deep breath together. Let’s sink intoour chairs and feel the earth supporting us”
Trauma-informed care:Care Emphasize good self-care and compassion for bothyourself and the patientDe-stigmatize harmful behaviors NOT—what’s wrong with you? Instead What happened to you?Guilt and shame common—create non-judgmental spacein which all feelings are validAcknowledge FEELINGS (never wrong, often conflicting)while EXPLORING(without criticism) whether arelationship /behavior has harmful aspects or dynamics
Trauma-informed care:CareExpress CARE and COMPASSION (especiallyabout stigmatized behaviors andconditions):“No wonder you started drinking when you were 10. Itwas so important for you to find a way to cope with animpossible and painful situation”“It can be very hard to learn to take good care of yourselfwhen you were hurt as a child”“We all deserve to be treated well. “I am so sorry thosethings happened to you”
Trauma-informed care:Cope Emphasize skills, behaviors, and interventions thatbuild upon strength, resiliency, socialconnectedness and hope.Help patient recognize the behaviors and skills thathave helped her/him/they SURVIVE!! “You have survived such difficult circumstances”“I am so glad you had the strength to reach out forhelp today.”“I hear how loved you felt by your favorite aunt. Itsounds like she was really important in your life.”
Trauma Informed Care:Cope COPING TECHNIQUES:“When you feel stressed, what do you do to cope?” DISCUSS the benefits of adverse copingtechniques:“It sounds like alcohol really helps you cope. Howdoes it help you? What do you like about drinking?” DISCUSS alternatives:“Can you think of anything else besides alcoholthat helps you feel better?”
Trauma Informed Care:CopeEmphasize skills, behaviors, and interventions thatbuild upon strength, resiliency, social connectednessand hope. These are your healing tools!! R eligion/prayer/spiritualityE xpertise/EmploymentS ocial support & NetworkI ntimatesL aughterI nstitutionsE nergy & Enthusiasm/ExerciseN avigate Life’s DifficultiesC ultural AssetsE ntertainment/EnjoymentThanks to Dean Schillinger, MD for mnemonic
Trauma Informed Care:Cope Refer to evidence-based trauma-specifictreatments*Trauma treatment: Emotional regulation skillsRelationship skillsRe-framing of the trauma narrative*http://www.samhsa.gov/nrepp
Trauma Informed Care:CopeAddress adverse and traumatic socialdeterminants of health(housing, food, job training, benefits, etc.) Make structural barriers/structural violenceexplicit and express solidarity about injusticeUnder-promise and over-deliverEmpower patient to take actions patient wantsto take (and provide support without “takingover”)
www.leapsf.org46
Caring for ourselves:Practice
Trauma-informed care allows you tocare for yourself while caring forothers
Summary Trauma is commonTrauma is a risk factor for: early mortality,chronic illnesses,adverse behaviors,more traumaResilience factors can mitigate trauma’s effectsTrauma-informed Care Integrates recognition of high prevalenceBuilds on resilience—Calm/Contain/Care/CopeRecognizes need to care for patients and providers
May 17, 2012 · Trauma Informed Systems Principles: San Francisco DPH A system in which there is a healing space for all (all employees and all patients) created by continuous commitment to these “trauma informed principles”: Trauma Understanding Cultural Humility** & Responsiven
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
Historical trauma - Cumulative emotional and psychological wounding from massive group trauma across generations, including lifespan Historical trauma response (HTR) is a constellation of features in reaction to massive group trauma, includes . historical unresolved grief (similar to Child of Survivors Complex re: Jewish Holocaust survivors and
Trauma-informed ServicesTrauma-informed Services Trauma-informed services: 1. Take the trauma into account. 2. Avoid triggering trauma reactions and/or traumatizing the individual. 3. Adjust the behavior of counselors, other staff and the organization to support the individual’s coping capacity. 4. Allow s
Authored by Dr Samia Addis, Tegan Brierley-Sollis, Vicky Jones, Dr Caroline Hughes trauma-informed trauma aware trauma sensitive 'Trauma-informed': Identifying Key Language and Terminology through a Review of the Literature Authors: Dr Samia Addis1 Tegan Brierley-Sollis2 Vicky Jones1
life course and research, practice, and training for caseworkers and supervisors from a trauma-informed framework is crucial. Join us for this interactive, foundational training on a trauma-informed framework for APS supervisors. We'll learn about a trauma-informed care approach from biological, programmatic, and policy levels.
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