Shifting Towards Trauma- Informed Care: From Understanding to Collaboration April 28, 2015
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PCPCH Model of Care Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures • Access to Care “Health care team, be there when we need you” • Accountability “Take responsibility for making sure we receive the best possible health care” • Comprehensive Whole Person Care “Provide or help us get the health care, information and services we need” • Continuity “Be our partner over time in caring for us” Coordination and Integration “Help us navigate the health care system to get • the care we need in a safe and timely way” • Person and Family Centered Care “Recognize that we are the most important part of the care team - and that we are ultimately responsible for our overall health and wellness” Learn more: http://primarycarehome.oregon.gov
Introduce Presenter Daren Ford, LCSW, CADC II Trainer and Research Associate Addiction Technology Transfer Center
Learning Objectives • Describe trauma theory and the spirit of Trauma- Informed Care • Explore Attachment Theory, adverse childhood experiences and its impact of patients • Discuss strategies to identify champions and supporters of Trauma-Informed Care within your agency • Discuss how to assess and strategically plan to implement a Trauma-Informed Care model in your setting
Tammy
Tammy’s Problem List Mid 50’s female Smoker Obesity Bi-polar disorder Diabetic/Insulin Dependent Hx of Poly-substance use Hx of acute hospital stays for manic episodes and suicidal ideation
When Tammy Came into the Clinic…
A Typical Office Visit Hyper-manic Angry Putting out fires Threatening Paranoid
What we Learned Over Time
During Peak of Symptoms Substance Use Anniversaries Exploitation Tammy Non-active
Tammy’s Experience Lived with Runaway Bikers Sexually Assaulted Adverse Impact
How would Tammy’s Adverse Experiences Impact… • Mid 50’s female • Smoker Physical • Obesity • Bi-polar disorder • Diabetic/Insulin Dependent • Hx of Poly-substance use Behavioral • Hx of acute hospital stays for manic episodes • Hx of sub-acute stays for suicidal ideation • Lives on SSI/SSD and SNAP Mental • Supportive Housing
Not what is wrong but… What has Blame Shame happened?
A trauma-informed approach is based on the recognition that many behaviors and responses expressed by survivors are directly related to traumatic experiences. http://youtu.be/UYa6gbDcx18 -The Center for Mental Health Services National Center for Trauma- Informed Care
Johnny Thunders “The plaster fallin' off the wall My girlfriend cryin' in the shower stall It's hot as a bitch I should've been rich But I'm just diggin' a Chinese ditch. I’m livin on a Chinese rock All my best things are in hock I’m livin on a Chinese rock Everything is in the pawn shop”
Johnny Thunders • Mother died after birth • Father left after shortly after that • Died of a suspected methadone overdose (still ruling out murder) • Born to Lose (Born into loss)
John Beverley- Sid Vicious • Father left him at early age • Step father died of cancer during childhood • Supposedly murdered his partner Nancy Spungen • Died 1979 of heroin overdose (new evidence was recently revealed)
Why Remedy? Felitti VJ, Anda RF, Nordenberg DF, et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14 , 245 ‐ 258.
Gabor Mate’ “Any repeated behavior, substance related or not, in which a person feels compelled to persist, regardless of its negative impact on his or her life and the lives of others.”
A way of controlling experience A way of Paradoxical remedy No text by nature seeking Spiraling
Beautiful Tragedy • 8 of 13 children • Poverty • Father died at age 16 • Raped at knife point • PTSD • Intoxicated during work • Divorce, foreclosure, debt, poverty, spousal abuse • Died at age 32 Pinuppickspenup.com
The Cage Study or Rat Park
When a Behavior becomes a Problem (Mate’) Compulsive Impairing Replaces other ways to self-remedy Seen as a way towards Replaces genuine love and vitality intimacy and compassion
Secure Attachments Lead to health exploration Healthy brain development Healthy ways of differentiation
Insecure Attachments and Misplaced Attunement Unreliable Failure to Exaggerated Insecure self-soothe Response Neglectful
Impact of an Insecure Attachment (Seigal/Perry) Impacts brain profoundly People are seen as a source of terror, neglect or ambivalence Poor self-esteem Struggles with self regulation Low frustrations of tolerance Anxiety and mood disorders
Not why the Addiction, but why the Pain? Marginalization Racism Poverty Economic exploitation Distress of daily living
Gabor Mate’ When we plant a seed… No text No text No text No text
Why Trauma Informed Care? (Brown, Harris & Fallot) “We cannot begin to address the totality of a client’s healthcare without addressing trauma.” (Rosenburg, 2011) Ignoring trauma leads to inadequate recovery, health care and treatment dropout and poorer population health Trend towards integrated care requires us to look at whole person illness and health
The ACE Study • Cost of untreated trauma-related substance use disorders alone estimated $161 billion in 2000 (Felitti & Anda, 2010) • National Survey 8.2% of US population struggles with and SUD and receiving care in a FQHC (SAMHSA, 2014 ) • Only ½ of the US services that needs preventive services recieves it (ACA, 2010)
• Why is Understanding Trauma in Primary Care Important? • What are the implications for the Primary Care and Behavioral Health workforces? • What are the challenges in adopting a Trauma-Informed approach?
Why is Understanding Trauma Important? •To provide effective services we need to understand the life situations that may be contributing to the persons current problems •Many current problems faced by the people we serve may be related to traumatic life experiences •People who have experienced traumatic life events are often very sensitive to situations that remind them of the people, places or things involved in their traumatic event •These reminders, also known as triggers, may cause a person to relive the trauma and view our setting/organization as threatening
Why Medical Settings may be Distressing for People with Trauma Experiences: Invasive procedures Removal of clothing Physical touch Personal questions that may be embarrassing/distressing Power dynamics of relationship Gender of healthcare provider Vulnerable physical position Loss of and lack of privacy
What we do and how it Feels (Ferencik & Ramirez-Hammond, 2012) Traumatic Triggers Intrusive Practices Lack of trust Lack of follow up Hierarchical boundaries Not seeing patient as the expert Talking in whispers about patient Secrets and information withheld Not listening Invisible Evasive procedures without explanation Feelings of powerlessness Pathology or label Not validating patient’s perspective
Signs that a Person may be Feeling Distressed Emotional reactions – anxiety, fear, powerlessness, helplessness, worry, anger Physical or somatic reactions – nausea, light headedness, increase in BP, headaches, stomach aches, increase in heart rate and respiration or holding breath Behavioral reactions – crying, uncooperative, argumentative, unresponsive, restlessness Cognitive reactions – memory impairment or forgetfulness, inability to give adequate history
What Can We Do to Provide Trauma Sensitive Care and Practices?
We must Change First (Ferencik & Ramirez- Hammond, 2012) A person’s response to trauma should not be seen through the lens of pathology Change our lens to view behavior as a normal response to an abnormal situation Reframe these behaviors as coping strategies Understand that many coping strategies are resourceful These coping strategies are not signs of a mental health condition https://youtu.be/e7JVO03tKIY
“Above all else, do no harm.” Physician’s Credo
Trauma Informed Services (Ferencik & Ramirez-Hammond, 2012) Providers and staff Patients are build an alliance experts with the patient Patient leads the Set goals, be recovery process proactive and every step of the promote way empowerment
Trauma Informed Care (Herman, 1992) • Since most trauma was brought upon by relationships, healing needs to take place within the context of relationships to build trust and safety • Many staff members (especially in substance use treatment program) are trauma survivors themselves • Making any systems-level change requires sustained focus over time and must involve everyone in the organization
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