Transcript Text

Trauma- Informed Care
and
Inuit Mental Health and Wellbeing
Allison Crawford, MD, FRCPC
Purpose of this module
This module on trauma-informed care builds on the
cultural safety module.
It increases the safety of care we deliver within our
healthcare settings, by considering the possibility that
each individual we engage with may have a traumatic
history that we are unaware of.
This universal precaution allows us to shape our
practice to minimize the possibility that we will retraumatize someone within our healthcare settings.
What is trauma-informed care and practice?
Every institution, organization, agency and healthcare provider has the potential to
either re-traumatize people and interfere with recovery OR to contribute to and
support healing.
Healthcare settings and providers often represent power and control to individuals
who have experienced trauma, and this can be frightening and overwhelming.
Without being trauma-informed we may misinterpret people’s reactions and act in
punitive ways that worsen their fear and feeling of lack of control
When we are trauma-informed we understand people’s reactions (e.g., such as rage,
treatment refusal, mistrust) as a result of previous injury, rather than as sickness or
bad behaviour.
We can ask “what has happened to you?” and create a culture of understanding,
rather than “what is wrong with you?” and create a culture of shame.
Trauma-informed providers and organizations:
Acknowledge the widespread impacts of trauma,
Recognize the signs and symptoms of trauma in clients, and
in staff and other providers
Understand the variety of creative means that people can use to
manage trauma (e.g., substance use)
Recognize that people follow different pathways to healing.
Respond by integrating knowledge about trauma into policies,
procedures, practices and settings.
Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Core trauma – informed principles
Acknowledgement – that trauma is pervasive
Safety
Trust
Choice and Control
Compassion
Collaboration
Strengths- based
From http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
What is psychological trauma?
An event which causes someone to fear for their life or physical
safety, or the life or physical safety of another
Emotional response may include fear, terror, horror or
helplessness – “trapped and terrified” - or numbness or
dissociation.
20-25% of people will have a traumatic stress syndrome (such
as PTSD) 1 month following a traumatic event
75% of people experience at least one traumatic event in their
lifetime.
What kinds of psychological trauma are there?
Single event – the person has exposure to one event
that has a clear beginning and end (e.g., car accident;
hurricane; sexual assault)
Prolonged trauma – the person encountered a series,
of ongoing traumatic events (e.g., combat; domestic
violence; persecution in their home country)
Developmental trauma – is a form of prolonged trauma
that also overlaps with and can interfere with normal
development (e.g., child abuse, neglect)
Recognizing the signs and symptoms of trauma:
What is the impact of psychological trauma?
No or limited impact in some
Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD)
Dissociative Disorder
Co-morbid mental health disorders
Complex PTSD and personality disorders
Historical Trauma
From: http://trauma-informed.ca/wpcontent/uploads/2013/10/Traumainformed_Toolkit.pdf
Post-traumatic Stress Disorder Symptoms
(DSMV)
A. Exposure – exposure to actual or threatened death, serious injury or
sexual violation, in which the individual:
•directly experiences the traumatic event;
•witnesses the traumatic event in person;
•learns that the traumatic event occurred to a close family member or
close friend (with the actual or threatened death being either violent or
accidental);
•Or experiences first-hand repeated or extreme exposure to aversive
details of the traumatic event (not through media, pictures, television or
movies unless work-related).
Post-traumatic Stress Disorder Symptoms
(DSMV)
B.
Re-experiencing – e.g., through intrusive thoughts, nightmares,
flashbacks
C.
Avoidance – e.g., avoiding distressing memories, thoughts, feelings
or external reminders of the event.
D.
Negative alterations in cognitions and mood – e.g., persistent
and distorted sense of blame of self or others; estrangement from
others; or markedly diminished interest in activities
E.
Alterations in arousal and reactivity – e.g., aggressive, reckless
or self-destructive behavior, sleep disturbances, hyper-vigilance
Duration of symptoms > 1month
Developmental trauma and complex PTSD
Results from early exposure to multiple or repeated traumatic
events
Reactions to the trauma interfere with normal developmental
processes
Alterations in:
regulating affect
attention
identity
personality development
systems of meaning
(van der Kolk, 1996)
Complex PTSD or Disorders of Extreme Stress
(DESNOS)
Regulating affect: anger, self-destructive behaviour, suicidal
preoccupation, risk taking
Attention: amnesia, dissociation, depersonalization
Alterations in self-perception: ineffectiveness; permanent damage;
guilt and responsibility; shame; no one can understand; minimizing
Alterations in relationships with others: inability to trust;
revictimization; victimizing others
Somatization: digestive sx; chronic pain; cardiorespiratory; conversion
sx; sexual symptoms
Alterations in systems of meaning
(van der Kolk, 2001)
Developmental trauma and complex PTSD
Historical trauma
1995, Maria Yellow Horse Brave Heart applied this idea of collective
suffering, memory, and trauma to the historical trauma experienced
by American Aboriginals, specifically the Lakota, over the course of
colonial conquest and attempts at assimilation.
These traumatic losses included theft and removal from homelands;
violence against indigenous peoples; assimilation through residential
schools, and suppression of language, ceremonies and spirituality,
leading to an erosion of culture; and de-stablization of the social
order through loss of roles and destruction of indigenous family
systems.
Duran and Duran similarly proposed that the effects of this cumulative
trauma, and the accompanying sense of grief, affect the very core of
Aboriginal identity and cultural cohesion, creating a ‘‘soul wound’’
(Duran & Duran, 1995)
Historical trauma: Impacts
‘‘the historical trauma response’’
behaviors, including:
Brave Heart (2003) is
a complex of
depression, anxiety, anger
alexithymia (problems naming feelings);
difficulty modulating affect
low self-esteem and shame
suicidal behaviors, wishes to join the dead
‘‘survivor guilt’’
development of a ‘‘victim identity’’
use of substances as a means of emotional numbing and
avoidance.
Historical trauma is collective – it extends beyond the
individual to the family and community
Historical trauma: Intergenerationsl Impacts
Intergenerational impacts – beyond the generation that was directly
effected; one possible mechanism for this is through an impact on
parenting
L.L. Myhra (2011). Used with permission.
Walking both sides of an invisible border
It is never easy
Walking with an invisible border
Separating my left and right foot ...
I did not ask to be born an Inuk
Nor did I ask to be forced
To learn an alien culture
With an alien language
...
So I am left to fend for myself
Walking in two different worlds
Trying my best to make sense
Of two opposing cultures
Which are unable to integrate
Lest they swallow one another whole
Alootook Ipellie
Historical trauma among Inuit Communities
The history of the Canadian government’s relations with the Inuit is
addressed in the Royal Commission on Aboriginal Peoples
(RCAP), which acknowledged the distinctness of the Inuit from other
Aboriginal people in Canada.
The RCAP concluded that relocations of Inuit people to the High Arctic
constituted an ‘‘abuse’’ by the government.
Additional impacts of contact and colonialism, including: settlement;
residential schooling; loss of traditional belief systems; loss of
traditional relationship with the land; and language.
The RCAP makes an explicit link between these historic abuses and
present-day social suffering.
Historical trauma among Inuit Communities
According to Alexina Kublu, (past) Languages Commissioner of
Nunavut:
- the idea of HT was not something that people a few generations ago
had to deal with
- although the oral histories frequently describe the intervention of
elders when people felt they needed to talk or receive counsel.
- the notion of intergenerational impacts may be captured in the phrase
‘‘sivulirijat aksururnaqtukkuurnikugijangat aktuiniqaqsimaninga
kinguvaanginnut’’ (translated as ‘‘the trauma experienced by
generations past having an effect in their descendants’’)
Documentation of historical trauma in the Qikiqtaaluk (Baffin) region was
undertaken by the Qikiqtani Truth Commission
http://www.qtcommission.com
Some cautions about the historical trauma
concept
It is NOT culturally safe to assume that everyone
within a group or community or family has been
impacted by historical trauma, or by the same
experiences as others
The concept of HT can be stigmatizing and can overlook
resilience, strength and persistence of culture in
individuals and communities
The idea of intergenerational trauma
can pathologize indigenous
parenting practices
Practice considerations
Power and control – whose needs are being served, and do policies
providing the service (e.g., is emphasis being placed on control
Doing with and not doing to
Explaining what, why and how
Offering real choices
Flexibility
Understanding and being able to identify fight, flight and freeze
Focusing on strengths, not deficits
Examining power issues within the organization and promoting
Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Five Universal Qualities of a Therapeutic
Environment
Attachment: A culture of belonging
Containment: A culture of safety
Communication: A culture of openness
Involvement: A culture of participation & citizenship
Agency: A culture of empowerment
Haigh, 1999
Providing and receiving information can be times of
increased intensity or distress.
Inquire about trauma history, and facilitate a supportive discussion with the
client while keeping it focused on the present moment.
Make sure the client is comfortable with the conversation and knows they do not
need to answer questions and/or go into detail.
Check in with the client to make sure the discussion of trauma feels safe and not
overwhelming.
Make time for questions and concerns that the client may have.
Write things down for clients who may dissociate during encounters.
Provide a suicide risk assessment where indicated and follow up with the client
when the risk has passed.
Inquire about a possible history of trauma if a client has behaved or is currently
behaving abusively themselves.
Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Tips for when providing choices
Involve the client in the decision-making process with regard to
Allow the client to set the pace, slow down and take breaks as required.
Continually inform the client of what is happening during healthcare encounters
Where possible, give the client choices about referrals.
Strive to be culturally appropriate and informed.
Understand the meaning the client gives to the trauma from their own cultural
Understand what healing means to the client within their cultural context.
Be open to learning and asking questions about the client’s culture.
Be open to referring clients to traditional healing services, and become educated in
community services.
Work through historical distrust
Teach Western ways as skills, not as identity replacement (Brokenleg, 2008).
Advocate on behalf of clients who speak English as a second language . Become
translator.
Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Create a climate of hope and resilience
Acknowledge the client’s abilities to survive and even grow
Acknowledge the strength it takes to get to where the client
Refer to the client as “someone who has experienced trauma,”
happened to them. Focus on healing and recovery as “possible.”
Move beyond mere survival to the context of a healing process,
path to healing consists of.
Let the client know that you believe in them and support their
From http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Annie Pootoogook, Memory of My Life Breaking Bottles
Further reading and resources
Historica Trauma and Aboriginal Healing
http://www.ahf.ca/downloads/historic-trauma.pdf
Qikiqtani Truth Commission http://www.qtcommission.com
Manitoba Trauma and Information Centre
http://trauma-informed.ca
Royal Commission Report on Aboriginal Peoples
https://www.aadnc-aandc.gc.ca/eng/1307458586498/1307458751962
A. Crawford (2013). ''The trauma experienced by generations past having an
effect in their descendants'': Narrative and historical trauma among Inuit in
Nunavut, Canada” Transcultural Psychiatry
http://tps.sagepub.com/content/early/2013/03/07/1363461512467161.full.pdf