Transcript Trauma Informed Care - Pennsylvania Association of Community

PRACTICAL TRAUMA INFORMED
CARE FOR COMMUNITY HEALTH
Abner Santiago, LPC
Behavioral Health Consultant
La Communidad Hispana
[email protected]
Adapted From Post-Traumatic Stress Disorder and Medical Comorbidities: Screening and Intervention in
Collaborative Care Settings. Andrea Auxier, PhD and Christine Runyan, PhD, ABP. Collaborative Family
Healthcare Association 14th Annual Conference. October 4-6, 2012, Austin, Texas U.S.A.
Trauma Informed Care
Care that is grounded in and directed by a thorough
understanding of the neurological, biological,
psychological and social effects of trauma and violence
on humans and is informed by knowledge of the
prevalence of these experiences in persons who receive
mental health services.
(NASMHPD, 2004)
Changing the Fundamental Question From
"What's wrong with you?"
to
"What's happened to you?"
Defining Post Traumatic Stress Disorder
(PTSD)
DSM 5
Experienced, witnessed an event involving actual or threatened
death/ serious injury, or threat to physical integrity of self/ others
Intrusion Symptoms
 Persistent Avoidance
 Alterations in Cognitions and Mood
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Hyperarousal and Reactivity Symptoms
Three new symptoms:
 Erroneous self- or other-blame
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Negative
mood states
 Reckless and maladaptive behavior
What Do We Know About Trauma in the USA?
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About 80% of US citizens will experience 1 or more traumatic
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events in their lifetime
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About 8% of US adults will develop PTSD during their lives
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8% of men and 20% of women develop PTSD after a trauma
Rates of PTSD in primary care clinics are about 12%
Exposure to trauma does not guarantee that the person will have
a specific diagnosis or pathology e.g. PTSD
Resilience can be developed and improved
Risk Factors for Developing PTSD
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A previous traumatic event
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Psychological difficulties prior to the event
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Family hx of of psychological difficulties
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Extent to which there was a threat to life
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Amount of support following the event
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Emotional response during the event
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Dissociation
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Being a child
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Being a woman
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Being a recent immigrant from a troubled country
Trauma is to the Body what a Virus is to the Computer
 Increased
rates of tobacco use and obesity
 Increased
rates of DM, CVD, HTN, autoimmune disease,
and dementia
 Increased
rates of inpatient psychiatric care and suicide
 Increased
poverty, unemployment
 Increased
rates of depression, substance abuse, and
anxiety disorders
 Reduced
adherence to medical treatment and
preventive care
Psychiatric Comorbidities Commonly Seen
in Primary Care
88% of men and 79% of women with PTSD meet
criteria for another psychiatric disorder.
 Men: alcohol abuse/dependence; MDD; conduct
disorders; drug abuse/dependence.
 Women: MDD; simple phobias; social phobias; and
alcohol abuse/dependence.
U.S. Department of Veteran Affairs, National Center for PTSD
How Do We Know About Trauma And Health?
ACE Study
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Over 17,000 adults studied from 1995-1997
Almost 2/3 of participants reported at least one ACE,
and over 1/5 reported three or more ACEs, including
abuse, neglect, and other types of childhood trauma
Significant adversity in childhood is strongly
associated with unhealthy lifestyles and poor health
decades later
"Major Findings," Centers for Disease Control and Prevention (CDC)
“You are just as likely to develop heart disease
from Adverse Childhood Experiences as you are
from high blood pressure, high cholesterol or
family history.”
Vince Felitti, MD
Co-Principle Investigator
THE BIOLOGY OF HOPE:
YOUR ACES ARE NOT YOUR DESTINY
Trauma Informed Care Is…
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Being able to recognize that if a person has had a
significant traumatic stress exposure then it can
present physically, emotionally or both
Engaging the person in treatment so that he/she no
longer has to feel vulnerable or in the victim role
Understanding that many people who have
experienced severe trauma are resilient and will not
require trauma specific treatment
Why Address Trauma In Primary Care?
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It’s the principal point of contact
12% of patient’s in community settings have PTSD
compared to 8% in general population
BUT . . .
 Patients don’t come in saying they have PTSD
 It’s up to us to identify it
Trauma Costs Money
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High rates of healthcare services utilization
Difficulty in provider-patient communication
leads to:
 Reduction in active collaboration in evaluation and
treatment
 Increase in the likelihood of somatization
 Reduction in adherence to medical regimens
Addressing Trauma in Primary Care
Patients want you to ask …
“But … I’m not sure I want to know the answer”
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Focus on current symptoms and circumstances, not
detailed information about the traumatic event (s)
Don’t Reflexively Say “I’m Sorry”
Let the patient know that you recognize how difficult it
may be for him or her to answer questions
If he/she begins to get upset and wants to stop, give
them choices and control
PC-PTSD Screening
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Brief, 4 item Screen for Primary Care
Does not ask patient the traumatic event
Asks Y/N symptoms in the past month
 Nightmares, Intrusive thoughts, On guard or easily
startled, Feeling detached
Cut off score of 3 recommended
• Sensitivity: Women: .70, Men: .94
• Specificity: Women: .84, Men: .92
Prins, et al. (2003). The primary care PTSD screen (PC-PTSD): development and operating
characteristics. Primary Care Psychiatry, 9, 9-14
When a Patient Discloses Trauma
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Relax
Appreciate she trusted you enough to disclose
emotionally painful material
Provide psycho-education materials
Encourage self-soothing activities – walking, meditation,
yoga, vigorous exercise, writing
Promote mastery and self-help
Write down any medical instructions – assume that
under stress people aren’t taking in all the information
they need
In 15 Minutes?! …
Key Principles of Trauma Informed Care
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Your are not alone
This is not your fault
Help is available – I have a colleague that I trust
can help you…would you like top speak with them
In 15 Minutes?! …
Key Principles of Trauma Informed Care
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Recognize trauma’s central role in health and illness
Validate patient’s experience
Link symptoms to past experiences of trauma
Meet patient where they are
Encourage patient to play an active role in goal setting
Build trust in relationship
Facilitate choice whenever/as much as possible
May get worse before it gets better
Talk less … Listen more
Healing is Possible – Evidence Based Treatments
Adopted from Weinreb, L. NIAAA Manual
Key Intervention Goals
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Break silence about trauma and abuse
Shift blame from survivor
If relevant, establish short term safety plan
 Give the patient control and choice
Contextualize and normalize the experience
Validate coping strategies
Integrate trauma factors in how you conceptualize and
address problems
Maintain positive relationship
Offer referrals for services
Healing is Possible
Evidence Supported Treatments
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Narration (oral, written, past tense, imaginal)
Trauma Focused Cognitive Behavioral Therapy
Exposure Therapy
Stress Inoculation Training (SIT)
Psychoeducation
Eye Movement Desensitization and Reprocessing
DBT Strategies
Mindfulness Based Strategies
Complementary and Integrative Modalities (Yoga, Meditation,
Acupuncture)
Pharmacotherapy (SSRI, SNRI)
Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD).
Cochrane Database of Systematic Reviews 2007
Conclusion
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Many of our patients are suffering from unrecognized
trauma
They most likely will not tell us unless we ask the right
questions, at the right time, in the right way
If they don’t have the words to tell us, we have to
help them find the words
When they are ready to tell us their stories, we have
to be willing to hear them
Questions