Shifting Towards Trauma- Informed Care: From Understanding to - - PowerPoint PPT Presentation

Shifting Towards Trauma- Informed Care: From Understanding to Collaboration

April 28, 2015

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Patient-Centered Primary Care Institute

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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

PCPCH Model of Care

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

Tammy

Substance Use Exploitation Non-active Anniversaries

Tammy’s Experience

Adverse Impact

Sexually Assaulted

Lived with Bikers

Runaway

How would Tammy’s Adverse Experiences Impact…

Physical Behavioral Mental

• 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

• Hx of sub-acute stays for

suicidal ideation

• Lives on SSI/SSD and SNAP
• Supportive Housing

Not what is wrong but…

Blame What has happened? Shame

A trauma-informed approach is based

• n the recognition that many

behaviors and responses expressed by survivors are directly related to traumatic experiences.

• The Center for Mental Health Services

National Center for Trauma- Informed Care

http://youtu.be/UYa6gbDcx18

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
• verdose (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 remedy seeking

Spiraling

Paradoxical by nature

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 love and vitality Replaces genuine intimacy and compassion

Secure Attachments

Lead to health exploration Healthy brain development Healthy ways of differentiation

Insecure Attachments and Misplaced Attunement

Insecure

Unreliable Exaggerated Response Neglectful Failure to self-soothe

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

Marginalization Racism Poverty Economic exploitation Distress of daily living

Not why the Addiction, but why the Pain?

Gabor Mate’

When we plant a seed…

Why Trauma Informed Care?

(Brown, Harris & Fallot)

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

“We cannot begin to address the totality of a client’s healthcare without addressing trauma.” (Rosenburg, 2011)

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
• ften 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

Lack of trust Hierarchical boundaries Secrets and information withheld Invisible Feelings of powerlessness Not validating patient’s perspective

Intrusive Practices

Lack of follow up Not seeing patient as the expert Talking in whispers about patient Not listening Evasive procedures without explanation Pathology or label

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)

Patients are experts Providers and staff build an alliance with the patient Patient leads the recovery process every step of the way Set goals, be proactive and promote 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

• rganization

Promoting Trauma Informed Care

(Harris 2009; Harris and Fallot, 2001)

Creating a place that is both physically and emotionally safe All staff (not just clinicians) having a basic understanding of trauma and its impact on our patients Supporting patient control and choice Enhancing collaboration between patient and provider Ensuring cultural competence

We Want To Hear From You!

Type questions into the Questions Pane at any time during this presentation

Resources & Thanks!

• http://www.samhsa.gov/nctic/trauma-

interventions

• http://www.sanctuaryweb.com/

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