TRAUMA AND HELP SEEKING How to understand underreporting DENISE - - PowerPoint PPT Presentation

How to understand underreporting

TRAUMA AND HELP SEEKING

DENISE SAINT ARNAULT, PHD, RN UNIVERSITY OF MICHIGAN

¡ Worked with Safe Ireland for about 5 years to understand the nature of trauma, trauma healing trajectory and help seeking trajectory ¡ Note: There are differences between concepts of abuse, violence and trauma;

§ We believe that ANY FORM of abuse and violence has EFFECTS on the brain, mind, body, social systems and society

INTRODUCTION TO THE WORK

¡ Briefly describe trauma theory that can explain women’s inability to seek help for trauma even years after the violence ¡ Understand the data concerning and help seeking provided in the FRA report

AIMS OF THIS PRESENTATION

¡ Domestic Violence is characterised by Complex Trauma, which is defined as:

§ cumulative § emotionally and socially complex § chronic § being under siege § never knowing when events might occur § feeling that they cannot escape.

(Courtois & Ford,2004; Herman, 1997)

COMPLEX TRAUMA

¡ Social engagement system ¡ Sympathetic nervous system ¡ Immobilization nervous system

(Porges, 2001)

ASPECTS OF THE NERVOUS SYSTEM

¡ Deals with the social world

§ Moving toward

§ Speech, eye movement, voice, hearing and listening, facial expressions § Exploration of the world

§ Reaching out § Asking for help § Receiving help

¡ Requires safety and security

“Explore and Engage”

SOCIAL ENGAGEMENT SYSTEM

¡ Deals with escapable threat

§ Moving away § Regulates preparation for action § Primarily for short bursts of activity

“Fight or Flight”

SYMPATHETIC NERVOUS SYSTEM

¡ Deals with inescapable threat ¡ Protective withdrawal to preserve life “Freeze to Protect”

IMMOBILIZATION SYSTEM

(Adapted from Bracha, 2004)

¡ However, sympathetic activation may cause chronic physical problems throughout life § Undergoing trauma or witnessing trauma are associated with a significant unadjusted risk for CVD, arteriosclerosis or hypertension, gastrointestinal (GI) disease, diabetes, arthritis, and obesity § 81 % of abused women experience chronic health problems (70% non-abused) and are 2X as likely to experience chronic physical health conditions § Women who have been abused spend 42% more on health care than non-abused women

(APA, 2011; NPIPC, 2003; SWHR, 2013)

CHRONIC PHYSICAL HEALTH CONDITIONS

¡ Splitting off of segments of the “self” from consciousness

§ Contains memories, emotions and behavioral patterns that were associated with the traumatic event Allows the rest of the self to "carry on” functioning § Environment can “light up” or “trigger” the mind to “go to that place” § When activated, the person is flooded with memories, emotions and associated behaviors

(Nijenhuis, van der Hart, & Steele, 2010; van der Hart et al., 2004; van der Kolk et al., 1996)

DISSOCIATION

Functioning aspect of the personality

(Inspired by van der Hart, et al, 2004)

¡ Details comparing Ireland and the EU regarding:

§ Emotional reactions to violence § How many women do not seek help § Why women do not seek help

FROM THE FRA REPORT

35 55 28 22 17 58 68 43 39 24 shock fear shame embarrasment guilt Ireland EU average

EMOTIONAL REACTIONS TO THE VIOLENCE (%)

(European Union Agency for Fundamental Rights, 2014)

86 89 84 95 96 96 97 88 79 80 76 96 92 95 97 79 police hospital doctor or health centre social services women's shelters victim's support church/faith based legal service Ireland EU

DO NOT SEEK HELP (%)

(European Union Agency for Fundamental Rights, 2014)

53 31 3 9 7 12 3 6 12 70 14 4 7 10 17 2 9 21 deal with it alone too minor thought it was my fault no one can help fear of offender shame/embarrassment wouldn’t be believed did not know where to turn private matter Ireland EU average

REASONS FOR NOT SEEKING HELP(%)

FROM ANY ORGANIZATION OTHER THAT POLICE (European Union Agency for Fundamental Rights, 2014)

¡ Understand the need for help

§ Recognizing that their feelings (or situation) are abnormal § Is it normalized in the culture? § Is it so prevalent that it is “normal”? § Recognizing that it is significant enough § Are their personal needs important? § Does the potential benefit outweigh the trouble of the disclosure? ¡ Ask for help § Can they describe their feelings and what has caused them? § Can trust that they will be safe when ask for help? § Can they “reach out” from behind the shock and shut down? ¡ Fully engage in the help § May come forward for certain help § Cannot seek help or benefit from other

(Saint Arnault, 2009)

HELP SEEKING CAPACITY IS THE WOMEN’S CAPABILITY TO:

¡ Dissociation

§ Limits ability to identify and label distress as abnormal and significant § Limits memory and access to emotions

¡ Freeze and/or immobilization

§ Interrupts social engagement system needed to communicate and to reach out § Cannot operate with full emotional, cognitive and behavioral capacities necessary for negotiating the help seeking process

¡ Interacting social norms for self disclosure and response from the environment Shame, guilt and stigma make them unwilling to ask

§ Society reinforces shame, guilt and stigma § Rules for communication of distress § Norms about violence and relationships

(Saint Arnault, 2009)

POSSIBLE CAUSES OF DIMINISHED HELP SEEKING CAPACITY

¡ Examining the prevalence of violence against women: ¡ Reliance that the women are accurately reporting the extent

• f their exposure.

¡ When the extent of violence seems lower it can be that:

§ Women cannot report violence because of the theories reported here

AND/OR

§ Social and cultural norms make it unacceptable to talk to others about their experiences

AND/OR

§ The levels of gender inequality are too low for them to feel safe and heard

CULTURE AND “PREVALENCE” RATES

¡ Training in trauma informed services § Assessment of effects of trauma physical, psychological and social effects § Thinking of recovery and help seeking across a continuum ¡ Research § Study of Help Seeking trajectories, comparing cultures § Investigating internal and social help seeking barriers as well as system barriers § How can we communicate with women about their risks and available resources when we know about the neurological and dissociation barriers § Learn ways to open women up to making full use of services

FUTURE DIRECTIONS

¡ American Psychiatric Association (APA) 2011 Annual Meeting: Scientific and Clinical Report Session 6, No. 3. Presented May 14, 2011 ¡ Courtois, C.A. & Ford, J. D. (2009). Treating complex traumatic stress disorders: An evidenced-based

• guide. New York: Guilford Press.

¡ Bracha, H. S. (2004). Freeze, flight, fight, fright, faint: Adaptationist perspectives on the acute stress response spectrum. CNS spectrums, 9(9), 679-685. ¡ European Union Agency for Fundamental Rights (2014). Violence against women: an EU- wide survey. Luxembourg: Publications Office of the European Union. ¡ Herman, J. L. (1997). Trauma and recovery. New York: Basic Books. ¡ Nijenhuis, E., van der Hart, O., & Steele, K. (2010). Trauma-related structural dissociation of the

• personality. ANS: The Journal for Neurocognitive Research, 52(1).

¡ Porges, S. W. (2001). The Polyvagal Theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123- 146. ¡ Saint Arnault, D. M. (2009). Cultural Determinants of Help-Seeking. Research and Theory for Nursing Practice, 23(4),259-278. ¡ van der Hart, O., Nijenhuis, E., Steele, K., & Browne, D. (2004). Trauma-related dissociation: conceptual clarity lost and found. Australian and New Zealand Journal of Psychiatry, 38(11-12), 906-914. ¡ van der Kolk, B. A., Pelcovitz, D., & Roth, S. (1996). Dissociation, somatisation, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry, 153, 83-93. ¡ National Center for Injury Prevention and Control. Costs of Intimate Partner Violence Against Women in the United States. Atlanta (GA): Centers for Disease Control and Prevention; 2003. ¡ Society for Women’s Health Research (2013). Increased Chronic Health Risk of Domestic Violence on Women Congressional Caucus for Women’s Issues. Washington, DC, Capital Hill Briefing.

REFERENCES