PRACTICAL TRAUMA INFORMED CARE FOR COMMUNITY HEALTH

Abner Santiago, LPCBehavioral Health Consultant

La Communidad Hispanaasantiago@lchps.org

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 Hyperarousal and Reactivity Symptoms

Three new symptoms: Erroneous self- or other-blame Negative mood states Reckless and maladaptive behavior

What Do We Know About Trauma in the USA?

About 80% of US citizens will experience 1 or more traumatic

events in their lifetime

About 8% of US adults will develop PTSD during their lives 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

A previous traumatic event Psychological difficulties prior to the event Family hx of of psychological difficulties Extent to which there was a threat to life Amount of support following the event Emotional response during the event Dissociation Being a child Being a woman 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 Seenin 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

"Major Findings," Centers for Disease Control and Prevention (CDC)

ACE Study 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

How Do We Know About Trauma And Health?

“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, MDCo-Principle Investigator

THE BIOLOGY OF HOPE:YOUR ACES ARE NOT YOUR DESTINY

Trauma Informed Care Is…

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

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

Why Address Trauma In Primary Care?

Trauma Costs Money

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” 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

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: .92Prins, 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 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

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

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

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 PossibleEvidence Supported Treatments

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

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