Trauma informed care and the intersection with brain injury ·  · 2015-11-23Trauma informed care and the intersection with brain injury Rohini Gupta, ... do you plan to ... McMillan,

Trauma informed care and the intersection with brain injury

Rohini Gupta, PsyD

October, 2015

Introduction

❖ Core faculty at University of Denver, Graduate School o Professional Psychology,

International Disaster Psychology Program

❖ Private Practice: Gupta Psychology that specializes in trauma treatment and cross cultural

counseling

❖ rohiniguptapsyd.com

❖ 303-675-7009

❖ Director of the Trauma and Disaster Recovery Clinic

❖ Training clinic that provides services to those who have experienced adversity

❖ Individual child and adults, couples, family, groups, outreach presentations, and program

❖ http://www.du.edu/gspp/services/tdrc.html

❖ 303-871-3087

Learning objectives

❖ Introduction to trauma and the overlap with TBI

❖ Understanding Trauma informed care and examples

that illustrate the concepts

❖ Challenges to implementing this approach

❖ Questions

What is trauma?

❖ “An event that overwhelms a person’s ability to cope (Herman, 1997)

❖ “Individual trauma results from an event, series of events, or set of

circumstances that is experience by an individual as physically or

emotionally harmful or life threatening and that has lasting adverse

effects on the individuals’s functioning and mental, physical, social,

emotional, or spiritual well-being (SAMHSA, 2014, pg. 7)

❖ DSM Definition:

❖ Stressor

❖ Intrusive symptoms, avoidance, negative alterations in cognitions

and mood, alterations in arousal and reactivity

Prevalence and impact (Harris and Fallot, 2009)

❖ Pervasive:

❖ National community based surveys reveal 55% to 90% have experienced 1 traumatic event

❖ Impact is broad reaches many domains

❖ Increase risk of MH problems, depression, anxiety, SA, health problems, eating disorders,

suicidality, and difficulty in relationships

❖ ACE Study (Felitti et al., 1998)

❖ Impact is deep and life shaping

❖ Can be life altering

❖ Neurological and psychosocial adaptions can occur

❖ Insidious and some are more vulnerable

❖ Ethnic minorities, low income, homelessness, severe mental heath, developmental disabilities,

substance abuse issues

Overlap of Trauma and TBI: Increased vulnerability

❖ Increased vulnerability to victimization (CDC, N.D)

❖ Exploitation (Oktay and Tompkins, 2004)

❖ Caregivers may respond with violence due to the

frustrations with caregiving (Kim, 2002)

❖ Demeaning and abusive behavior due to lack of

understanding (Sequeira and Halsted, 2001)

Overlap of trauma and TBI: comorbidity

❖ PTSD can occur after a TBI, even in severe cases where

there is little or no recall of the event that caused injury

(Taney et al., 2004)

❖ Prevalence rates

❖ Remains uncertain (McMillan et al., 2003)

Overlap of trauma and TBI: Symptomology

❖ Symptom overlap: insomnia, irritability, impaired

concentration (Sumpter et al., 2006)

❖ Memory impairment, social withdrawal, and difficulty

adjusting to TBI injury can look like PTSD symptoms

(Sumpter et al., 2006; Kennedy et al., 2007)

❖ Misattribution of symptoms can occur and/or misdiagnosis of

either condition (Sumpter et al., 2006; McMillian, 2001)

❖ Intrusive recollection is a symptom that distinguishes PTSD

from TBI (Stein et al., 2009)

What is Trauma informed care (TIC)?

❖ TIC involves a system focused framework of service

delivery (Kessler, 2014; Wolf et al., 2014)

❖ Organizational commitment to providing services that

are helpful to the special needs of trauma survivors

What is trauma informed care (TIC)?

❖ “What has happened to you?” NOT “What’s

wrong with you?” (Jennings, 2008)

Case example

Trauma informed care: a culture change

❖ TIC involves a culture change in the organization (Harris and Fallot,

2009; Kessler, 2014)

❖ Involves developing policies and working environments that are

organized around five principles (Harris & Fallot, 2009)

❖ Safety

❖ Trustworthiness

❖ Collaboration

❖ Empowerment

❖ Choice

Trauma informed care: safety

❖ Safety for consumer and staff

❖ Creating physical and emotional safety

❖ Examples for consumers and staff

Trauma informed care: Trustworthiness

❖ Trustworthiness for consumer and staff

❖ task clarity, consistency, and interpersonal

boundaries

❖ Examples for consumer and staff

Trauma informed care: Choice

❖ Choice for consumer and staff

❖ Maximizing choice and control

❖ Examples for consumer and staff

Trauma informed care: collaboration

❖ Collaboration for consumer and staff

❖ Creating collaborations and sharing power

❖ Examples for consumer and staff

Trauma informed care: empowerment

❖ Empowerment for consumers and staff

❖ Emphasizing empowerment and skill building

❖ Examples for consumers and staff

What can you do as an administrator (Harris & Fallot, 2009)

❖ Integration of knowledge abut violence and abuse into all

program practices

❖ Policy statement

❖ Develop a trauma initiative

❖ Consumer advisory group (has trauma survivors present)

❖ Collaborative and shared decision making style

❖ Provide resources and opportunity for learning

Trauma informed care: Does it work?

❖ TIC approaches can increase effectiveness of MH and SA

services (Harris & Fallot, 2009; Wesley & Power, 2005)

❖ Better outcomes have been found for TIC than traditional

treatment approaches (Cocozza et al., 2005; Morrissey & Ellis,

2005; Kammerer et al., n.d.)

❖ Improvement in daily functioning, decreased trauma

symptoms, decreased MH/SA symptoms

❖ No differences in cost to program with using TIC vs traditional

approaches and better clinical outcomes (Domino et al., 2005)

Challenges to Trauma Informed Care

❖ Staff attrition and high turnover (Bloom et al., 2003;

Rivard et al., 2004)

❖ Encouragement of flattened organizational hierarchy

(Bloom et al., 2003)

❖ Lack of time for communication and team building

(Rivard et al., 2004)

Challenges to Trauma Informed Care Continued (Wolf et al., 2014)

❖ Difficulty to agree on what emotional safety looks like

❖ Challenging to have choice and control for clients

❖ Concrete examples of collaboration can be difficulty

❖ TIC principles were applied to clients but many did not

include staff

Discussion

❖ Turn to the person next to you

❖ Are there ways your organizations are trauma informed?

❖ How can your organizations be more trauma informed?

Think of concrete examples

❖ What challenges might you have to implementing a TIC

approach and how can you respond to those challenges?

❖ When you go into the office on Monday, do you plan to

do anything differently?

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author.

Bloom, S. L., Davis, M., Farragher, B., McCorkle, D., Martini, K, & Wellbank, K. (2003). Multiple

opportunities for creating sanctuary. The Psychiatric Quarterly, 74, 173-190.

Bryant, RA. (2001) Posttraumatic stress disorder and traumatic brain injury: can they co-exist?

Clinical Psychology Review, 21, 931-938.

Center for Disease Control (n.d). Victimization of persons with traumatic Brain injury or other

disabilities: a fact sheet for friends and families. Retrieved from

http://www.cdc.gov/traumaticbraininjury/pdf/VictimizationPerson_Fact

%20Sheet4FrdsFal-a.pdf

References

Cocozza, J.J., Jackson, E.W., Hennigan, K., Morrissey, J.B., Reed, B.G., & Fallot, R. (2005).

Outcomes for women with co-occurring disorders and trauma: Program-level effects.

Journal of Substance Abuse Treatment, 28(2), 109-119.

Domino, M. E., Morrissey, J. P., Chung, S., Huntington, N., Larson, M. J., & Russell, L.A. (2005).

Service use and costs for women with co-occurring mental and substance use disorders

and a history of violence. Psychiatric Services, 56, 1223-1232.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, et al.

(1998).The relationship of adult health status to childhood abuse and household

dysfunction. American Journal of Preventive Medicine, 14:245-258.

Harris, M., & Fallot, R. (Eds.). (2001). Using trauma theory to design services systems. New

directions for mental health services. San Fransisco, CA: Jossey-Bass

References

Harris & Fallot (2009). Creating cultures of Trauma-Informed Care (CCTIC): A self assessment

and planning protocol. Community Connections. Retrieved from http://

www.theannainstitute.org/CCTICSELFASSPP.pdf

Harvey, AG, Brewin CR, Jones C, Kopelman MD. (2003). Coexistance of postraumatic stress

disorder and traumatic brain injury: Towards a resolution of the paradox. Journal of the

international Neuropsychological Society, 9, 663-676.

Herman, J. L. (1997). Trauma and recovery. New York: BasicBooks

Jennings, A. (2008). Models for developing trauma informed behavioral health systems and

trauma specific services. National Center for Trauma Informed Care. Retrieved from

http://www.theannainstitute.org/Models%20for%20Developing%20Traums-Report

%201-09-09%20_FINAL_.pdf

References

Kennedy JE, Jaffee MS, Leskin GA, Stokes JW, Leal FO, Fitzpatrick PJ. (2007).

Posttraumatic stress disorder and posttraumatic stress disorder-like symptoms

and mild traumatic brain injury. Journal of Rehabilitation Research &

Development , 44, 895–920.

Morrissey, J.P., and Ellis, A.R. (2005). Outcomes for women with co-occurring disorders and

trauma: Program and person-level effects. Journal of Substance Abuse Treatment,

28(2), 121-133.

Kessler, J. M. (2014). A call for the integration of trauma informed care among intellectual and

developmental disability organizations. Journal of policy and practice in intellectual

disabilities, 11(1), 34-42.

Kim E. (2002). Agitation, aggression, and disinhibition syndromes after traumatic brain injury. Neurorehabilitation, 17(4), 297–310

References

Machtinger, E. L., Cuca, Y.P., Khanna, N., Dawson Rose, C., Kimberg, L.S. (2015). From

treatment to healing: the promise of trauma informed primary care. Women’s health

issues, 25(3), 193-197.

McMillan, TM. (2001). Errors in diagnosing post-traumatic stress disorder after traumatic brain

injury. Brain Injury, 15, p.39–46

McMillan TM, Williams WH, Bryant R. (2003) Post-traumatic stress disorder and traumatic

brain injury: A review of causal mechanisms, assessment, and treatment.

Neuropsychological Rehabilitation, 13, 149–164

Oktay JS, & Tompkins CJ. (2004). Personal assistance providers’ mistreatment of disabled

adults. Health & Social Work, 29(3), 177–88

References

Rivard, J.C., McCorkle, D., Duncan, M.E., Pasquale, L.E., Bloom, S. L., & Abramovitz, R.

(2004). Implementing a trauma recovery framework for youths in residential treatment.

Child and Adolescent social work journal, 21, 529-550.

SAMHSA (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed

Approach. Retrieved from http://traumainformedcareproject.org/resources/SAMHSA

%20TIC.pdf

Sequeira H, Halstead S. (2001). “Is it meant to hurt, is it?”: management of violence in women

with developmental disabilities. Violence Against Women, 7(4), 462–76.

Stein, MB., & McAllister, TW (2009). Exploring the convergence of postraumatic stress disorder

and mild traumatic brain injury. American Journal of Psychiatry, 166, 768-776.

References

Sumpter RE, McMillan TM. (2006). Errors in self-report of post-traumatic stress disorder after

severe traumatic brain injury. Brain Injury, 20, 93–99.

Tanev, K.S., Pentel, K.Z., Kredlow, M.A., & Charney, M.E. (2014). PTSD and TBI co-morbidity:

scope, clinical presentation and treatment options. Brain Injury, 28(3), 261-270.

Tanielian T, & Jaycox LH. (2008). Invisible wounds of war: Psychological and cognitive injuries,

their consequences, and services to assist recovery. RAND Report, 143.

Wesley, C. H., Power, A. K. Women, Co-occurring disorders, and Violence study: a case for

trauma informed care. Journal of substance abuse treatment, 28(2),145-146

References

Williams, W.H., Evans, J.J., Wilson B.A., Needham, P (2002). Brief report: Prevalence of post

traumatic stress disorder symptoms after severe traumatic brain injury in a

representative community sample. Brain Injury, 16(8), 673-679

World Heath Organization (2006). Preventing child maltreatment: a guide to taking action and

generating evidence. Retrieved from http://apps.who.int/iris/bitstream

10665/43499/1/9241594365_eng.pdf

Wolf, M. R., Green S. A., Nochajski, T. H., Mendel, W. E., & Kusmaul, N.S. (2014). We’re Civil

Servants: The status of trauma informed care in the community. Journal of Social

Service Research, 40,111-120