Trauma in Special Populations

Julie P. Gentile, M.D.Professor of PsychiatryOhio’s Coordinating Center of ExcellenceIn Mental Illness/Intellectual Disability

Steven

• Trauma history dates back to developmental years•Completed prison sentence for felony

charges; on parole •Admitted to state psychiatric hospital

Trauma in Prison Population

• Fact: Individuals who are incarcerated have high prevalence of psychopathology including PTSD and Mood D/O• Fact: Far more likely to have had traumatic

experiences, especially early sexual and physical abuse• Fact: More than 1 million prison and jail

inmates with mental illness

Traumatic Victimization

• FACT: Victimization once in a correctional facility is prevalent• FACT: Inmates with MI are up to 8

times as likely to be victims of sexual abuse •Recidivism rates are higher•Gender differences

Kathryn

•34 year old divorced female•Co-occurring mental illness/substance

dependence•Domestic dispute resulted in legal

charges

Prison Population

•Re-entry into the community

• Legal issues/restrictions•Housing• Employment•Basic necessities

Prison Population

• Re-entry• Feeling safe and in control• Navigating relationships (feel the need to defend

yourself, feelings of injustice, hypervigilance, etc)• Trauma during incarceration versus trauma in

the community

• What is needed?

Trauma Informed Correctional Care

Goal: Identify trauma (and trauma symptoms) among inmates

Train staff to understand the impact of trauma

Minimize re-traumatizationMaintain sensitivity to triggersKnow trauma dynamics in prisons

Trauma and the Influence of Culture•Means of sharing wisdom and skills

necessary to the survival of the community, the individual, and the community’s view of humanity• Shapes how we identify and interpret

traumatic events and how we manifest our distress in response to these events

Cultural Identity

• Important when interfacing with individuals who have experienced trauma that responders attempt to understand their own cultural identities as they reach to serve others

• Transference Effects

Sources of Cultural Identity

Culture and Trauma

• Convey respect; be honest• Request permission • Acknowledge differences and apologize

for discrepancies between your behaviors and those with whom you are talking • Be aware of your own cultural biases• Be curious: ‘Bring it into the room’

Trauma Informed Care

The world breaks everyone, and at the end, some are stronger at

the broken places.

--Ernest Hemingway

Trauma Informed Care Research suggests that many people

have some form of traumatic event in his or her lives. Some experts believe as many as 95% of individuals with ID have some level of traumatic stress. It makes sense to treat EVERYONE as if trauma has possibly occurred. Making sure someone feels safe and in control of their own lives will help someone with trauma, and will not hurt anyone who does NOT have a history of trauma.

“Sit in the chair”

--Jerald Kay MD

Grief and Loss Issues:

Attempt to characterize developmental level (for children and individuals with IDD) and concept of loss/death at that stage

Developmental Implications of Loss and Grief/ Piaget

Sensorimotor stage Severe/Profound ID; developmental age

0-2 years Experience of loss may be one of an

expectation that lost object will return Constantly unfulfilled expectation

Developmental Implications of Loss and Grief/ Piaget Pre-operational Stage:

Developmental age 2-7 years Severe/Moderate ID How will the loss affect me? Who will

understand me now? Who will take care of me? Who will be my friend? Who will give me things?

Fantasy and magical thinking may be used

Developmental Implications of Loss and Grief/ Piaget Concrete operations

Developmental age 7-11 years Moderate/Mild ID Can understand clear and specific

explanations of loss and death Tend to take things literally

Bio-Psycho-Social-Developmental Formulation

A complete gathering of information through client interview, discussion with family members and/or caretakers, review of clinical records, and contact with collaborating agencies that leads to a formulation, diagnoses and treatment plan. The goal is to address and understand the developmental needs of the individual in a meaningful way utilizing Trauma Informed Care principles as a universal precaution.

Biological Aspects

Trauma is a major driver of medical illness

85% have untreated, under-treated or undiagnosed medical problems

worsened by restrictions on care (labs, office visit frequency and length)

medications used in ways they were never intended, in unsafe ways, with abbreviated monitoring protocols

Communication Issues

Talk to the patientExpressive language vs. receptive languageSet the stage when appointment beginsSummarize at the endManage the triangle

Communication Issues

•Observation•Relatedness• Expression of Affect• Impulse Control•Attention Span•Activity Level•Unusual or Repetitive Behavior

Interview Techniques and Considerations

• Sub-vocalizations• reflects a strategy to vocalize the thought

processes in the individual’s mind (“hearing)” what they are thinking• rehearse what is going to be said or to practice

something the individual is planning to do• These should not be considered stalling tactics

or an attempt to lie• Not the same as “talking” from person with a

psychiatric disturbance (hallucination)

Fragile X SyndromeCommunication Patterns• Avoidance of eye contact• Staccato speech• Fragile X handshake•Mental Status Examination• Perseveration (Automatic Phrases)

•What works: recapping, summarizing, clarifying, use of anchor events

How Trauma is Experienced

•Understanding the trauma experience at each developmental stage

Severe/Moderate ID (~ages 2-7) : Trauma Experience

Brains may not have the ability to calm fears; may have startle responses, night terrors, or aggression

May regress behaviorally (enuresis/encopresis, fetal position, etc) in response to stress

May not understand that some losses are permanent (Where’s Russell?)

Responses are behavioral or somatic; will SHOW you that he/she is upset, rather than tell you

Trauma Experience: Mild/Moderate ID (~ages 5-11) Will take cues from others’ non-verbal behavior

regarding the seriousness of situations and how to respond

May discount verbal explanations May over-estimate or under-estimate the

seriousness of situations (knowledge is power) Use imagination to ‘fill in the blanks’ when

limited or no information is given to them (“The staff left because of me”)

Trauma Experience: Mild/Moderate ID (~ ages 5-11) Often react out of frustration and helplessness;

responses can be impulsive, but are not necessarily intentional

Can experience significant grief/loss reactions, even if loss expected (complicated grief processes)

Need routine, predictability, and behavioral limits to re-establish feelings of safety and security (What/who is home base for you?)

May imagine illness, injury or pain (physical or emotional) are punishments for past wrong doing

Trauma Experience: Mild ID (~ ages 7-11)

Think logically about concrete events, but have difficulty understanding abstract or hypothetical concepts (“Don’t put trash in the trash can” “You can’t use the TV after 3:00”)

May act ‘grown up’ to protect others from distress

Are sensitive to being excluded from discussions about him/her (Manage the triangle)

Trauma Interventions

•Trauma interventions at each developmental stage

Trauma Interventions: Severe/Moderate (~ ages 2-7 years) Provide him/her with a SAFE ZONE in the

environment where everything is predictable, routinized and controlled

Encourage expression of emotions through play, drawing or storytelling

Help identify and label what he/she may be thinking and remind him/her that others feel the same way (community)

Trauma Interventions

• Provide concrete explanations for what is happening, what will happen next, and for potentially traumatic sights and sounds in the environment

Trauma Interventions: Moderate/Mild ID

• Address distortions and magical thinking and help ‘fill in the blanks’ with realistic information• Help them create a coherent story to tell

others about when happened or what will happen • Explain and talk about events before they

happen; tell them what to expect

Trauma Interventions: Moderate/Mild (~ ages 5-11 years) Help them acknowledge the bad things that have

happened, and balance it with good Reassure him/her that they have done nothing

wrong to cause the trauma Ask open ended questions about what they are

imagining Help him/her understand it is common to react

to anger by feeling numb or acting out

Trauma Interventions: Mild (~ ages 7-11 years)

Help him/her anticipate challenges ahead and help problem solve preemptively to overcome the challenges

Allow them time to acknowledge losses and to grieve (Bowling night is Tuesday)

Actively involve him/her in discussions and decisions that will impact him/her whenever possible

TRAUMA

• Trauma syndromes have a common pathway

• Recovery syndromes have a common pathway • Establish safety• Reconstruct story• Restore connections

Trauma Victims

• If already vulnerable (children, individuals with ID) the most dramatic moments in your life may not be socially recognized or validated

At the moment of trauma

•Powerlessness•Helplessness

•Complex and integrated systems of reactions encompassing both body and mind

Trauma Symptoms

•Three categories:

•Hyperarousal• Intrusion•Constriction

Hyperarousal

• Permanent alert; startle response • Over reactions; explosive anger• Shattered fight or flight• Chronic or random physiological phenomena

may persist• Repetitive stimuli: perceived as new and

dangerous crisis • Do you feel you need to defend yourself?

Intrusion

Flashbacks (reliving trauma while awake)Nightmares (during sleep)Disturbing images/thoughts/fantasiesPhysical response (sweating, shaking, freezing, lashing out) to internal or external triggers that resemble the eventAs if time stops at the moment of trauma

Constriction

•Avoids activities, places, people, things to keep from being reminded• State of surrender• Self defense shuts down; detached• Escapes not by action, but by altering

state of consciousness• Possible alterations in pain perception?

Trauma Informed Care

•Manipulating• Lying• Stealing•We can explore these behaviors,

determine the underlying meaning and assist the patient in communicating his or her needs more effectively.

Children who have suffered abuse…. …must find a way to preserve a sense of

trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is unpredictable, power in a situation of helplessness…..

--Judith Lewis Herman

Healing

• Survivors hold the power to heal and recover• Do not need to include perpetrators,

family or others in the process• The work can be completed in the room

Recovery

• Allow individuals to save themselves• Remember what your role is• Not a savior or rescuer• Facilitator, support• Help reinstate renewed control• The more helpless, dependent and

incompetent the patient feels, the worse the symptoms become

The Contract

•Commitment to the future•Commitment to moving forward•Commitment to health and well being

•Clarify roles

Summary• ID do not protect one from developing MI• ID do not make one resistant to the effects

of psychotropic medications• Danger of over-diagnosis AND under-

diagnosis• Be aware of cultural aspects of trauma•Myth that all patients can’t benefit from

mental health services including trauma informed care, psychotherapies and state of the art medication regimens

Summary

•Create a protected space where survivors can speak their truth

•No matter your role in the life of the trauma survivor, bearing witness is an act of solidarity

Contact Information:

• julie.gentile@wright.edu• Julie P. Gentile, M.D.• Professor of Psychiatry, Wright State University• Project Director, Coordinating Center of

Excellence in Mental Illness/Intellectual Disability