Trauma Informed Care and Houselessness

Lydia Bartholow, DNP, PMHNP, CARN-APAssociate Medical Director at

Central City Concern

Who am I?

• Psychiatric Nurse Practitioner

• Addiction Specialist

• Person in long term recovery

• Working with unhoused communities for 2 decades

• Obsessive about how to make the client experience better

Agenda: Conceptual

• What to know

• What to believe

• What to do, specifically for individuals without stable housing

Agenda: logistical

• Neurophysiology of toxic stress and trauma

• Brief ACES overview

• Trauma Informed paradigm shift

• How this translates into working with houseless individuals

Neurophysiology

Nervous System Organization

Initial signs and symptoms of the stress

response:

(aka fight, flight or freeze or HPA axis)

Blurred

vision

Increased

heart rate

Inability to

focus/

think

straight

Thoughts of

impending doom

Sweaty palms

Muscle

tension

Increased blood

pressureshaky

nausea

Stressor or

Threat:(cop in rearview mirror)

Amygdal

aattaches fear to stimuli

Stressor or

Threat:(cop in rearview mirror)

Amygdal

aHypothala

mus

Stressor or

Threat:(cop in rearview mirror)

Amygdal

aHypothalamus

Direct

stimulation of

fight or flight

neuronsAdrenal

Glands

pituitary

Adrenal

Glands

adrenaline/c

atecholamine

s

-- pupil dilation

-- sweat

-- dried out mucous membraines

-- muscle contractility

-- increased HR

-- increased BP

-- blow flow away from stomach

-- blow flow away from prefrontal

cortex

-- blood flow to vital organs

-- increased blood sugar

Nervous System Organization

Stressor or

Threat:(cop in rearview mirror)

Amygdal

aHypothalamus

Direct

stimulation of

fight or flight

neuronsAdrenal

Glands

adrenaline/c

atecholamine

s

Adrenal

Glandscortisol

adrenaline/c

atecholamine

s

-- immune system suppression

-- suppression of inflammation

-- water retention

-- hyperglycemia

-- insulin resistance

-- muscle breakdown

-- increased gastric juices

-- removal of calcium from bones

-- pupil dilation

-- sweat

-- muscle

contractility

-- increased HR

-- increased BP

-- blow flow away

from stomach

-- blow flow away

from brain

Affects of long term

cortisol…

-- immune system suppression/suppression of

inflammation =

-- water retention =

-- hyperglycemia =

-- fat redistribution =

-- decreased gastric integrity =

-- Thyroid down regulation =

-- decreased serotonin (for some people) =

-- dopamine dysregulation in the NA =

Affects of long term

cortisol-- immune system

suppression/suppression of inflammation

=

-- water retention =

-- hyperglycemia =

-- fat redistribution =

-- decreased gastric integrity =

-- Thyroid down regulation =

hypothyroidism

-- decreased serotonin (for some people)

=

Diabetes

IBS / Food sensitivities /

ETC

White folks

Cisgendered

folks

Higher SES

Straight Folks

Men

Folks of Color

Transgender

folks

Lower SES

LGBTQI Folks

Women

Privelege

Oppression

Allostatic

loadMcEWEN, B. (2001). Stress, Adaptation, And Disease:

Allostasis And Allostatic Load. Annals of the New

York Academy of Sciences, 33-44.

But that’s genetics, right?

Barr, D. (2008). Health disparities in the United States: Social class, race, ethnicity, and health. Baltimore:

Johns Hopkins University Press.

Stress Trauma

Trauma is:

-- a ghost that haunts your body

and brain

-- a “blow out” of your fight or flight

system

-- “The result of exposure to an

inescapably stressful event that overwhelms

a person’s coping mechanism” – Bessel

2 central aspects of trauma:

• Lack of control

• Lack of being seen (mirror neurons)

Stressor or

Threat:(cop in rearview mirror)

Adrenal

Glands cortisol

adrenaline/c

atecholamine

s

Hippocam

pus

negative feedback

Stressor or

Threat:(cop in rearview mirror)

Adrenal

Glands cortisol

adrenaline/c

atecholamine

s

Hippocam

pus

negative feedback

Locus Ceruleus ->

stimulation of

adrenergic

neurons

Stressor or

Threat:(cop in rearview mirror)

Amygdala

When the amygdala is stimulated and our “fight,

flight or freeze” system is always on and rest and

repair is rarely engaged (homeostatic imbalance).

So, what happens if the amygdala is not being

“calmed” and we can’t rest and repair?

Alcoholism and ACES

IV Drug Use and ACES

Thinking about the Trajectory:

Hot spots for unhoused individuals seeking services?

Hot Spots

Trauma Informed Paradigm Shift

Trauma Informed Tenets and Values• Acknowledges the prevalence of trauma, and the subsequent changes to neurophysiology.

• Transparent

• Strengths Based and Rewarding

• (love as contingency management)

• Predictable

• Collaborative

• Shared Decision making

• Actively resists re-traumatization

• Emphasizes Just Culture

• Highlights Peer Inclusion

• Addresses equity

• Attentive to staff trauma burden

Trauma Informed VS Trauma Specific?

Informed Specific

Universal precautions Treats disorder in an

individual

Builds attentive systems for

cts and staff

Target specific symptoms

of trauma (e.g. prazosin for

nightmares)

Changes how we think

about the pathology

Utilizes modalities such as

EMDR, SE, etc

Doesn’t necessarily screen

for Trauma

Screens and offers

intervention for PTSD

How do we build systems that are trauma informed, specifically when thinking about the trauma of homelessness or for those who are experiencing houselessness?

• Lydiabartholow.pmhnp@gmail.com

Reading list on trauma, trauma informed care and allostatic load

• Post Traumatic Slave Syndrome - Joy Degruy

• In the Realm of Hungry Ghosts - Gabor Mate

• The Deepest Well - Nadine Burke Harris

• Childhood Disrupted - Donna Nakazawa

• Public Health in the United States - Donald Barr (great review of allostatic load though the name is boring sounding)

• The Body Keeps the Score - Besssel Van Der Kolk

• When the Body says no - Gabor Mate

References• Felitti, V. J. (2004). The origins of addiction: evidence from the adverse childhood

experiences study. Kaiser Permanente Department of Preventative Medicine

• Leary, J. (2005). Post traumatic slave syndrome: America's legacy of enduring injury and healing. Milwaukie, Oregon: Uptone Press.

• Nakazawa, D. J. (2015). Childhood disrupted: How your biography becomes your biology, and how you can heal. New York, NY: Atria.

• Nusslock, R., & Miller, G. E. (2015). Early-life adversity and physical and emotional health across the lifespan: a neuroimmune network hypothesis. Biological psychiatry.

• Shah, P., Fonagy, P., & Strathearn, L. (2010). Is attachment transmitted across generations? The plot thickens. Clinical Child Psychology and Psychiatry, 329-345.

• Van der Kolk, B. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. NY, NY: Penguin Books.