Trauma Informed Care and Houselessness · Childhood disrupted: How your biography becomes your...
Transcript of Trauma Informed Care and Houselessness · Childhood disrupted: How your biography becomes your...
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?
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.