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WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
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WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."


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The keynote speech at our 2013 Women in Mind Conference on Women's Mental Health. …

The keynote speech at our 2013 Women in Mind Conference on Women's Mental Health.
"Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
By Catherine Classen, Associate Professor in the Department of Psychiatry at the University of Toronto. She is the Director of the Women’s Mental Health Research Program at the Women’s College Research Institute at Women’s College Hospital, and the academic leader of the Trauma Therapy Program at Women’s College Hospital.

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  • 1993 National Prevalence Survey. There hasn’t been a Canadian national prevalence survey since this one. Prevalence of child physical and sexual abuse in the community. Results from the Ontario Health Supplement.[JAMA, 1997] H L MacMillan, et al
  • Prevalence of child physical and sexual abuse in the community. Results from the Ontario Health Supplement.[JAMA, 1997] H L MacMillan, et al
  • WHO’s recently released guidelines for treating survivors of intimate-partner violence recommend two specific therapies: CBT and EMDR.
  • Transcript

    • 1. Catherine C. Classen, PhD, CPsych Associate Professor, Dept. of Psychiatry, University of Toronto Academic Leader, Trauma Therapy Program, Women’s College Hospital Director, Women’s Mental Health Research Program, Women’s College Research Institute Presented at The Women in Mind | Body and Mind Conference, November 15, 2013
    • 2. 1. 2. 3. Describe the mental, physical, behavioral and societal consequences of trauma especially for women. Explain why our health system and community services should be trauma-informed. Identify the advantages and disadvantages in providing evidence-based treatment for traumatized women.
    • 3. Single incidents: Accidents, natural disasters, crimes, surgeries, deaths, and other violent events. PTSD Chronic or repetitive: Child abuse, neglect, combat, urban violence, concentration camps, battering relationships, forced dislocation, and enduring deprivation. Complex PTSD
    • 4. In U.S. National Comorbidity Survey  60.7% of men and 51.2% of women experienced at least one traumatic event (other research reports 90%)  Majority experienced two or more traumas  Men more likely to report witnessing someone injured or killed, involved in fire floor or natural disaster, lifethreatening accident, physical attacks, combat, threatened with a weapon, held captive, kidnapped  Women more likely to report rape, sexual molestation, childhood neglect, childhood physical abuse
    • 5. In Canada,  50% of women have experienced at least one episode of violence in adulthood 1993 National Prevalence Survey
    • 6. Physical Abuse 21% of females 31% of males Sexual Abuse 13% of females 4% of males 50% females & 33% of males were victims of unwanted sexual acts during childhood Neglect The most prevalent form of child abuse Results from the Ontario Health Supplement. [JAMA, 1997] H L MacMillan, et al
    • 7. Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)
    • 8. Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)
    • 9. Measuring violence against women: Statistical trends (2013), Juristat,Sinha, M (Ed.)
    • 10.  Biggest threat is within their homes and with those they should be able to trust
    • 11. Individual Family Community Society
    • 12. Emotions Depression  Anxiety  Shame and guilt  Fear  Anger  Affect dysregulation  Overwhelming emotion
    • 13. Millions 2.5 2 1.5 2009 2010 1 2011 2012 0.5 0 Overall Males Females Note: Population aged 12 and over who reported diagnosis by a health professional as having a mood disorder (depression, bipolar disorder, mania or dysthymia). Source: Statistics Canada
    • 14. Emotions Behaviours  Addiction  Interpersonal problems Revictimization  Self harm  Violent behaviour  Eating disorders  Poor parenting  Avoiding reminders of trauma
    • 15. Statistics Canada: Bethell& Rhodes, 2009, Health Reports
    • 16.  Shame (I’m bad)  Guilt (It’s my fault)  World is unsafe  Distrust Emotions Beliefs Behaviours
    • 17.  Rumination about traumatic experiences  Difficulties concentrating  Memory deficits and decline in cognitive function with aging Emotions Cognition Behaviours Beliefs
    • 18.  Dissociation  Dissociative disorders Emotions Consciousness Cognitive Behaviours Beliefs
    • 19.  Loss of meaning  Struggle to make meaning Emotions Spirituality Behaviours Consciousness Beliefs Thoughts
    • 20. Migraines, frequent headaches  Pelvic pain  Heart disease  Chronic obstructive pulmonary disease  Liver disease  Sexually transmitted diseases  Obesity  Autoimmune disease  Unexplained symptoms Emotions Physical health Behaviours Spirituality Beliefs Consciousness Thoughts
    • 21. Death Early Death Disease & disability Health-risk behaviors Social, emotional, and cognitive impairment Neurological changes Adverse childhood experiences Birth Anda & Felitti, 2003
    • 22. Neocortex (thinking brain) Limbic system (emotional brain) Three brains One mind Brainstem (instincts) (Paul MacLean, 1960’s)
    • 23. Neocortex (thinking brain) Limbic system (emotional brain) Brainstem (instincts)
    • 24. Neocortex (thinking brain) Limbic system (emotional brain) Brainstem (instincts) Bottom-up processing
    • 25.   Attach cry Amygdala sounds the alarm Social engagement system  Attachment cry  Sympathetic nervous system  Fight, flight, freeze Submit Fight Trauma Freeze  Parasympathetic nervous system  Submit (feigned death) Flight
    • 26.   Trauma overwhelms Psyche splits  Apparently normal personality  Emotional parts
    • 27. Pre-trauma personality ANP Attach cry EP Fight Flight Freeze Submit
    • 28.  Developmental neglect  Underdeveloped cortical and limbic system  Poor modulation of impulsivity, persisting immature emotional and behavioral functioning and a predisposition to violence  Developmental trauma  Overdeveloped brainstem  Predisposition to act in aggressive, impulsive, reactive fashion  Developmental trauma and neglect  Problemscompounded
    • 29.  "Traumatic events of the earliest years of infancy and childhood are not lost but, like a child's footprints in cement, are often preserved life-long. Time does not heal the wounds that occur in those earliest years; time conceals them. They are not lost; they are embodied.” Felitti, 2010.
    • 30.    Females more likely to internalize distress Women are at greater risk of violence at home Women are more likely to suffer sexual violence    Males more likely to externalize distress Males are at greater risk outside the home Males more likely to be violent towards others and towards themselves
    • 31. Measuring violence against women: Statistical trends (2013), Juristat, MaireSinha (Ed.)
    • 32.  Difficult to estimate but in the billions every year in Canada  Total cost of partner violence against women estimated at $4.8 billion in 2009 (Zhang, et al, 2013)  Health costs of partner violence are $79 million per year
    • 33. Trauma-specific treatment 1.  What do we know about effective treatments for complex trauma? Trauma-informed care 2.  Trauma survivors are over-represented in our health care system and not receiving the care they need
    • 34.   The current paradigm for state-of-the-art care in medicine Aim is to provide the best possible care with the least risk of harm
    • 35.  Decision-making based on  Best available evidence  Patient characteristics, situations and preferences  Recognizes that care is individualized and ever changing
    • 36. Best available research evidence Clinical Decision-Making Patient’s values, characteristic s, and circumstances Clinical Expertise
    • 37. Systematic Reviews RCTs NR controlled studies Observational studies Case series Case reports Expert opinion
    • 38.     Client group must be clearly defined Intervention must be standardized and clearly defined Outcome must be clearly identified in advance and measurable Intervening variables must be known and controlled for
    • 39.  Advantages  Causal conclusions can be drawn  Eliminates random causal findings  Randomization ensures statistically equivalent groups  Typically focuses on pure diagnoses with no comorbidity
    • 40.  Disadvantages  Typically focuses on pure diagnoses with no comorbidity ▪ A review of PTSD research found that severe comorbid psychopathology is often an exclusion criteria (Spinazzola, Blaustein& van der Kolk, 2005) or those with severe comorbidity drop out  Not “real world” clinically  Expensive  Short-term treatments  Ethical concerns with randomization
    • 41.  Best available evidence  PTSD  Brief interventions (6-16 sessions) ▪ Cognitive behavioural ▪ Prolonged exposure ▪ EMDR  Complex trauma is understudied  Best available evidence either extrapolates from PTSD research or is lower quality evidence
    • 42. 1. Training programs emphasize EBM  Students learn empirically supported treatments ▪ Funding not available for research on long-term treatments addressing complex problems  Bias against intensive treatments (such as, psychodynamic) and novel treatments (e.g., sensorimotor psychotherapy) 2. Most training programs do not provide training in trauma treatment
    • 43.    Pressure to provide brief interventions Often lack expertise in trauma Often view complex trauma survivors as too difficult or beyond their scope of expertise
    • 44. Best available research evidence Clinical Decision-Making Patient’s values, characteristic s, and circumstances Clinical Expertise
    • 45.  Complex trauma requires complex treatment  Include evidence lower on the evidence pyramid   Longer term treatment A range of treatment modalities  Individual, group, substance abuse, couple, family  Continuity of care  Consistency, predictability, safety
    • 46.  If the wounds of trauma are embodied, should treatment include a focus on the body?
    • 47.  Incorporates a bottom-up with a top-down approach  Works with the body directly using mindfulness  Aims to change activation in the lower part of the brain, which will change thought process and help to integrate traumatic experience
    • 48.    The ability of our brain to change in response to experience Mindfulness is deliberately focusing on one’s present moment experience without judgment Mindfulness stimulates brain function that supports neuroplasticity (Daniel Siegel)
    • 49.   Too many women are not getting the treatment they need Too many women are handicapped by their trauma history and are marginalized
    • 50.        Powerlessness Lack of control Damaged goods Unworthy Unsafe Fear of authority figures Others are untrustworthy
    • 51.      Appointment cancellations Non-adherence to treatment Fear of common medical examination procedures Avoids regular health checks Or, excessive utilization of health care system  Especially emergency care
    • 52. • • • • Mistrust of authority Easily triggered – Dissociates (flashbacks, intense emotion, spaces out) Disconnected from the body Fearful, angry, agitated, anxious – Especially uncomfortable with person who is same gender as • • • • abuser Passive, unable to voice needs Addicted Interpersonal problems Evidence of self harm (Schachter, Stalker, Teram, Lasiuk & Danilkewich, 2008)
    • 53.  Patient-blaming  Somatization, secondary gain   Emphasis on compliance Misuse/overuse of power
    • 54. … 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. Sandra Bloom, 2006
    • 55.      Safety Trustworthiness Choice Collaboration Empowerment
    • 56. 1. 2. 3. 4. 5. 6. 7. 8. 9. Respect Take time Rapport Share information Share control Respect boundaries Foster mutual learning Understand nonlinear healing Demonstrate awareness / knowledge Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C., Danilkewich, A. (2008). Ottawa: Public Health Agency of Canada.
    • 57. A need for universal precautions
    • 58.       Trauma is a pervasive and complex problem Raise awareness of the prevalence and impacts Incorporate training about trauma across all disciplines and not just health disciplines Lobby for funding for research on best practice for trauma, cost-effectiveness, etc. Commit to addressing the root causes of interpersonal violence and Apply necessary resources to help victims heal
    • 59. Catherine Classen, PhD, CPsych 416-323-6041