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Being Trauma-Informed in the Care of People Living with HIV

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Marcy Witherspoon, MSW, LSW of the Health Federation of Philadelphia discussed trauma-informed care with the Philadelphia EMA HIV Integrated Planning Council on November 9, 2018.

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Being Trauma-Informed in the Care of People Living with HIV

  1. 1. www.healthfederation.org Being Trauma-Informed in the Care of People Living With HIV By Marcy Witherspoon, MSW, LSW Senior Training Specialist Health Federation of Philadelphia
  2. 2. www.healthfederation.org Health policymakers and practitioners across the country are increasingly recognizing the effects of trauma on the health status of individuals … let’s examine why.
  3. 3. www.healthfederation.org Session Objectives • To relay the profound impact of childhood trauma on brain development, temperament and adult-specific behavior. • To discuss the Adverse Childhood Experiences (ACE) Study and its potential effects over the life course. • To provide trauma-informed principles to reduce the negative sequelae associated with HIV diagnosis, disclosure, and treatment
  4. 4. www.healthfederation.org Childhood decides … Jean Paul Sartre
  5. 5. www.healthfederation.org Early experiences help to determine brain structure, thus shaping the way people learn, think, and behave for the rest of their lives.
  6. 6. www.healthfederation.org Trauma occurs when one’s internal resources are not adequate to deal with one’s external threats … these events are deeply distressing and/or threatening and can have long-lasting negative effects.
  7. 7. www.healthfederation.org What are some examples of childhood trauma?
  8. 8. www.healthfederation.org Trauma is under-reported and under-diagnosed (NTAC, 2004) Exposure to Trauma Trauma can be: • A single event • A connected series of events • Chronic lasting stress Used with permission from Trauma Informed Florida Project http://www.djj.state.fl.us/trauma-informed-care/index.html
  9. 9. www.healthfederation.org •race •gender •ethnicity •religion •socio-economic group •community •workforce •sexual orientation •gender identity Trauma can occur at any age. Trauma can affect any: Used with permission from Trauma Informed Florida Project http://www.djj.state.fl.us/trauma-
  10. 10. www.healthfederation.org 10 21 Lower part of brain over-wired at expense of upper parts Unremitting Stress Childhood Trauma Challenging behaviors associated with lower brain functions Excessive stress hormones dumped into brain Ongoing social, emotional, cognitive difficulties The Brain on Trauma Adult trauma and related problems
  11. 11. www.healthfederation.org
  12. 12. www.healthfederation.org Body’s Automatic CNS Response
  13. 13. www.healthfederation.org www.traumahealing.com
  14. 14. www.healthfederation.org Toxic Stress & The Brain • Causes disruption of brain architecture, brain organization and brain chemistry – Impairs cell growth – Interferes with healthy neural circuits – Changes chemical and hormonal responses in the brain
  15. 15. www.healthfederation.org Toxic Stress & PTSD • After trauma, some people develop stress- related symptoms that don’t go away … 1) re-experiencing the trauma 2) avoiding reminders of trauma 3) hypervigilance 4) change in mood/thoughts
  16. 16. www.healthfederation.org We need to know that … • trauma is common, pervasive & universal • trauma is about perception of the event • trauma can change the brain & concomitant behavior • trauma can impact one’s health
  17. 17. www.healthfederation.org Trauma’s Lasting Negative Effects 1) world view 2) feelings of safety 3) sense of future 4) relationships with others 5) health & well-being 6) emotional awareness & expression
  18. 18. www.healthfederation.org The ACE Study -- the largest public health study of its kind that nobody has ever heard of …
  19. 19. www.healthfederation.org Study method 17,421 members of the Kaiser Health Plan in San Diego County from 1995-1997 Confidential survey asking questions about childhood trauma and current health status and behaviors combined with physical examination Demographics: • primary care setting • educated • middle class • predominantly white
  20. 20. www.healthfederation.org Ten Original ACEs • 1)physical abuse • 2)emotional abuse • 3)sexual abuse • 4)physical neglect • 5)emotional neglect • 6)mother a victim of IPV • 7) HH member incarcerated • 8) HH member mental health • 9) HH member substance use • 10)one/both bio parents absent
  21. 21. www.healthfederation.org aces 5-minute primer
  22. 22. www.healthfederation.org
  23. 23. www.healthfederation.org Adverse Childhood Experiences Heart Disease Chronic Lung Disease Liver Disease Suicide Substance Abuse HIV and STI’s Adverse Childhood Experiences Increase the Risks of: Used with permission from Trauma Informed Florida Project: http://www.djj.state.fl.us/trauma-informed-care/index.html
  24. 24. www.healthfederation.org
  25. 25. www.healthfederation.org Philadelphia Expanded ACE Study www.instituteforsafefamilies.org/philadelphia-urban-ace-study Experiencing Racism/Discrimination Witnessing Community Violence Living in an Unsafe Neighborhood Living in Foster Care Experiencing Bullying
  26. 26. www.healthfederation.org
  27. 27. www.healthfederation.org Philadelphia Urban ACE Project , a collaboration of (PHMC, CHOP, St. Christopher’s, ISF, Drexel University
  28. 28. www.healthfederation.org Original Study vs. 11th Street Results # of ACEs (ACE Score) Women Men Total 11th Street Patients Original Study 11th Street Patients Original Study 11th Street Patients Original Study 0 6.8% 34.5% 3.9% 38.0% 6.3% 36.1% 1 12.5% 24.5% 9.9% 27.9% 12.0% 26.0% 2 18.5% 15.5% 14.5% 16.4% 17.8% 15.9% 3 14.6% 10.3% 16.4% 8.6% 14.9% 9.5% 4 or more 47.5% 15.2% 55.3% 9.2% 49.0% 12-16% From Dr. Patty Gerrity and Dr. Roberta Waite, The Healing Project
  29. 29. www.healthfederation.org
  30. 30. www.healthfederation.org
  31. 31. www.healthfederation.org
  32. 32. www.healthfederation.org People Living With HIV … • More likely to have significant trauma histories (childhood sexual & physical abuse) • More likely to have co-morbid medical conditions • 95% of people living with HIV report at least one severe traumatic stressor • 54% are reported to have PTSD • Behavioral, neurobiological and psychological changes often prevent effective coping strategies and positive health behaviors.
  33. 33. www.healthfederation.org HIV and Current Trauma • Any childhood trauma is worsened by stigma, discrimination, and bias – by others, often in health care settings • Some settings are re-traumatizing and trigger patients • For some patients, learning of their status is traumatic. • A woman living with HIV is 4x more likely to experience treatment failure and not remain virally suppressed. • Women who had experienced trauma are more likely to have sex with partners whose HIV status is unknown to them, have sex without condoms, and are more likely to spread the infection with unprotected sex. • 55% of women living with HIV experience IPV
  34. 34. www.healthfederation.org Due to systemic issues related to homophobia, transphobia, patriarchy and other systemic types of oppression, HIV treatment is often not working for: • Women living with HIV • Transgender women • Young black gay men
  35. 35. www.healthfederation.org Many clinics work with patients who get to undetectable viral loads, but … • about 50% are depressed • almost 50% are using substances • most are poor • most aren’t fully “out” re: status • many are living with abusive partners • many are not working
  36. 36. www.healthfederation.org What would help? • This information is important to consider when assessing impact on members of the HIV positive community. • Focus has been on biomedical model (adherence to medication, getting to an undetectable viral load, etc.) and ignored other pieces of personal health & experiences. • More helpful focus might be a medical home model where primary care is integrated into HIV treatment • Routine screening for ACEs would exist – behavioral health consultation would be available on-site • Health-providing sites would be “safe spaces.” • Harm reduction models would be utilized Please keep in mind, there are protective factors available to people to lessen the impact of ACES on future health outcomes
  37. 37. www.healthfederation.org Just because you have had trauma, this does not mean your disease will spiral out of control … But you must be aware of how unresolved trauma impacts health choices, lifestyle decisions, and begin to learn ways to ameliorate the effects of stress …
  38. 38. www.healthfederation.org These challenges impact adherence to medication and engagement in care … so, in spite of new medications/treatment, HIV is the leading cause of death among Black women ages 25-34.
  39. 39. www.healthfederation.org At one clinic, 16% of deaths were HIV-related, while 84% were related to murder, substance use, suicide and hopelessness…
  40. 40. www.healthfederation.org What happened to you? vs. What’s wrong with you? Trauma-Informed Care
  41. 41. www.healthfederation.org TIC moves from shame, blame and punishment to … Understanding (What happened to you and how has it affected you?) Nurturing (How can I help you?) Healing (How can I help you to heal, and not create more problems for you?)
  42. 42. www.healthfederation.org Trauma-Informed Care • requires universal trauma precautions and screening • practice changes with patients with known trauma histories • patient-centered communication and care • safe clinical environments • shared decision-making for patients • provider collaboration across disciplines • requires awareness of own trauma histories
  43. 43. www.healthfederation.org Trauma-Informed Care Framework • requires change to organizational policies, practices and culture • reflects an understanding of the impact of trauma and paths for recovery • actively seeks to prevent re-traumatization • reviews how services can trigger patient • understands strengths-based approaches that promote resiliency
  44. 44. www.healthfederation.org For People Living with HIV • Know this is a real and present phenomenon • Have patience with yourself • Re-evaluate your coping strategies • Seek out safe, stable and nurturing supports • Engage your allies (peer, personal, and professional) • Explore, identify and manage your triggers (as much as is possible) • Multiply your connections • Handle yourself gently • Seek consistency • Consider trauma specific services
  45. 45. www.healthfederation.org The goal of TIC … The entire health care community integrates trauma-informed practices into daily practice based on awareness of how the brain works and the science of ACEs so that individuals, no matter what their health challenges, can maximize their health and have better outcomes…
  46. 46. www.healthfederation.org “If you think you’re too small to make a difference, try sleeping in a room with a mosquito.” African Proverb
  47. 47. www.healthfederation.org The Health Federation of Philadelphia is continually developing new programs in response to both the needs of underserved communities and the availability of data indicating improved approaches to health care and behavioral support. For more information about our initiatives, please visit: www.healthfederation.org HFP0617001

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