ADULTS AFFECTED BY
INTERPERSONAL VIOLENCE
(IPV) IN CHILDHOOD
A Public Health Problem that contributes to
High utilization,...
VIOLENCE
“Violence is the intentional

against oneself, against another
person or against a group or community, which eith...
IPV GOES BEYOND PHYSICAL
VIOLENCE
• Any attempt to dominate or control through
behaviors that engender fear and helplessne...
IPV

norma-peace-stuff-page2.blogspot.com
THE ADVERSE CHILDHOOD EVENTS (ACE)
STUDY
(CDC & KAISER PERMENANTE 1995-1997)

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

D...
PREVALENCE OF EXPOSURE TO IPV IN CHILDHOOD
Category

Type

Abuse

Emotional abuse

Total
(N=17,337)

13.1

7.6

10.6

27.0...
TRAUMA
Individual trauma results from an event, series of
events, or set of circumstances that is experienced by
an indivi...
LASTING ADVERSE AFFECTS
SUGGESTED IN THE ACE STUDY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Chronic obstructive pulmonary disease ...
ACE STUDY DATA

CDC, 2013
PYRAMID DEPICTING MECHANISMS
SUGGESTED BY THE ACE STUDY

CDC, 2013
HIGH COSTS, BUT HOW HIGH IS
UNKNOWN
HOW EQUIPPED ARE WE TO RESPOND?
A LOOK AT RECOMMENDATIONS:
YIKES!
• 1. Assess patients/clients via interview, questionnaire, history taking and
health exa...
AND THEY GO ON!
• 8. Offer continuity of care and appropriate referrals to community
resources. (s)
• 9. Provide thorough ...
WHAT IS MISSING
• Digestible information to help health care providers
understand the problem conceptually so that they
ca...
THIS PRESENTATION WILL HOPEFULLY
• Empower you through:
• An increased understanding of IPV and the complex
trauma respons...
IS THIS FAMILIAR?
You greet your next patient, Sally, a 42 year-old
married white female
She is late for her appointment
S...
THE CHARACTERISTICS OF A PATIENT
TRAUMATIZED BY IPV IN CHILDHOOD
Emotional
Dysregulation

Relational
Dysregulation

Physio...
THE PHYSIOLOGICAL DYSREGULATION
AT THE CENTER OF IT

Courage-counseling.com
DSM-V CRITERIA
•
•
•
•
•

•

•
•
•
•
•
•
•

Criterion A: stressor
The person was exposed to: death, threatened death, actu...
DSM-V CRITERIA
•
•
•
•
•
•
•
•
•
•
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•
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•

Criterion C: avoidance
Persistent effortful avoidance of distres...
DSM-V CRITERIA
•
•
•
•
•
•
•
•
•
•
•
•

Criterion F: duration
Persistence of symptoms (in Criteria B, C, D, and E) for mor...
COGNITIVE DYSREGULATION
•
•
•
•
•
•

Intrusive negative, fear-based thoughts
Negative thoughts about self
Cognitive distor...
EMOTIONAL DYSREGULATION
• Emotional lability, i.e. reactivity
• Difficulty modulating emotions
BEHAVIORAL DYSREGULATION
• Unable to mobilize behavior to meet one’s needs
• Impulsivity
• The prefrontal cortex and highe...
RELATIONAL DYSREGULATION
•
•
•
•
•

Disturbed attachment
Lack of trust
Confused interpersonal boundaries
Tendency to engag...
TRAUMA/DRAMA REPETITION
• The Karpman Drama Triangle
SALLY SEEN THROUGH A TRAUMAINFORMED LENS
• Sally’s physical conditions and behaviors are
consistent with exposure to IPV a...
HOW TO SCREEN
Be alert to trauma’s sequelae
Suspect trauma when the sequelae is present
Ask questions to explore functioni...
MEANWHILE
• Establish and maintain a relationship over time that
is characterized by respect, shared power, healthy
bounda...
HOW TO KEEP THE RELATIONSHIP ON
TRACK
• Practice non-violence
• Model healthy limits and boundaries appropriate to
your re...
NON-VIOLENCE

www.advocates-oz.org
IDENTIFY HYPER AND HYPO AROUSAL
AND INTERVENE
• Hyper arousal: agitation, restlessness, fast
speech, muscle tension, etc.
...
SEVERE DISSOCIATION
• Personality fragmentation
• Changes in ego state
• Disturbances in continuous consciousness---loss o...
PATIENT TEACHING
• Help the patient understand his/her experience
• Your patient knows something’s wrong---demystify it
• ...
USE MOTIVATIONAL
INTERVIEWING
• Identify the patient’s goals
• Plan interventions with the patient, prioritizing his/her
g...
LET THE STAGES OF CHANGE GUIDE
INTERVENTIONS
DON’T WORK ALONE
• Keep Maslow’s Hierarchy in mind: basic needs first
(safety, food, shelter, transportation)
• Give focus...
REFERRAL OPTIONS
•
•
•
•
•

Social Services
Psychopharmacology
Community-based mental health services
Psychotherapy (traum...
A NOTE ABOUT DEALING WITH
SUBSTANCE ABUSE
Discuss it with concern and caring
Fully appreciate why the patient self-medicat...
WHAT WOULD YOU DO?
You greet your next patient, Sally, a 42 year-old
married white female
She is late for her appointment
...
SUMMARY
• A large number of our adult patients have been
traumatized in childhood
• If you see smoke, think fire
• Recogni...
REFERENCES
Adverse Childhood Experiences (ACE) Study. Center for
Disease Control and Prevention. n.d. Web. 2 Nov. 2013.
<h...
SUSAN’S CONTACT INFORMATION
• Email: suprilax@hotmail.com
• Phone: 617-372-5784
• Practice Locations: 23 Main Street Water...
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The Effects of Trauma on Health Care Utilization

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This webinar will discuss the effects of childhood trauma on health care utilization and chronic illness. Susan Lax is an Advanced Practice Nurse with a dual degree in psychiatry/mental health nursing and primary care nursing from the Institute of Health Professions at Massachusetts General Hospital. She is certified in Trauma Studies by the Trauma Center at JRI, trained by Bessel van der Kolk and his colleagues. She has completed trainings in Sensorimotor Psychotherapy, a mindfulness approach to treating trauma disorders. In all, she has completed more than 300 hours of training in the treatment of acute and developmental trauma. In 2010 Susan was awarded a leadership in nursing award for her success incorporating a trauma treatment as she worked in acute, residential, and community settings in the Greater Boston Area, including on a PACT team.

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  • Acting dismissive, intentionally ignoring or shunning someone, or engaging in put-downs, sarcasm, eye rolling, yelling, and name calling
  • There is an actual or implied threat to a person’s physical, emotional, social, or economic well-beingCharacteristic of this kind of aggression is invasion of personal boundaries.The perpetrator does not respond to no or please stop…
  • The Adverse Childhood Experiences (ACE) Study is one of the largest studies of childhood maltreatment and later-life health and well-being. More than 17,000 Health Maintenance Organization (HMO) members agreed to fill out a questionnaire about exposure to stress in childhood and then underwent a comprehensive physical examination.The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente&apos;s Health Appraisal Clinic in San Diego.The ACE Study findings suggest that certain experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. Expanding this study is underway.
  • .http://www.cdc.gov/ace/prevalence.htm
  • SAMHSA definition
  • The ACE Study uses the ACE Score, which is a count of the total number of ACE respondents reported. The ACE Score is used to assess the total amount of stress during childhood and has demonstrated that as the number of ACE increase, the risk for the following health problems increases in a strong and graded fashion:Alcoholism and alcohol abuse
  • Diabetes—insulin resistanceObesityMetabolic SyndromeChronic Stress and Disease: Immune dysfunction, contributing to inflammatory conditionsChronic painGI disordersMigrainesSkin disease (psoriasis/eczema)COPD (exacerbated by smoking)Medical conditions related to the abuse of alcohol and other substancesMedical conditions related to risk-taking, including STDsChronicity and severity exacerbated by poor diet and inactivity(Does not include psychiatric problems: PTSD, depression, and comorbidity
  • The problem has not been fully researchedThe mechanisms by which disease and dysfunction arise are not fully understoodMost healthcare provider probably are not recognizing the relationshipIPV in childhood is under-reported
  • Most healthcare providers aren’t privy sophisticated understanding of IPV, including the interpersonal dynamic, the trauma response that may result, and what it requires to interveneSystemically, healthcare professionals are pressured to treat IPV related health conditions in a way that is fragmented and disjointed, limiting the influenceLimited time with the patient
  • Competencies Needed by Health Professionals for Addressing Exposure to Violence and Abuse in Patient Care, Academy on Violence and Abuse, Eden Prairie, MN, April 2011
  • This is a downloadable publication that is helpfulMore comprehensive than other recommendations I foundBut, unyieldy
  • Ask: Does this sound familiar? How many of you have encountered similar patients?Patients like Sally are challenging.How do you frame the problem in your mind? How do you respond to it? Are your interventions effective?
  • Extremes of sympathetic and parasympathetic arousalAnd all the associated medical conditions associated with thisAdd to this Substance Use, Risky Behaviors, and poor self-care---exacerbating the physiological dysfunction and the dysfunction across domains
  • distinct from what is seen in Bipolar Affective Disorder or Depression alone
  • She is physiologically unhealthy, emotionally labile---unable to mobilize cognition, emotion, and behavior in ways that enable her to grow and adapt toward greater health
  • This does not mean rigid, inflexible, alienating boundariesConsider when disclosure might be helpful to equalize power, as in communicating, “I respect you,”; “I’m a human being, too”; “We share things in common”
  • HonestRespectfulNon-coerciveNon-aggressiveIt communicates acceptance and high regardAvoid interrupting the patientBe aware of body language: rolling eyeballs, acting dismissive/impatient, being sarcasticRegulate your own body when stressed or tense
  • Interventions: Grounding
  • Implications: If you suspect this, involve mental health
  • Ask: Does this sound familiar? How many of you have encountered similar patients?Patients like Sally are challenging.How do you frame the problem in your mind? How do you respond to it? Are your interventions effective?
  • The Effects of Trauma on Health Care Utilization

    1. 1. ADULTS AFFECTED BY INTERPERSONAL VIOLENCE (IPV) IN CHILDHOOD A Public Health Problem that contributes to High utilization, inappropriate utilization, poor health outcomes, and high social and economic costs WHAT CAN A HEALTHCARE PROVIDER DO?
    2. 2. VIOLENCE “Violence is the intentional against oneself, against another person or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” -World Health Organization; 2011
    3. 3. IPV GOES BEYOND PHYSICAL VIOLENCE • Any attempt to dominate or control through behaviors that engender fear and helplessness • The behavior inflicts emotional pain with intent • Ranges in quality from overt to more subtle forms of aggression
    4. 4. IPV norma-peace-stuff-page2.blogspot.com
    5. 5. THE ADVERSE CHILDHOOD EVENTS (ACE) STUDY (CDC & KAISER PERMENANTE 1995-1997) • • • • • • • • • • • • • • • • • • • • • Demographic Categories Gender Female 54% Male 46% Race White 74.8% Hispanic/Latino 11.2% Asian/Pacific Islander 7.2% African-American 4.6% Other 1.9% Age (years) 19-29 5.3% 30-39 9.8% 40-49 18.6% 50-59 19.9% 60 and over 46.4% Education Not High School Graduate High School Graduate 17.6% Some College 35.9% College Graduate or Higher Percent (N = 17,337) 7.2% 39.3%
    6. 6. PREVALENCE OF EXPOSURE TO IPV IN CHILDHOOD Category Type Abuse Emotional abuse Total (N=17,337) 13.1 7.6 10.6 27.0 29.9 28.3 Sexual 24.7 16.0 20.7 Emotional Neglect 16.7 12.4 14.8 Physical Neglect Household Dysfunction Men (N=7,970) Physical Neglect Women (N=9,367) 9.2 10.7 9.9 Mother Treated Violently 13.7 11.5 12.7 Household Substance Abuse 29.5 23.8 26.9 Household Mental Illness 23.3 14.8 19.4 Parental Separation or Divorce 24.5 21.8 23.3 Incarcerated Household Member 5.2 4.1 4.7 CDC, 2013
    7. 7. TRAUMA Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being SAMHSA: http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx
    8. 8. LASTING ADVERSE AFFECTS SUGGESTED IN THE ACE STUDY • • • • • • • • • • • • • • • • Chronic obstructive pulmonary disease (COPD) Depression Fetal death Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy CDC, 2013
    9. 9. ACE STUDY DATA CDC, 2013
    10. 10. PYRAMID DEPICTING MECHANISMS SUGGESTED BY THE ACE STUDY CDC, 2013
    11. 11. HIGH COSTS, BUT HOW HIGH IS UNKNOWN
    12. 12. HOW EQUIPPED ARE WE TO RESPOND?
    13. 13. A LOOK AT RECOMMENDATIONS: YIKES! • 1. Assess patients/clients via interview, questionnaire, history taking and health examination processes. Use reliable, valid and normed instruments developed for the assessment of abuse, violence and its symptoms where available. (s) • 2. Intervene using evidence-based and evidence-informed treatments. (s) • 3. Prevent violence using evidence-based and evidence- informed methods of primary, secondary and tertiary prevention. (s) • 4. Recognize risk factors for victimization and perpetration of violence. (k) • 5. Recognize physical and behavioral presentations and signs of abuse and neglect, including patterns of injury across the life span. (k) • 6. Educate patients and clients regarding limits of confidentiality and reporting requirements. • 7. Identify and address the problems associated with emotional, physical, and sexual abuse and neglect. (s) Academy on Violence and Abuse, 2011
    14. 14. AND THEY GO ON! • 8. Offer continuity of care and appropriate referrals to community resources. (s) • 9. Provide thorough documentation of patient’s and client’s statements, clinical observations, and visual documentation of injuries, using body maps and photographs. (s) • 10. Be aware of and comply with state reporting laws, collaborating with the victim of violence to make reports whenever appropriate. (s) • 11. Organize and prioritize to provide an accurate, profession- specific assessment of the problem, and safe, efficient, effective care. (s) • 12. Acknowledge that achieving safety is often a long-term goal that is achieved by the patient/client, requires significant preparation, and that many successful interventions can be applied during the course of this process (i.e. naming the abuse, offering support, identifying resources, safety planning, etc.). (k, a) • 13. Utilize models of health behavior change, advocacy and empowerment to promote harm reduction strategies as part of an intervention. (k, s) Academy on Violence and Abuse, 2011
    15. 15. WHAT IS MISSING • Digestible information to help health care providers understand the problem conceptually so that they can problem solve • Straight-forward, simple, realistic guidelines about • How to engage patients and relate to them • How to conceptualize the underlying dynamics and barriers to change • Interventions to facilitate better health outcomes
    16. 16. THIS PRESENTATION WILL HOPEFULLY • Empower you through: • An increased understanding of IPV and the complex trauma response • The ability to recognize the sequelae • The ability to understand the dynamics at play • Provide guidelines about: • • • • When and how to screen a particular patient How to engage a patient How to manage the relationship dynamics How to facilitate positive change
    17. 17. IS THIS FAMILIAR? You greet your next patient, Sally, a 42 year-old married white female She is late for her appointment She missed her last 3 appointments . She is obese, smokes, has diabetes type 2, HTN, chronic insomnia and several other health problems. Her last Hgb A1C was 11; Today her BP is 160/90 Historically, she hasn’t adhered to recommendations She demands that you refill a pain medication She asks you to fill out a form that she needs to apply for disability When you set limits, she starts crying You feel pressured for time, manipulated, powerless, and frustrated as you feel your stress level go up You’re tempted to give her a piece of your mind
    18. 18. THE CHARACTERISTICS OF A PATIENT TRAUMATIZED BY IPV IN CHILDHOOD Emotional Dysregulation Relational Dysregulation Physiological Dysregulation Behavioral Dysregulation Cognitive Dysregulation
    19. 19. THE PHYSIOLOGICAL DYSREGULATION AT THE CENTER OF IT Courage-counseling.com
    20. 20. DSM-V CRITERIA • • • • • • • • • • • • • Criterion A: stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) Direct exposure. Witnessing, in person. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures. Criterion B: intrusion symptoms The traumatic event is persistently re-experienced in the following way(s): (one required) Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s). Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli.
    21. 21. DSM-V CRITERIA • • • • • • • • • • • • • • • • • • • • • Criterion C: avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) Trauma-related thoughts or feelings. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations). Criterion D: negative alterations in cognitions and mood Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs). Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). Constricted affect: persistent inability to experience positive emotions. Criterion E: alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required) Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance
    22. 22. DSM-V CRITERIA • • • • • • • • • • • • Criterion F: duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. Criterion G: functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational). Criterion H: exclusion Disturbance is not due to medication, substance use, or other illness. Specify if: With dissociative symptoms. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream). Derealization: experience of unreality, distance, or distortion (e.g., "things are not real"). Specify if: With delayed expression. Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately. American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: Author.
    23. 23. COGNITIVE DYSREGULATION • • • • • • Intrusive negative, fear-based thoughts Negative thoughts about self Cognitive distortions generally Impaired memory Impaired concentration and attention Impaired learning
    24. 24. EMOTIONAL DYSREGULATION • Emotional lability, i.e. reactivity • Difficulty modulating emotions
    25. 25. BEHAVIORAL DYSREGULATION • Unable to mobilize behavior to meet one’s needs • Impulsivity • The prefrontal cortex and higher brain functions are shut down • Reptilian brain functions dominate
    26. 26. RELATIONAL DYSREGULATION • • • • • Disturbed attachment Lack of trust Confused interpersonal boundaries Tendency to engage in abusive relationships Unconsciously engages others to replay the drama : victim, rescuer, or perpetrator
    27. 27. TRAUMA/DRAMA REPETITION • The Karpman Drama Triangle
    28. 28. SALLY SEEN THROUGH A TRAUMAINFORMED LENS • Sally’s physical conditions and behaviors are consistent with exposure to IPV and unresolved trauma • She exhibits “dysregulation” across physiological, cognitive, emotional, behavioral, and relational domains • She could be using pain medication to soothe distress • She probably can not identify with having an internal locus of control • Unconsciously, she might pull to repeat unresolved trauma in her relationships
    29. 29. HOW TO SCREEN Be alert to trauma’s sequelae Suspect trauma when the sequelae is present Ask questions to explore functioning across domains Ask a general question about exposure to stress in childhood • Avoid eliciting details about specific traumas • Contain patients who spill • • • •
    30. 30. MEANWHILE • Establish and maintain a relationship over time that is characterized by respect, shared power, healthy boundaries, and safety • Do what you can to equalize power • Use humor and a light touch • Facilitate optimal arousal=optimal functioning/performance
    31. 31. HOW TO KEEP THE RELATIONSHIP ON TRACK • Practice non-violence • Model healthy limits and boundaries appropriate to your relationship
    32. 32. NON-VIOLENCE www.advocates-oz.org
    33. 33. IDENTIFY HYPER AND HYPO AROUSAL AND INTERVENE • Hyper arousal: agitation, restlessness, fast speech, muscle tension, etc. • Hypo-arousal: numbing, dissociation, glazed over and checked out www.skybrary.aero
    34. 34. SEVERE DISSOCIATION • Personality fragmentation • Changes in ego state • Disturbances in continuous consciousness---loss of time • Psychological conflicts may be held by different parts of consciousness with apparently distinct personalities
    35. 35. PATIENT TEACHING • Help the patient understand his/her experience • Your patient knows something’s wrong---demystify it • Most patients respond to teaching about exposure to stress, the stress response, and how this relates to their symptoms, health conditions, problems functioning, and interventions • Use diagrams and pictures • Address shame about problems functioning • Address fear and hopelessness • Link your recommendations to your teaching
    36. 36. USE MOTIVATIONAL INTERVIEWING • Identify the patient’s goals • Plan interventions with the patient, prioritizing his/her goals • Be realistic: consider problems functioning, the patient’s living circumstances, and resources • Don’t go forward without buy-in • Explore resistance
    37. 37. LET THE STAGES OF CHANGE GUIDE INTERVENTIONS
    38. 38. DON’T WORK ALONE • Keep Maslow’s Hierarchy in mind: basic needs first (safety, food, shelter, transportation) • Give focus to physiological stabilization: Is medication needed to address emotional lability, intrusive symptoms, insomnia, etc.? • Then consider referrals for skill building: Mindfulness training, coping skill training, stress reduction, Yoga, Tai Chi • Social support • Trauma treatment
    39. 39. REFERRAL OPTIONS • • • • • Social Services Psychopharmacology Community-based mental health services Psychotherapy (trauma-informed) Substance Abuse Treatment (trauma-informed)
    40. 40. A NOTE ABOUT DEALING WITH SUBSTANCE ABUSE Discuss it with concern and caring Fully appreciate why the patient self-medicates Avoid asserting power and control over the patient Simply set boundaries: what you can and cannot do and why • If there’s prescription drug abuse, refer to a specialist if possible • Never withdraw medications abruptly • Replace a problematic medication with one that has less potential for abuse or harm • • • •
    41. 41. WHAT WOULD YOU DO? You greet your next patient, Sally, a 42 year-old married white female She is late for her appointment She missed her last 3 appointments . She is obese, smokes, has diabetes type 2, HTN, chronic insomnia and several other health problems. Her last Hgb A1C was 11; Today her BP is 160/90 Historically, she hasn’t adhered to recommendations She demands that you refill a pain medication She asks you to fill out a form that she needs to apply for disability When you set limits, she starts crying You feel pressured for time, manipulated, powerless, and frustrated as you feel your stress level go up You’re tempted to give her a piece of your mind
    42. 42. SUMMARY • A large number of our adult patients have been traumatized in childhood • If you see smoke, think fire • Recognize the dysregulated physiology at the root of the problem • Keep in mind that this gives rise to dysregulated functioning across domains • Practice non-violence • Be aware of the relational dynamics • Intervene with an understanding of the problem • Don’t work alone; consult with others • Maintain empathy • Raise consciousness
    43. 43. REFERENCES Adverse Childhood Experiences (ACE) Study. Center for Disease Control and Prevention. n.d. Web. 2 Nov. 2013. <http://www.cdc.gov/ace/> Adverse Childhood Experiences (ACE) Study. Center for Disease Control and Prevention. n.d. Web. 2 Nov. 2013. <http://www.cdc.gov/ace/findings.htm> Ambuel, B, K Trent, P Lenahan, P Cronholm, D Downing, M Jelley, A Lewis-O’Connor, M McGraw, A Marjavi, L Mouden, J Wherry, M Callahan, J Humphreys, R Block, Competencies Needed by Health Professionals for Addressing Exposure to Violence and Abuse in Patient Care, Academy on Violence and Abuse, Eden Prairie, MN, April 2011. Web. 1 Nov. 2013. <http:// www.avahealth.org/resources/ava_publications/> Definition and Typology of Violence. World Health Organization, n.d. Web. 3 Nov. 2013. <http:// www.who.int/violenceprevention/approach/definition/en/>
    44. 44. SUSAN’S CONTACT INFORMATION • Email: suprilax@hotmail.com • Phone: 617-372-5784 • Practice Locations: 23 Main Street Watertown, MA • & The North Shore

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