Catherine C. Classen, PhD, CPsych
Associate Professor, Dept. of Psychiatry, University of Toronto
Academic Leader, Trauma ...
1.
2.
3.

Describe the mental, physical, behavioral and societal
consequences of trauma especially for women.
Explain why ...
Single incidents: Accidents, natural disasters,
crimes, surgeries, deaths, and other violent
events.
PTSD

Chronic or repe...
In U.S. National Comorbidity Survey
 60.7% of men and 51.2% of women experienced at least one

traumatic event (other res...
In Canada,
 50% of women have

experienced at least one
episode of violence in adulthood

1993 National Prevalence Survey
Physical Abuse
21% of females
31% of males

Sexual Abuse
13% of females
4% of males
50% females & 33% of males were victim...
Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)
Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)
Measuring violence against women: Statistical trends (2013), Juristat,Sinha, M (Ed.)


Biggest threat is within their homes and with
those they should be able to trust
Individual
Family
Community
Society
Emotions

Depression
 Anxiety
 Shame and guilt
 Fear
 Anger
 Affect dysregulation
 Overwhelming emotion
Millions

2.5
2
1.5

2009

2010
1

2011
2012

0.5
0
Overall

Males

Females

Note: Population aged 12 and over who reporte...
Emotions

Behaviours

 Addiction
 Interpersonal problems
Revictimization
 Self harm
 Violent behaviour
 Eating disor...
Statistics Canada: Bethell& Rhodes, 2009, Health Reports
 Shame (I’m bad)
 Guilt (It’s my fault)
 World is unsafe
 Distrust
Emotions

Beliefs

Behaviours
 Rumination about traumatic experiences
 Difficulties concentrating
 Memory deficits and decline in cognitive
function ...
 Dissociation
 Dissociative disorders

Emotions

Consciousness

Cognitive

Behaviours

Beliefs
 Loss of meaning
 Struggle to make meaning

Emotions

Spirituality

Behaviours

Consciousness

Beliefs

Thoughts
Migraines, frequent headaches
 Pelvic pain
 Heart disease
 Chronic obstructive pulmonary disease
 Liver disease
 Sex...
Death

Early
Death
Disease &
disability
Health-risk
behaviors
Social, emotional, and
cognitive impairment
Neurological cha...
Neocortex
(thinking
brain)
Limbic system
(emotional
brain)

Three brains
One mind

Brainstem
(instincts)
(Paul MacLean, 19...
Neocortex
(thinking
brain)
Limbic system
(emotional
brain)

Brainstem
(instincts)
Neocortex
(thinking
brain)
Limbic system
(emotional
brain)

Brainstem
(instincts)

Bottom-up
processing




Attach
cry

Amygdala sounds the alarm
Social engagement system
 Attachment cry



Sympathetic nervous system
 Fig...



Trauma overwhelms
Psyche splits
 Apparently normal

personality
 Emotional parts
Pre-trauma
personality

ANP

Attach cry

EP

Fight

Flight

Freeze

Submit


Developmental neglect
 Underdeveloped cortical and limbic system
 Poor modulation of impulsivity, persisting

immatur...


"Traumatic events of the earliest years of
infancy and childhood are not lost
but, like a child's footprints in
cement,...




Females more likely to
internalize distress
Women are at greater risk
of violence at home
Women are more likely to
...
Measuring violence against women: Statistical trends (2013), Juristat, MaireSinha (Ed.)


Difficult to estimate but in the billions every
year in Canada
 Total cost of partner violence against women

estimate...
Trauma-specific treatment

1.


What do we know about effective treatments for
complex trauma?

Trauma-informed care

2.
...




The current paradigm for
state-of-the-art care in
medicine
Aim is to provide the best
possible care with the
least r...


Decision-making based on
 Best available evidence
 Patient characteristics, situations and preferences



Recognizes...
Best available
research evidence

Clinical Decision-Making

Patient’s
values, characteristic
s, and circumstances

Clinica...
Systematic
Reviews
RCTs
NR controlled studies
Observational studies
Case series
Case reports
Expert opinion





Client group must be clearly defined
Intervention must be standardized and
clearly defined
Outcome must be clearl...


Advantages
 Causal conclusions can be drawn
 Eliminates random causal findings

 Randomization ensures statistically...


Disadvantages
 Typically focuses on pure diagnoses with no comorbidity
▪ A review of PTSD research found that severe c...


Best available evidence
 PTSD
 Brief interventions (6-16 sessions)
▪ Cognitive behavioural
▪ Prolonged exposure
▪ EMD...
1.

Training programs emphasize EBM
 Students learn empirically supported treatments
▪ Funding not available for research...




Pressure to provide brief interventions
Often lack expertise in trauma
Often view complex trauma survivors as too
d...
Best available
research evidence

Clinical Decision-Making

Patient’s
values, characteristic
s, and circumstances

Clinica...


Complex trauma requires complex treatment
 Include evidence lower on the evidence pyramid




Longer term treatment
...


If the wounds of trauma are
embodied, should treatment include a focus
on the body?


Incorporates a bottom-up
with a top-down approach



Works with the body directly
using mindfulness



Aims to change...





The ability of our brain to change in response
to experience
Mindfulness is deliberately focusing on one’s
present...



Too many women are not getting the
treatment they need
Too many women are handicapped by their
trauma history and are...








Powerlessness
Lack of control
Damaged goods
Unworthy
Unsafe
Fear of authority figures
Others are untrustwor...






Appointment cancellations
Non-adherence to treatment
Fear of common medical examination procedures
Avoids regul...
•
•
•
•

Mistrust of authority
Easily triggered
– Dissociates (flashbacks, intense emotion, spaces out)

Disconnected from...


Patient-blaming
 Somatization, secondary gain




Emphasis on compliance
Misuse/overuse of power
… care that is grounded in and directed by a thorough understanding
of the neurological, biological, psychological, and so...






Safety
Trustworthiness
Choice
Collaboration
Empowerment
1.
2.
3.
4.
5.
6.
7.
8.
9.

Respect
Take time
Rapport
Share information
Share control
Respect boundaries
Foster mutual lea...
A need for universal precautions







Trauma is a pervasive and complex problem
Raise awareness of the prevalence and impacts
Incorporate training ...
Catherine Classen, PhD, CPsych

catherine.classen@utoronto.ca
416-323-6041
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."
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.
"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.
  • WOMEN IN MIND KEYNOTE: Everybody Hurts: The personal and political ramifications of trauma and its treatment for women."

    1. 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. 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. 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. 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. 5. In Canada,  50% of women have experienced at least one episode of violence in adulthood 1993 National Prevalence Survey
    6. 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. 7. Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)
    8. 8. Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)
    9. 9. Measuring violence against women: Statistical trends (2013), Juristat,Sinha, M (Ed.)
    10. 10.  Biggest threat is within their homes and with those they should be able to trust
    11. 11. Individual Family Community Society
    12. 12. Emotions Depression  Anxiety  Shame and guilt  Fear  Anger  Affect dysregulation  Overwhelming emotion
    13. 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. 14. Emotions Behaviours  Addiction  Interpersonal problems Revictimization  Self harm  Violent behaviour  Eating disorders  Poor parenting  Avoiding reminders of trauma
    15. 15. Statistics Canada: Bethell& Rhodes, 2009, Health Reports
    16. 16.  Shame (I’m bad)  Guilt (It’s my fault)  World is unsafe  Distrust Emotions Beliefs Behaviours
    17. 17.  Rumination about traumatic experiences  Difficulties concentrating  Memory deficits and decline in cognitive function with aging Emotions Cognition Behaviours Beliefs
    18. 18.  Dissociation  Dissociative disorders Emotions Consciousness Cognitive Behaviours Beliefs
    19. 19.  Loss of meaning  Struggle to make meaning Emotions Spirituality Behaviours Consciousness Beliefs Thoughts
    20. 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. 21. Death Early Death Disease & disability Health-risk behaviors Social, emotional, and cognitive impairment Neurological changes Adverse childhood experiences Birth Anda & Felitti, 2003
    22. 22. Neocortex (thinking brain) Limbic system (emotional brain) Three brains One mind Brainstem (instincts) (Paul MacLean, 1960’s)
    23. 23. Neocortex (thinking brain) Limbic system (emotional brain) Brainstem (instincts)
    24. 24. Neocortex (thinking brain) Limbic system (emotional brain) Brainstem (instincts) Bottom-up processing
    25. 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. 26.   Trauma overwhelms Psyche splits  Apparently normal personality  Emotional parts
    27. 27. Pre-trauma personality ANP Attach cry EP Fight Flight Freeze Submit
    28. 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. 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. 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. 31. Measuring violence against women: Statistical trends (2013), Juristat, MaireSinha (Ed.)
    32. 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. 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. 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. 35.  Decision-making based on  Best available evidence  Patient characteristics, situations and preferences  Recognizes that care is individualized and ever changing
    36. 36. Best available research evidence Clinical Decision-Making Patient’s values, characteristic s, and circumstances Clinical Expertise
    37. 37. Systematic Reviews RCTs NR controlled studies Observational studies Case series Case reports Expert opinion
    38. 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. 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. 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. 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. 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. 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. 44. Best available research evidence Clinical Decision-Making Patient’s values, characteristic s, and circumstances Clinical Expertise
    45. 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. 46.  If the wounds of trauma are embodied, should treatment include a focus on the body?
    47. 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. 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. 49.   Too many women are not getting the treatment they need Too many women are handicapped by their trauma history and are marginalized
    50. 50.        Powerlessness Lack of control Damaged goods Unworthy Unsafe Fear of authority figures Others are untrustworthy
    51. 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. 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. 53.  Patient-blaming  Somatization, secondary gain   Emphasis on compliance Misuse/overuse of power
    54. 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. 55.      Safety Trustworthiness Choice Collaboration Empowerment
    56. 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. http://www.phac-aspc.gc.ca/
    57. 57. A need for universal precautions
    58. 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. 59. Catherine Classen, PhD, CPsych catherine.classen@utoronto.ca 416-323-6041

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