Trauma- Informed Care and!
Inuit Mental Health and Wellbeing
Allison Crawford, MD, FRCPC
Purpose of this module This module on trauma-informed care builds on the cultural safety module. It increases the safety of care we deliver within our healthcare settings, by considering the possibility that each individual we engage with may have a traumatic history that we are unaware of. This universal precaution allows us to shape our practice to minimize the possibility that we will re-traumatize someone within our healthcare settings.
What is trauma-informed care and practice? Every institution, organization, agency and healthcare provider has the potential to either re-traumatize people and interfere with recovery OR to contribute to and support healing. Healthcare settings and providers often represent power and control to individuals who have experienced trauma, and this can be frightening and overwhelming. Without being trauma-informed we may misinterpret people’s reactions and act in punitive ways that worsen their fear and feeling of lack of control When we are trauma-informed we understand people’s reactions (e.g., such as rage, treatment refusal, mistrust) as a result of previous injury, rather than as sickness or bad behaviour.! We can ask “what has happened to you?” and create a culture of understanding, rather than “what is wrong with you?” and create a culture of shame.
Trauma-informed providers and organizations: Acknowledge the widespread impacts of trauma, Recognize the signs and symptoms of trauma in clients, and in staff and other providers Understand the variety of creative means that people can use to manage trauma (e.g., substance use) Recognize that people follow different pathways to healing. Respond by integrating knowledge about trauma into policies, procedures, practices and settings. Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Core trauma – informed principles Acknowledgement – that trauma is pervasive Safety Trust Choice and Control Compassion Collaboration Strengths- based
From http://trauma-informed.ca/wp-content/uploads/ 2013/10/Trauma-informed_Toolkit.pdf
What is psychological trauma? An event which causes someone to fear for their life or physical safety, or the life or physical safety of another Emotional response may include fear, terror, horror or helplessness – “trapped and terrified� - or numbness or dissociation. 20-25% of people will have a traumatic stress syndrome (such as PTSD) 1 month following a traumatic event 75% of people experience at least one traumatic event in their lifetime.
What kinds of psychological trauma are there? Single event – the person has exposure to one event that has a clear beginning and end (e.g., car accident; hurricane; sexual assault) Prolonged trauma – the person encountered a series, of ongoing traumatic events (e.g., combat; domestic violence; persecution in their home country) Developmental trauma – is a form of prolonged trauma that also overlaps with and can interfere with normal development (e.g., child abuse, neglect)
Recognizing the signs and symptoms of trauma: What is the impact of psychological trauma? No or limited impact in some Traumatic Stress Disorder! Post-traumatic stress disorder (PTSD) ! Dissociative Disorder Co-morbid mental health disorders Complex PTSD and personality disorders Historical Trauma
From: http://trauma-informed.ca/ wp-content/uploads/2013/10/ Trauma-informed_Toolkit.pdf
Post-traumatic Stress Disorder Symptoms (DSMV) A. Exposure – exposure to actual or threatened death, serious injury or sexual violation, in which the individual: • directly experiences the traumatic event; • witnesses the traumatic event in person; • learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); • Or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).
Post-traumatic Stress Disorder Symptoms (DSMV) B.
Re-experiencing – e.g., through intrusive thoughts, nightmares, flashbacks
C. Avoidance – e.g., avoiding distressing memories, thoughts, feelings or external reminders of the event. D. Negative alterations in cognitions and mood – e.g., persistent and distorted sense of blame of self or others; estrangement from others; or markedly diminished interest in activities E.
Alterations in arousal and reactivity – e.g., aggressive, reckless or selfdestructive behavior, sleep disturbances, hyper-vigilance
Duration of symptoms > 1month
Developmental trauma and complex PTSD Results from early exposure to multiple or repeated traumatic events Reactions to the trauma interfere with normal developmental processes Alterations in:
regulating affect! attention! identity! personality development! systems of meaning
(van der Kolk, 1996)
Complex PTSD or Disorders of Extreme Stress (DESNOS) Regulating affect: anger, self-destructive behaviour, suicidal preoccupation, risk taking! Attention: amnesia, dissociation, depersonalization! Alterations in self-perception: ineffectiveness; permanent damage; guilt and responsibility; shame; no one can understand; minimizing ! Alterations in relationships with others: inability to trust; revictimization; victimizing others! Somatization: digestive sx; chronic pain; cardiorespiratory; conversion sx; sexual symptoms! Alterations in systems of meaning
(van der Kolk, 2001)
Developmental trauma and complex PTSD
Historical trauma 1995, Maria Yellow Horse Brave Heart applied this idea of collective suffering, memory, and trauma to the historical trauma experienced by American Aboriginals, specifically the Lakota, over the course of colonial conquest and attempts at assimilation. ! These traumatic losses included theft and removal from homelands; violence against indigenous peoples; assimilation through residential schools, and suppression of language, ceremonies and spirituality, leading to an erosion of culture; and de-stablization of the social order through loss of roles and destruction of indigenous family systems. Duran and Duran similarly proposed that the effects of this cumulative trauma, and the accompanying sense of grief, affect the very core of Aboriginal identity and cultural cohesion, creating a ‘‘soul wound’’ !
(Duran & Duran, 1995)
Historical trauma: Impacts ‘‘the historical trauma response’’ behaviors, including: !
Brave Heart (2003) is
a complex of
depression, anxiety, anger! alexithymia (problems naming feelings); ! difficulty modulating affect! low self-esteem and shame ! suicidal behaviors, wishes to join the dead ! ‘‘survivor guilt’’ ! development of a ‘‘victim identity’’ ! use of substances as a means of emotional numbing and avoidance.
Historical trauma is collective – it extends beyond the individual to the family and community!
Historical trauma: Intergenerationsl Impacts Intergenerational impacts – beyond the generation that was directly effected; one possible mechanism for this is through an impact on parenting
L.L. Myhra (2011). Used with permission.
Walking both sides of an invisible border ! It is never easy Walking with an invisible border ! Separating my left and right foot ... I did not ask to be born an Inuk ! Nor did I ask to be forced To learn an alien culture With an alien language ... So I am left to fend for myself ! Walking in two different worlds ! Trying my best to make sense Of two opposing cultures Which are unable to integrate Lest they swallow one another whole
Alootook Ipellie
Historical trauma among Inuit Communities The history of the Canadian government’s relations with the Inuit is addressed in the Royal Commission on Aboriginal Peoples (RCAP), which acknowledged the distinctness of the Inuit from other Aboriginal people in Canada. The RCAP concluded that relocations of Inuit people to the High Arctic constituted an ‘‘abuse’’ by the government. Additional impacts of contact and colonialism, including: settlement; residential schooling; loss of traditional belief systems; loss of traditional relationship with the land; and language. The RCAP makes an explicit link between these historic abuses and present-day social suffering.
Historical trauma among Inuit Communities According to Alexina Kublu, (past) Languages Commissioner of Nunavut: ! - the idea of HT was not something that people a few generations ago had to deal with ! - although the oral histories frequently describe the intervention of elders when people felt they needed to talk or receive counsel. ! - the notion of intergenerational impacts may be captured in the phrase ‘‘sivulirijat aksururnaqtukkuurnikugijangat aktuiniqaqsimaninga kinguvaanginnut’’ (translated as ‘‘the trauma experienced by generations past having an effect in their descendants’’) Documentation of historical trauma in the Qikiqtaaluk (Baffin) region was undertaken by the Qikiqtani Truth Commission http://www.qtcommission.com
Some cautions about the historical trauma concept It is NOT culturally safe to assume that everyone within a group or community or family has been impacted by historical trauma, or by the same experiences as others The concept of HT can be stigmatizing and can overlook resilience, strength and persistence of culture in individuals and communities The idea of intergenerational trauma ! can pathologize indigenous ! parenting practices
Practice considerations Power and control – whose needs are being served, and do policies empower those being served or those providing the service (e.g., is emphasis being placed on control rather than the comfort of those being served) Doing with and not doing to Explaining what, why and how Offering real choices Flexibility Understanding and being able to identify fight, flight and freeze responses Focusing on strengths, not deficits Examining power issues within the organization and promoting democratic principles (Poole, 2013) Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Five Universal Qualities of a Therapeutic Environment ! Attachment: A culture of belonging! Containment: A culture of safety Communication: A culture of openness Involvement: A culture of participation & citizenship Agency: A culture of empowerment !
Haigh, 1999
Providing and receiving information can be times of increased intensity or distress. Inquire about trauma history, and facilitate a supportive discussion with the client while keeping it focused on the present moment. Make sure the client is comfortable with the conversation and knows they do not need to answer questions and/or go into detail. Check in with the client to make sure the discussion of trauma feels safe and not overwhelming. Make time for questions and concerns that the client may have. Write things down for clients who may dissociate during encounters. Provide a suicide risk assessment where indicated and follow up with the client when the risk has passed. Inquire about a possible history of trauma if a client has behaved or is currently behaving abusively themselves. Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Tips for when providing choices Involve the client in the decision-making process with regard to treatment/service options. Allow the client to set the pace, slow down and take breaks as required. Continually inform the client of what is happening during healthcare encounters and assessments (Havig, 2008). Where possible, give the client choices about referrals. Strive to be culturally appropriate and informed. Understand the meaning the client gives to the trauma from their own cultural perspective. Understand what healing means to the client within their cultural context. Be open to learning and asking questions about the client’s culture. Be open to referring clients to traditional healing services, and become educated in traditional Inuit healing ways and community services. Work through historical distrust Teach Western ways as skills, not as identity replacement (Brokenleg, 2008). Advocate on behalf of clients who speak English as a second language . Become familiar with best practices in using a translator. Adapted from http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Create a climate of hope and resilience Acknowledge the client’s abilities to survive and even grow from adversity. Acknowledge the strength it takes to get to where the client currently is. Refer to the client as “someone who has experienced trauma,” and who is more than what has happened to them. Focus on healing and recovery as “possible.” Move beyond mere survival to the context of a healing process, and let the client decide what their path to healing consists of. Let the client know that you believe in them and support their efforts to heal. From http://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf
Annie Pootoogook, Memory of My Life Breaking Bottles
Further reading and resources Historica Trauma and Aboriginal Healing! http://www.ahf.ca/downloads/historic-trauma.pdf Qikiqtani Truth Commission http://www.qtcommission.com Manitoba Trauma and Information Centre! http://trauma-informed.ca Royal Commission Report on Aboriginal Peoples ! https://www.aadnc-aandc.gc.ca/eng/1307458586498/1307458751962 A. Crawford (2013). ''The trauma experienced by generations past having an effect in their descendants'': Narrative and historical trauma among Inuit in Nunavut, Canada� Transcultural Psychiatry http://tps.sagepub.com/content/early/2013/03/07/1363461512467161.full.pdf