Okay, great. So we'll go ahead and get started. Today we'll be talking about trauma-informed care for individuals admitted to the acute rehab unit, but I think a lot of this can apply to other populations as well. I'm Rachel Teranishi and I have the pleasure of presenting with two of my colleagues, Dr. Kelly Crawford and Jennifer Myatt who is on her way and we'll be splitting up the talk into three different portions today. We have nothing to disclose and these are our objectives for today. So one, we want to talk about trauma and discuss the emotional, physical, and cognitive responses. Two, we want to define what trauma-informed care is. And three, we want to describe specific interventions that hopefully you guys can incorporate into your clinical practice. Again, I'm Rachel Teranishi. I did my brain injury fellowship at Carolinas Rehab, which is how I got to know Kelly and Jennifer, and I have since joined the faculty at UAB in Birmingham. And I'll be starting off the talk today by talking about definition, epidemiology, and pathophysiology of trauma. So what is trauma? There are a lot of different definitions, but one that comes up a lot in the trauma literature is by the Substance Abuse and Mental Health Services Administration, and they define trauma as an event, series of events, or set of circumstances that is physically or emotionally harmful and has lasting effects on an individual's function, as well as their physical, social, emotional, or spiritual well-being. Trauma is something that's not experienced just by individual persons, but it can affect communities as well. And trauma is not just this single point in time. It's the event, but it's also the individual's experience and then their response to it, and everybody's response is going to be different and unique. Trauma can also be experienced indirectly, so something that's witnessed or overheard, and this is illustrated by this article from the New England Journal of Medicine that came out after the 9-11 attacks, and they looked at over 1,000 residents of Manhattan, and they looked at rates of PTSD and depression. Obviously, those that were on site and had experienced the event directly had the highest rates, but even those who just heard about the events or witnessed it on TV, they still had significantly higher rates of PTSD and depression compared to the baseline. When we think about trauma, there are a lot of different ways to sort of categorize it and organize it. This is one way, kind of splitting it into natural or human-caused. So if we think about our acute rehab patients and their admitting diagnoses, a lot of them will fall under the physical ailment or natural type, but then a lot of our TBIs, traumatic spinal cord injuries, will come in because of something human-caused, like a car accident, fall, or something intentional like a physical assault. As I mentioned earlier, everybody's response to trauma is going to be unique, and these are some of the characteristics that can really influence somebody's response to a trauma. So a big one is whether it's single or repeated. Single traumas don't necessarily have less impact than repeated, but it is thought that the effects of trauma are cumulative. So those with history of repeated trauma are really the ones who are at risk to having severe stress reactions to it. Another thing is the amount of processing time. You can have this syndrome called cascading trauma, where if you don't have enough time to process or recover from trauma before the next one occurs, you could be really vulnerable to some of the effects. The amount of perceived loss associated with a trauma will have an impact. And then whether it's expected or unexpected. In general, unexpected trauma leads to more psychological injury, and individuals may spend a lot of time thinking about how they could have anticipated it or how they could have prevented it. Other things that make an impact is whether it's intentional or accidental, and then the psychological meaning of trauma. Individuals may perseverate on why it happened to them, trying to assign blame, and these are some of the things that could be going on in their head as they're on a rehab unit. The next few slides are just really big picture, high yield statistics about how prevalent trauma is. And I'll be talking about prevalence kind of in two main ways. One, as it relates to their admitting diagnosis for why they're in rehab, and two, completely separate from their hospitalization, just sort of in the general public. So in the United States, trauma is a leading cause of death in young people, and it is very costly to the American health care system. When we think about TBI, there's almost 3 million TBIs every year between ER visits, hospitalizations, and deaths. And rates of PTSD vary anywhere from 0 to 36%. In general, it's more common and mild and moderate compared to severe. But we do know that severe TBIs, even with loss of consciousness and PTA, those people can still have PTSD and have effects from their trauma. In terms of traumatic spinal cord injury, about 18,000 new cases every year in the United States, and rates of PTSD are as high as 60% in this population. Stroke is obviously a leading cause of disability, a very common diagnosis in our rehab units, and it's thought that anywhere from 15 to 30% of those with TIA or stroke can develop PTSD symptoms. Trauma in the ICU is something I think we have all heard about, but it's probably more easily forgotten when compared to some of the other diagnoses. But a study by Parker found that almost a quarter of ICU patients reported PTSD symptoms between one and six months. And this makes sense because the ICU is a time where individuals are learning really bad news, or thinking they're going to die, or maybe seeing other patients get really sick and pass away. They're undergoing invasive and painful procedures, and with the medical complexity and some of the medications on board, hallucinations and delirium can play a role as well. What better way to illustrate this than by looking at some quotes from actual patients? I'll just read the first one. There were puffin birds jumping out of the curtains with toy guns firing blood at me. I kept wiping my face. There were loads of birds jumping on the next bed laughing at each other. I was really scared. I didn't say anything to anyone. Obviously, you can see how the hallucinations are creeping in, but it doesn't change the fact that this sounds absolutely terrifying, and this is something that can stay with a person. I've been saying a lot of statistics about PTSD. I just want to give a couple caveats. One, the rates will obviously vary depending on the literature, because different studies will define it or diagnose it differently. And PTSD is not the only syndrome that you can have after trauma. Dr. Crawford will talk about a few others, and it doesn't include the people who have subclinical stress reactions. So these numbers that I'm spitting out, that is still an underestimate of how people are affected after their trauma. Switching gears a little bit, talking about the prevalence of trauma sort of in the general population, so completely separate from why they may be in rehab. These are some more statistics from the Substance Abuse and Mental Health Services Administration, and they found that trauma is very common in the general population. So among adults, they found that 70% will experience at least one traumatic event in their lifetime. And then when you look at children, they found that one in seven had experienced child abuse or neglect in the past year, and that, of course, is going to be an underestimate. And not everybody who experiences trauma is going to develop PTSD, but it's said that about 20% of those who have a traumatic event will go on to develop PTSD, and that translates to about 8 million people in the United States in a given year. So the take-home message from these past few slides is that whether it's related to their admitting diagnosis or whether it's completely separate from their hospitalization, the chance that we will encounter someone on the acute rehab floor who's been exposed to trauma is very, very high. So this is something that's important for all of us to be aware of. It's difficult to talk about trauma without addressing some of the vulnerable populations. As I alluded to earlier, a history of trauma is a really big one, so it's thought that trauma effects are cumulative, and those with repeated chronic trauma are the ones who are going to be more vulnerable to having PTSD and other traumatic stress reactions. Mental health disorders is another one. Substance abuse, mood and anxiety disorders, those individuals are thought to have more traumatic stress reactions as well. And as a brain injury physician, I think about a subset of my patients who have a substance abuse disorder, and then they have a TBI, and then they're more at risk for having more substance use, and then they have this separate sort of risk factor for having a traumatic stress reaction, so you end up having just this really vulnerable person or population. Gender plays an interesting role in trauma. It's thought that men are exposed to more trauma, but women may be more vulnerable to developing PTSD. And gender also plays a role in the types of trauma that people experience. So women were more likely to be victims of physical and sexual assaults, and more likely to know their perpetrator, whereas males were more likely to witness combat or killings. In terms of age, we know a lot based on the Adverse Childhood Experiences Study, the ACE Study, that looked at thousands of children and kind of tracked the number of ACEs that they had, and then their development for other mood disorders and chronic health conditions. And we learned that, you know, ACEs are very common and they have really long-lasting impacts on individuals when the trauma is experienced at a young age when the brain is still developing. In terms of race, ethnicity and culture, there really aren't a lot of studies looking at, you know, rates of PTSD in different racial groups, but we do know that certain groups are more at risk for certain types of trauma. For example, African Americans are more likely to be victims of physical assaults compared to Caucasians. Sexual orientation and gender identity is another big one. There was a study by Dillon that looked at those who identified as gay, lesbian, or bisexual, and they found that rates of trauma in that group were 94%. So almost everybody that they looked at had been exposed to trauma. And then another vulnerable population is the homeless. Rates of trauma exposure were really high in women more than men. And a lot of individuals are homeless related to a trauma. For example, a lot of women are fleeing domestic violence and then they're homeless because of that. The last topic that I'll touch on before handing it over to Dr. Crawford is the pathophysiology of trauma. And this is obviously a very simplified version of it. An entire talk can be dedicated to it. But there are sort of three main systems at play here. So the neuroendocrine system, the neurotransmitter system, and then the limbic circuits and some of their connections. So we know that when there is trauma or stress, the sympathetic nervous system kicks in. There's a release of cortisol and catecholamines, dopamine, and norepinephrine. And that leads to a lot of the hyperarousal, hypervigilant symptoms. It relates to how memories are encoded and then the body's sympathetic response to these painful memories. There's also a lot of literature looking at different genetic variations in the dopamine system and how that actually increases vulnerability for the development of PTSD. As a reminder, these are some of the limbic circuits and their connections and the circuits that are really important in PTSD and some of the trauma symptoms. So the amygdala is really important in fear processing. The insula, which is tucked into the lateral sulcus there, is important for detecting novel stimuli and sort of assigning an emotional state to it. The anterior cingulate cortex is wrapped around the corpus callosum and then the prefrontal cortex is kind of on top of that. Those two play more of a mediator role trying to inhibit that threat detection network there. And then the hippocampus of course is important in learning and memory. In PTSD and trauma symptoms in general, it's thought that the amygdala and the insula are overactive so that circuit there is just kind of going over and over. And then it's thought that the anterior cingulate and prefrontal cortex are actually underactive so there's less inhibition of that system leading it to kind of go haywire. So the take home message of these past two slides are that there really is a scientific basis for trauma and trauma symptoms. So when we are encountering a challenging patient situation, it's not necessarily the patient being difficult to be difficult or being stubborn. There really is a hormonal, biochemical, and anatomical explanation for why we see some of the symptoms that we do after trauma. And with that I'll hand it over to Dr. Crawford to continue. Thank you. Good afternoon. So I am going to be tasked with going over the responses to trauma. When we go over this it's important to know that these are natural responses. Anybody who sustains trauma, it's normal to have a stress response. What becomes difficult is when those patterns continue or they start to affect daily life and that's where some of these can perpetuate issues going forward, especially when it comes to treatment or recovery. Oops, wrong direction. There you go. So I broke it up into four different categories, emotional, physical, cognitive, and behavioral. But then keep in mind there's a lot of overlap between each and every one of these. So your emotional state can affect your physical state. It can affect your cognition and vice versa. So there's a lot of overlay and you might see some repeated patterns as I go through these. But I'll try to give a general overview. Again, thinking that a lot of these are normal responses. It's just if they perpetuate and go forward for long term they can become issues. So first and foremost, emotional dysregulation. So it's normal after an acute stress response to have dysregulation of your emotions. In particular, anger, sadness, in some cases shame depending on what the trauma in itself holds, and anxiety. It's typical for people to have maybe weeks to months of some of these issues as they go forward. But if they become long term issues, particularly those who sustain child abuse, those can be patterns that go on through their lifetime. And there are two evoked emotional responses to stress reaction. And that is the feeling too much or the feelings of being overwhelmed by even the smallest little things of daily life. So feeling like that one thing is going to tip you over the edge and just having a difficult time dealing with everything going on. And the opposite reaction would be numbing or feeling too little. And that's the process of detaching your emotions from your behavior and your cognition and your memories. Some of the physical responses that can happen to trauma, there's actually various ones. I listed many of them up here. But to just go over a few and I'll go in depth a little bit more in the next slide. Gastrointestinal disorders in children sometimes it can manifest as upset stomach or pain areas that are associated with previous history of trauma. Cardiovascular disorders. If you have some basis of anxiety, perhaps you have some tachycardia. And of course dermatological disorders or symptoms. Some people break out in hives or rash when they have a stress response. So these are all different symptoms or disorders or systems that can be affected after a stress reaction or stress to trauma. Going a little bit further into some of these, a very common response is somatization. And that's where your bodily symptoms or dysfunctions to express you have dysfunction in order to express your emotional distress. A lot of folks are not, if not many, most are not aware of the connection between their emotional response and their somatic symptoms. Hyperarousal. So this is actually a protective mechanism after trauma where people have a heightened response. So they feel like they're ready for anything that's coming. They may, after they've been through, let's say, gosh, mass shootings going on now, if they've survived that, you might be in a room where they're hypersensitive to a door opening. They always have that hypersensitivity or that hyperarousal response. That can also manifest in different ways as well. So perhaps they're having some sleep disturbance or they have just muscle tension in general from being stressed. And they also have that lower threshold for a startle response. So even maybe the smallest of noises could startle them. And of course, in many cases, sleep disturbance can be manifested in very different ways. So you can have early awakenings. You can have difficulty going to sleep. You can have both. You can have restless sleep. In addition, you can also have perhaps nightmares where you're re-experiencing the trauma during your sleep. And then you have cognitive side effects or cognitive responses, I should say. And I put up here the Beck and colleagues cognitive triad model from 1979. And that's where it can relate trauma can alter three main cognitive patterns. And it can affect our views of ourselves. And it can affect our views of the world around us. And it can affect the views of our future. So survivors of trauma may feel a sense of being damaged or feeling worthless after a traumatic event. In addition, they may feel unprotected by the world. They may feel like the world's out to get them. And then as far as the future goes, they may feel like everything is stacked against them. It's very hard for them to feel like there's a positive outcome moving forward in some cases. So they're thinking that everything in front of them is going to have a negative outcome. Our thought processes can also be affected by trauma. And I have a list here, but cognitive errors in general. So misinterpreting a situation that by all means is not dangerous, but because of your hypersensitivity, you may perceive them as dangerous. And I think I was reading an example of someone who may have had a near drowning experience, caught in a riptide, may at the general local pool feel like it's a dangerous situation to be in the shallow end of the pool. And that they have this unsafe environment where they feel like they may drown. So that's a cognitive error and misinterpretation of a situation. In addition, excessive or inappropriate guilt. So people may take on the guilt after their trauma. And this is where particularly survival guilt comes in. Where you feel guilty for surviving a traumatic event when others may have passed away or sustained more significant injuries. Idealization. That's a process by where you justify or rationalize your perpetrator's behavior. And you see this a lot of times in relationships where they try to justify the behavior of their abuser. And that can be summed up under idealization. Trauma-induced hallucinations or delusions. Those are a little less common. But experiencing hallucinations that are congruent to your trauma event. So seeing somebody walk onto the bus who may wear a similar shirt to somebody who was your abuser, you may think that that is your abuser. You may hallucinate or have the delusion that that is your abuser. Not as common, but again, something that can happen. Intrusive thoughts and memories. So these are experiencing without warning these thoughts and memories that are associated with trauma. They can easily trigger strong and emotional responses. And they can be very detrimental or destructive at that time as they flood into your memory. The other notion of feeling different. So it's not uncommon for after you've undergone a traumatic experience to feel different. You may have gone through something that no one else has or very few people have. So you have this sense of people may not understand what you've gone through. You may look for support from people, or you may withdraw because you feel like you're not or you may withdraw because you don't know if they would understand how you are feeling or what your reactions are to the traumatic event. So those folks may have difficulty reaching out for help. Or there also may be triggers that are involved as well. So we all know a trigger is experiencing a stimulus that brings back those memories. And that can be associated with any sensory response. So whether it's a smell or a noise or even a visual scene that brings back that traumatic event often can bring on flashbacks. So flashbacks are kind of reenactments of the events, like you're there again experiencing that traumatic event. Not all flashbacks have to be associated with triggers. Sometimes they can come out of the blue, but often they are. Now they may only last seconds to minutes, but the emotional response or the after effect of the flashback can last for hours or even longer and can really cause some dysfunction. An example would be, I know growing up I had an uncle who was in the Vietnam War and I never knew why on the 4th of July, like my cousins and my dad would always go to the 4th of July fireworks. My uncle would never go and I never knew until I got into my 20s that he couldn't go to fireworks because he would have flashbacks of being in Vietnam. Didn't know that until I was a grown adult, but he to this day will not go to any fireworks display because it does trigger or he'll have a flashback of being back in Vietnam. There's also dissociation. So dissociation is a mental process that severs connections among a person's thoughts, memories, and feelings. And that can occur as a protective element in distancing oneself from the actual experience. And up here I have some potential signs of dissociation. Not to make light of it, but it also can be confused with boredom if you have any teenagers. Fixture glazed eyes, sudden flattening of affect, and stereotyped movements, and sometimes excessive intellectualization, so trying to talk through every issue, trying to make it a very concrete situation. And some behavioral responses. So reenactments are reoccur, or re-experiencing can occur through reenactments by trauma survivors who repetitively relive and recreate a past trauma in their current lives. So examples of this would be perhaps children in their mimic play. As Dr. Teranishi had mentioned, the terrorist attacks of 9-11, perhaps somebody who witnessed that on television as a young child may have recreated that instance in play where they're taking a toy plane and running it into a building because they witnessed that. In adulthood, a situation would be those folks who are involved in abusive relationships who continue to get involved in more abusive relationships over and over. It's like a repetitive pattern. Another behavioral response could be self-harm and self-destructive behaviors. So these folks may be self-harm or in some cases self-medicate in order to avoid feeling those feelings. They want to displace those emotions in any way possible. So they will self-medicate or self-harm in order to do that. Others may also self-harm because maybe they have that numbing feeling. Maybe they disassociated themselves so much from any feeling that self-harm is a way for them to have some type of feeling in some way. So it can actually work both ways. And of course avoidance. Avoidance is a way of really just avoiding a trigger or avoiding something that might bring about unpleasant emotions, often experienced with anxiety. So if somebody is going to go to a large crowd and they experience a large amount of anxiety, because of that, they might then avoid going into places that have large crowds. Now initially avoidance actually works pretty well. You avoid the issues that's going to trigger these unwanted emotions. But what happens over time is the anxiety associated with that event continues to increase. And it actually gets associated with more of an anxiety feeling each and every time or the more you continue to avoid it. So even though at the beginning it may help, it actually will perpetuate the issue and the emotional response. And looking at other common responses to trauma. So looking at social and interpersonal relationships. So a lot of survivors rely on social support or family support, that support system. That is if you are used to having a support system. So if you look at folks who may have had growing up childhood abuse, or folks who are involved in abusive relationships, they are in relationships with people that are supposed to be their caretakers or their loved ones. And there's a sense of betrayal or they're getting hurt by people that they perceive to love them. And so you may find that those folks who grew up or have that type of relationship may have trouble forming bonds or forming relationships or having a support system that they actually trust to reach out for for help. On the opposite end, you very well could grow up with a wonderful established social network. But again, that feeling of not feeling that people understand how you are reacting to the situation, you may pull away because you don't think they would understand what you've gone through. So those relationships and reaching out are very important. Also to keep in mind that developmentally, a lot of us have different stress reactions. So if you're a young child, you may have more of those somatic symptoms, like you may wet the bed, you may have stomach aches, you may be more clingy to your parent if you've gone through a traumatic event, whereas school-aged children may kind of regress to a younger age in their behavior. Adults may demonstrate hypersexuality or maybe some depression. Adults may manifest as sleep disturbance, agitation, or substance abuse, increase in substance use. And elderly, maybe they withdraw. They start withdrawing from their friends or society. Or you may see that their chronic illnesses may start to worsen or they don't take care of themselves like they used to. So each age group has developmentally a different way of how they may express stress or demonstrate that. Trauma-related psychological disorders. So the two main psychological disorders associated with stress are in the name there, so acute stress disorder and post-traumatic stress disorder. But other disorders are also associated with trauma as well. And Dr. Teranishi spoke upon it a little bit there, the substance abuse, mood disorders, anxiety disorders, and personality disorders. But going through the acute stress disorder, as mentioned earlier, it's actually a normal response. So acute stress disorder is normal. You can have the intrusive symptoms, a negative mood, dissociative symptoms, avoidant symptoms, or that hyper-arousal state that I spoke about earlier. The key with acute stress disorder, though, is that the duration. The duration usually is anywhere around two to three days up to four weeks. And it has to affect your social relationships or your occupational status. So there has to be some significant distress to be labeled with acute stress disorder. The key is the duration there. The other key is to know that with acute stress disorder, with early intervention, you can actually inhibit, or I shouldn't say, stop the progression to post-traumatic stress disorder. So the early effective intervention can help prevent progressing to post-traumatic stress disorder. The other key to acute stress disorder is that it's a good, one of the good predictors of moving on to post-traumatic stress disorder is dissociative symptoms. So if somebody after trauma has dissociative symptoms as an immediate response, that's actually a good predictor that they're going to move into the post-traumatic stress disorder category. But again, with early intervention, that can be prevented in a lot of cases. Okay, so moving on to post-traumatic stress disorder. This is the most diagnosed trauma-related disorder. It has four symptom clusters, and they're written there. But very similar to the acute stress disorder symptoms, the only difference is persistence. So persistence avoidance, negative alterations in cognition and mood, that hyperarousal or reactivity state, the key being is that it is beyond four weeks. So once those symptoms go beyond four weeks, they go into the category of post-traumatic stress disorder. Now the timing of the symptoms can be very different, and this is where it becomes very interesting. It usually begins in most cases within the first three months of trauma in adulthood. However, it can be delayed in months to even years. So there are people who had trauma as children and may have suppressed it. And there may be a trigger later in life that instantaneously brings back those symptoms, those traumatic symptoms come to light. If they were survivors of childhood trauma, maybe they're watching a documentary on TV and something triggers, and then all of a sudden you can have those traumatic symptoms come back and have post-traumatic stress disorder. Another issue is folks who self-medicate or maybe use substances to self-medicate and, you know, weigh off those uneasy feelings, maybe find themselves in recovery years later not taking substances, and they may have those feelings start to reemerge because they're no longer self-medicating. So there are certain situations in which those traumatic symptoms may not be within that first three months after trauma. And the trauma-related and co-occurring disorders, the number one co-occurring disorder is major depressive disorder. But as you can imagine, generalized anxiety disorder and obsessive compulsive disorder are quite common as well, and as I've mentioned plenty of times, substance abuse disorder. And so with all of this, going through all of this, why do we care? Well, hopefully we're all good human beings and we care about other people. But the other thing is trauma in the past can affect our health of the future. So as Dr. Teranishi was saying, the adverse childhood experiences study done in the late 90s actually did show that children that sustained trauma at a young age had increased health diseases as they got older. They mentioned ischemic heart disease, cancer, chronic lung disease, and liver disease. Actually more common in adults that had sustained childhood trauma. In addition, there have been numerous studies that say that women and children who experience violence or sexual or physical abuse also have increased risk of mental health disorders. They also have increased risk of substance abuse disorders. So all of the history of the past plays into our future health. And so with that, they can have maladaptive behaviors and health risk behaviors. And also it impacts relationships, and this is probably where it becomes our biggest concern as rehab physicians in the acute care setting, is we never know everybody's past, but it can also affect those relationships that we build within the rehab community. And I know Jennifer's gonna go over some examples, but what we do as rehab physicians is we have to establish a level of trust. They have to trust us to know that we're working towards getting them better. We're working towards getting them home in the best they can be. And so part of this trauma from the past may play into that relationship, and being able to address it appropriately would help us in getting them to the best person possible. And so with that, I will hand it over to Jennifer Myatt. Okay. So now we're gonna talk about how to implement trauma-informed care into the rehabilitation unit. So trauma-informed care is defined by SAMHSA as a program, organization, or system that demonstrates these four things. So we need to have realization of the widespread impact of trauma and the potential pathways that are available towards recovery. We need to have recognition of the signs and symptoms of the trauma individuals and groups are experiencing. We have to cultivate a response that involves fully integrating knowledge of trauma into our practices and policies, and then making efforts to prevent re-traumatization of individuals and groups. So just revisiting some of the statistics that Dr. Teranishi covered, and generally just keeping in mind, like they both mentioned, we don't know who has a trauma history. We don't know if something traumatic happened to them long ago, or if what they came to rehab for was a very traumatic event. But just keeping in mind these two, the 70% of adults in the U.S. have experienced some type of trauma at least once in their lives, and 8% of Americans at any given time are considered to have post-traumatic stress disorder. So those are pretty big numbers. So in realizing the prevalence of trauma, our first R word, it's largely considered to be under-reported. So we do have all these wonderful studies and all the information Dr. Teranishi shared, but even with all of that information, it's acknowledged that a lot of people who experience trauma do not share it, do not participate in studies, do not necessarily endorse it. And so again, just understanding that there's more people out there living with these symptoms than we realize. Also knowing that different individuals have their own unique perception and conceptualization of events that may or may not be traumatic. Two different people can have the same experience. One might come away with trauma symptoms, one might not. So it's definitely not a one-size-fits-all type of symptom. Trauma triggers are unpredictable and unique to each and every individual. All patients should be approached with the belief and understanding that it's possible that they may have sustained a trauma at some point in their life, okay? So in our efforts to recognize trauma, learning about this for each of our patients is very important. So incorporating it into our assessment and screening practices to learn about a patient's trauma history is really, really important and necessary. The key to getting this information from patients is how you approach it. So there are standardized assessments available that ask questions about trauma history, but normalizing it and broaching this topic in a way that makes the patient comfortable is important. And that's not gonna be the same for all of us either because we all have our own different communication styles. So some people may prefer to find a standardized measure. I think just normalizing it as something that a lot of people experience and inviting the patient to talk about it is important and I'll have some more detailed information on how to do that in a few slides here. But the primary goal of assessing trauma is to identify whether it exists in this patient, again whether it's a history or a recent event, how it's affecting them right now, current triggers that we need to be aware of, and feedback from the patient regarding what would help them to feel safe and supported within our interactions with them. As we're assessing this, just a few more things to be aware of. There's different types of trauma, so it's categorized in a few different ways. Acute trauma results from a single incident, maybe one remote event. Chronic is exposure to repeated and prolonged trauma. This could be an abusive situation, domestic violence, something of that nature. And then there are people who present with complex trauma where they've experienced multiple traumatic events, which could be varied in nature over a certain period of time. We talk about trauma and abuse is certainly a big factor in trauma, so also just being aware of the different types of abuse that exist that may be endorsed by patients. The more commonly known types that we've heard about a lot are emotional and mental, physical, sexual, neglect. There's a few more that are less talked about, spiritual and cultural abuse where people feel discriminated against or targeted based on their cultural beliefs or practices. Technological, which in more recent years kind of takes the form of like cyber bullying, things of that nature. And then financial abuse, which some of our patients who might be dependent on caregivers might be susceptible to where somebody else is abusing them financially, taking advantage of their money. So we can do our assessment. Another way to assess for signs of trauma is through our observation and interaction with our patients. So I've listed some of the common signs of abuse or neglect, whether it's being reported or not, just things to be aware of and notice. So unexplained injuries such as bruises, if your patient's exhibiting extreme behaviors that seem really incongruent with what's going on. Maybe excessive crying, that's in here twice, excessive crying. Some younger patients, maybe truancy or running away, if you're learning that they seem to be running away a lot to escape a situation. If your patient presents with poor hygiene, unsuitable clothing, seem fearful in the presence of a caregiver or a parent, or if they seem malnourished or just under cared for in general. Those are important things to notice. You may also notice some mood or behavioral changes, and this could be someone you may have, even within the context of inpatient rehab, if a patient's been there for a few weeks even, and then you're noticing sudden mood or behavioral changes, it's good to kind of investigate what's going on there. Interpersonal interactions, both with yourself, the interdisciplinary team, the family, and we'll talk a little bit about that too. And then noncompliance. Noncompliance, historically, it's just like, ugh, they don't want to do this. But again, with some of those physiological reactions to stress or trauma, it might kind of lead someone to refuse something. So in inviting this discussion when we're assessing, I just wrote some of the things that I tend to kind of say when I personally am talking about trauma history with patients. And if you come at them and say, do you have any trauma history, that's a little abrupt. They might not respond to that in a great way. So saying something a little softer may be, at any time in your life, have you experienced any kind of abuse or neglect? Or have you ever felt mistreated by someone else? That's a very gentle way. Have you ever felt like somebody mistreated you? Sometimes that's an easy way to lead into that discussion. If people seem like maybe they are hesitant to respond, I do tell them, you know, you don't have to share your experiences with me in detail. I just want to make sure that we're providing the best care we can and offering any resources that might be useful to you. I also frequently will normalize being in the hospitals uncomfortable. We want to make sure that we're doing everything we can to make you as comfortable as possible. So kind of inviting them to share what might be making you uncomfortable. And sometimes when we're dealing with challenging situations, it will remind us of other challenges we face. So I do tell, sometimes I'll ask people about their history and, you know, they'll get a little leery. I'm like, I'm only asking about the past because it could come up. You could find yourself thinking about it. It's just for us to be aware of. We don't have to delve into all of it right now. So I think normalizing it and just kind of bringing it up as a normal topic to talk about can help invite the patients to endorse anything that might be important. So in the rehab setting, we do have people with a variety of different injuries. Sometimes there are some symptoms from their injuries that may present barriers to getting a clear assessment. So any individuals who have any type of cognitive impairment or maybe a history of dementia might have trouble giving you a clear, detailed history of their experience with trauma. Some of our folks have communication deficits that also could limit their ability to give any detailed information. Family involvement, while family involvement can be great, sometimes that too can be a barrier. You might get a family member who wants to answer for the patient a lot of the time and doesn't give them the opportunity to share, or even just having the family present all the time may make the patient be inhibited about sharing about themselves. They might have some discomfort with the medical professionals. They might have a lack of trust from prior experiences. So as Dr. Crawford said, it's really important for us to kind of establish that rapport and build that relationship with our patients. And some people might fear consequences of endorsing trauma. So they might withhold that information, especially if they're in an ongoing type of traumatic event. Maybe they are in an abusive situation, or maybe they're having to receive care from someone who they don't feel comfortable with and don't necessarily want to exacerbate that situation by sharing information that would upset them. The way that the response to trauma presents can take several forms. So we have fight, flight, freeze, and fawn responses to trauma triggers. So in a fight response, you might see outbursts. They could be verbal or physical, or somebody might feel overwhelmed or anxious by something happening and become more aggressive. A flight response is avoidance. So they might refuse care. They might say, no, I don't want to go to therapy today. No, I don't want you to clean me up. And again, this takes that non-compliant form. This could also look like an elopement risk. So some patients might try to just completely escape the hospital setting entirely because they're uncomfortable or feeling overwhelmed or having a trauma response. The freeze response is basically what it sounds like. People just kind of withdraw. And this can cause inconsistencies in clinical presentation. So this might be somebody who's intermittently refusing, or they seem really good one day, but then the next day they just shut down and don't want to do anything. Fawning is over-compliance. So this might be a patient who's trying to say all the things that they think that we want to hear because they want to avoid confrontation, or if they don't feel safe or comfortable, then they might not want to endorse more symptoms that could potentially keep them in the hospital longer. But then that limits our information on how to best treat them if we don't know what's accurately going on with them. This is a list of common triggers for people who do have a trauma response. Being touched unexpectedly. That happens a lot in the hospital. People get touched all the time in the hospital. And so having the door of their room open or closed, sometimes that can be a trigger. Some people are claustrophobic when it open all the time. Some people are sensitive to noise when it closed all the time. Sometimes people can be emotionally triggered by a different time of day. People in certain uniforms. Again, we have no idea what these people's experiences are. I've even had people who had a traumatic event in the acute setting and then came over to rehab and then were trying to help undo whatever was done. Just, it could be one negative interaction with one person and then it can carry over and cause a lot of issues with their willingness to engage. So just, yeah, I won't read all of these to you, but just knowing there's a lot of different triggers. Some of these are very common in our setting. So what do we do about this? In our response, we want to, with the environment, make sure we're providing a safe and private environment for discussion of any sensitive topics, especially when we're having these conversations about trauma history. If the patient expresses a provider preference, maybe they're more comfortable with male providers versus female providers. We wanna try to respect that as much as possible. If they have choices of settings for treatment, if it's somebody who gets very stressed around crowds and lots of noise, a private, more quiet environment could be encouraged for their treatment sessions. And again, we're just constantly gonna work with talking to the patient to determine what it is that's making you feel uncomfortable and how can we adjust the environment to accommodate you as much as possible. And then communicating these preferences to the team so that we're all on the same page and being consistent. As a provider, approaching any warning signs or patient and family behaviors with curiosity. So if you notice something that seems concerning to you, investigating it in a curious manner, trying to remain calm and non-judgmental as you're talking to patients and or family about these triggers that you're noticing. And it's good for us as providers to pay attention to how we're feeling taking care of these patients too and noticing how we're emotionally responding to these situations. If necessary, it can help to use some calming or grounding exercises yourself when you're interacting with these folks. We wanna constantly elicit feedback from our patients. So you shared these triggers with me, you told me that this was bothering you, this is what we're trying to do, how is it working? We want it to be a kind of an ongoing discussion and providing summary of responses so that the patient knows that we hear what they're saying. We want to offer education to the patient to cultivate the understanding of trauma and its effects so they might not fully understand why they're refusing to do something, they might just know they don't wanna do it. If they're hijacked by that trauma response, they just know that they're uncomfortable. So as providers, helping them understand their own response to those situations as well can be very helpful in helping them to kind of work through it. We wanna discuss available options and resources. So knowing what resources you have within your facility and then also with discharge planning if it's something where they need some follow-up services. And we should know the limits to confidentiality and provide informed consent as well as we're having these conversations. So like knowing if somebody is in immediate danger or at risk, then we may have to notify someone. Cultural considerations are important as well. I know Dr. Taranishi talked about some of the more vulnerable populations who experience higher levels of trauma. We, there has been a movement over the past several years to improve cultural competence across the medical field and human services fields in general. So we have this education that's designed to build awareness of other cultures. There's this new movement towards cultural humility approach as well because cultural competence has been considered to be static. It's often like, this is the education, this is information about this specific culture, now you know about this culture. But we can't make these generalizations because even within a culture, people have a lot of variance, right? And so sometimes if we feel like we're very knowledgeable about a culture, then we might make false assumptions or over-generalizations about a patient from that background. So with cultural humility, it's still we wanna learn, but we wanna remain open to the fact that we don't know everything about these other cultures and remain self-aware and critique how we're responding to people. So egolessness, just not feeling like we know it all and having supportive interactions with our patients. They say it's a lifelong learning process, so it's okay to bring in what you do know, but then also inviting the patient to help you see things from their perspective so they do feel like we can understand where they're coming from as they're sharing things. All right, so in communicating with our patients, we wanna always provide patient-centered care. These green words. I think with trauma, the two biggest components that relate to triggers are the lack of sense of safety and the lack of sense of control. So any situation in which a patient feels unsafe or lacking control, which in a hospital, people don't feel like they have a lot of control, generally, can be triggering. So we want to be inviting the patient to be an active participant in their care and empowering them to make choices and help with determining their level of involvement in their treatment options. We wanna collaborate with the patient and then also with our treatment team. So as we're identifying triggers and figuring out approaches, we wanna make sure that we are sharing that so we can be consistent. At our facility, we do often do co-treatment with patients who are having a lot of trauma response-type behaviors. So I will go in with maybe physical therapy if they're having a lot of issues during a treatment session to figure out what are some strategies and tools and techniques we can use to help them work through these sessions and feel supported so that they can benefit from their time here. When we identify good strategies that seem effective, then we'll write up what we call treatment guidelines and share that with the team so that we can be consistent. The treatment guidelines usually have a list of the trauma triggers and then the best approach is to minimize those triggers. It allows the whole interdisciplinary team to approach the patient in a very consistent and supportive manner. And we also will share oftentimes with the family and caregivers for additional consistency if that's relevant, if they're having those issues generally. We also will continue to monitor a patient once we write up these guidelines to see if they're still effective over time or monitor for any additional strategies that might need to be added so we can modify the treatment approach. This is not easy to see, but it is a sample. So this would be on like one sheet of paper. So it's like, that's the top half, that's the bottom half. And I'm not gonna read this whole thing to you, but this is like kind of what we would write up for treatment guidelines. We have environmental guidelines at the top, just making sure consistent staff, low stimulation for this particular patient. We have the triggers that seem to be triggering a behavioral response and then specific guidelines for interacting with the patient. This patient was particularly sensitive to being touched unexpectedly and had a communication deficit as well. So we really emphasize like ask for permission to touch and then narrate your actions, kind of talking through what you're doing as you're doing it so you don't startle him. And then just emphasizing consistency in some of the communication strategies that speech identified for the patient to be more receptive to. Okay, so we wanna also work to prevent re-traumatization. So factors that can contribute to recent or ongoing trauma or re-traumatization. So again, this could be, if they're having a trauma reaction to something recently that happened to them, it could be going on still, especially with some of the changes, the symptoms that our patients present with. So if they're having confusion or confabulation, they don't understand what's going on clearly, then that can perpetuate a trauma response. Sensory changes can be very disorienting to our patients. So that too can bring up trauma. If they suddenly can't see or hear or can't perceive their environment properly. Restraints can be very triggering, especially if somebody does have a trauma history. We talk about the lack of sense of control when you're restrained. That's a pretty overt and significant lack of control. So again, recent negative experiences that they're generalizing over to rehab and sometimes just inhibition or discomfort confiding in the providers. So these are things that can perpetuate that re-traumatization, just to be aware of. When we're observing our patients interacting with their families, or sometimes even the families themselves can be having a trauma response to the situation, sometimes we will recognize them as high maintenance families. I hear, you know, that's kind of the term that I hear used sometimes, where they're either overly involved or they seem really anxious, or they're trying to call the doctor every two hours to ask a bunch of questions. But oftentimes that's also coming from a lack of sense of control, sometimes from grief around what's happening to their loved one, sometimes from a place of fear of the unknowns. And it's good for us to note these relationship dynamics between the patients and the family members as well. So just seeing how they relate to each other, if there's a lot of anxiety going on, like where's it coming from, who's being triggered by what, just to help us kind of engage more effectively with that family system. Red flags to be aware of, if the family's placing barriers between the patient and resources or treatment, and sometimes we see this happen if the patient does not have the cognitive ability or capacity to make their own choices. So a family member's in charge, but might be pushing back on a lot of medical recommendations or refusing things that we feel the patient really needs. Behavioral and mood changes of the patient and the presence of the family can be another red flag. So if they seem great and then all of a sudden family shows up and they're behavioral, there's something else going on. Or if the family has very domineering or controlling behaviors, sometimes that can indicate maybe a little bit of a warning sign, something to be curious about, kind of learning about their dynamics a little bit more. When you're charting about trauma history that patients share with you, it's really important to keep in mind who has access to their chart and how you're charting this. The 21st Century Cures Act gave patients a lot of access to their records without having to go through the medical facility. And I think there's fewer options for sensitivity of documentation now. So just keeping that in mind. I know when I have patients who are in the care of a family member and I know the family member has their chart, they're my chart access and they can get in there and see everything, I'm really very cautious about what I put in there. And so if you do have a patient with a chronic trauma or maybe even a questionable, maybe like abuse or neglect type situation, you may not want to put that information directly in the chart where the family can see it. That might not be good for the patient. So just kind of figuring out within your own facility, like how to handle that. It'd be a good thing to have a little bit of a policy around. Know the rules and guidelines too in your area about mandatory reporting. There can be some variation from place to place on this, but knowing like when you do need to call if you think somebody is in danger or is being mistreated. For patient resources, these again vary from area to area. So maybe having a handout for your patients if you feel like they are in some sort of abusive or ongoing re-traumatizing type situation. Being able to give them resources within your facility when possible and then referring them to outpatient resources as needed. Having information for your adult protective services and child protective services. I did put the National Domestic Violence Hotline number here. Sometimes when people are in an abusive situation, it's hard for them to get enough privacy to make a phone call and ask for help. So in recent years they did establish a text feature. So now they can also text to report domestic violence if they need assistance getting out of a situation. So that's a good resource. And if you have a patient who endorses being in an actively dangerous situation, kind of encouraging them to think of a safety plan. Like is there somebody you could call if you needed to get out of there really quickly? Where could you go? And then again, if you have some local resources to offer them as a part of that, that would be good. Okay. So I have just three case presentations I'll go through quickly to give a little bit of just an example of how this has presented with some of our folks. So we had a 30-year-old female with a traumatic brain injury after horseback riding accident. She had cognitive impairment, expressive aphasia, and was severely physically disabled, very dependent for care. She came to us as an inpatient and then went home with family. When she was an inpatient, the family was very controlling and actually limited access to psychology services, asking that we not go by. She went home with family and her father had passed away about two years after her injury. And her mother was caring for her and after her father passed, then she endorsed that she had a history of sexual abuse. And once that came to light, she came back for outpatient counseling. She still had a significant expressive aphasia. She was using a communication board and we were able to communicate, but she was having these severe outbursts at home. And so I was able to work with her and her mother about the things that were triggering her and they were very much related to her abuse history. I was able to help facilitate some conversations with them and identify some different strategies for them to use at home for her to feel a little bit more in control and feel like she had more input. And then she and her mother were able to communicate better around those things. Let's see. Oops. Okay. Number two, we had a 59-year-old male with a stroke, notable for severe visual impairment, confusion and aphasia. He was impulsively trying to get out of the bed in the acute setting. And so his place, after he transferred to rehab, they quickly put him into a net bed or veil bed. But his behaviors then increased because his lack of vision and his confusion, he had no idea where he was. And so at night he was like thrashing around in this bed. And so working with the family and the patient, we realized like the bed was the thing that was upsetting him. And so we had some back and forth about getting rid of the bed because the staff were like, oh, he needs it. He's just thrashing around in there at night. We can't let him out of there, you know. But we did get rid of it and allowed family to stay overnight to help with orientation. And he did much, much better. We were able to help him get more oriented to what was going on. We developed treatment guidelines to assist the interdisciplinary team in approaching his care in a way that supported his visual impairment and his anxiety and behaviors decreased significantly. All right. Number three, we had a 48-year-old female with a traumatic spinal cord injury after a car accident. She endorsed during her inpatient stay that she had a history of being involved in human trafficking in her youth. She felt very overwhelmed being in the hospital setting. She felt very trapped. She had a very strong stress response to being touched physically. And so in working with her to identify her triggers and then what would make her more comfortable, we did switch her to a full female staff. Staff were encouraged to, again, ask permission for touching, narrate actions as helping her with, you know, positioning and activities. And with that, her participation and compliance with care increased very significantly. Okay. I went through this a little quickly. Do you guys have questions for any of us or comments? Nothing? You've never had a traumatized patient? I was rehearsing this with a friend. She's a doctor as well. And she said, well, can you give me an outline for our treatment plan? And I was like, well, I was like, the outline is basically triggers. Here's your list of triggers. And what can we do in the environment to address the triggers? And what can we do as a team to address the triggers? And that's kind of the whole thing. I was like, anybody can do it. Oh, we have a quick... Wait, something popped up. You have a question? I had a question. I'm Edison Wong. I'm a physiatrist in private practice. And actually I do outpatient TBI multi-trauma. And one of the things I was wondering about, since I don't see patients on inpatient anymore, for those cases where it looks like there's a significant amount of PTSD, do you get them treatment for that with EMDR? I'm trained in EMDR. I mean, do you get them treatment with a practitioner who does EMDR? We do at our facility because I do it. Oh, cool, okay, great. I highly recommend it if you have resources to send them to somebody who does EMDR. One of my greatest challenges with people who have brain injury is if they have any ocular issues and they can't do the bilateral tracking with their eyes going back and forth, that can be challenging. There are other ways to approach it. I bet that's probably one of the... I would use that maybe as a screener. Can they smoothly pursue their eyes back and forth without developing a really bad headache or anything? Because sometimes you have to wait till they can. But yeah. On an outpatient basis, what's interesting is now you have a lot of providers doing it remotely. That's kind of interesting how they do the EMDR through telehealth. I have a lot of questions about how they're doing that. I need to reach out to some colleagues because I don't do it virtually. I don't know how they do that, but there are people doing it. It can be problematic, yeah. I can see that. Thank you. We did a great job. They have no questions. We answered all the questions. Thank you.

trauma-informed care

acute rehab unit

definition of trauma

emotional responses to trauma

physical responses to trauma

cognitive responses to trauma

behavioral responses to trauma

prevalence of trauma

impact of trauma on health

implementation of trauma-informed care