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.

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. 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. 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. 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. In Canada,
 50% of women have
experienced at least one
episode of violence in adulthood
1993 National Prevalence Survey

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. Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)

8. Measuring violence against women: Statistical trends (2013), Juristat, M. Sinha (Ed.)

9. Measuring violence against women: Statistical trends (2013), Juristat,Sinha, M (Ed.)

10. 
Biggest threat is within their homes and with
those they should be able to trust

11. Individual
Family
Community
Society

12. Emotions
Depression
 Anxiety
 Shame and guilt
 Fear
 Anger
 Affect dysregulation
 Overwhelming emotion

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

15. Emotions
Behaviours
 Addiction
 Interpersonal problems
Revictimization
 Self harm
 Violent behaviour
 Eating disorders
 Poor parenting
 Avoiding reminders of trauma

16. Statistics Canada: Bethell& Rhodes, 2009, Health Reports

19.  Shame (I’m bad)
 Guilt (It’s my fault)
 World is unsafe
 Distrust
Emotions
Beliefs
Behaviours

20.  Rumination about traumatic experiences
 Difficulties concentrating
 Memory deficits and decline in cognitive
function with aging
Emotions
Cognition
Behaviours
Beliefs

21.  Dissociation
 Dissociative disorders
Emotions
Consciousness
Cognitive
Behaviours
Beliefs

22.  Loss of meaning
 Struggle to make meaning
Emotions
Spirituality
Behaviours
Consciousness
Beliefs
Thoughts

23. 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

24. Death
Early
Death
Disease &
disability
Health-risk
behaviors
Social, emotional, and
cognitive impairment
Neurological changes
Adverse childhood experiences
Birth
Anda & Felitti, 2003

25. Neocortex
(thinking
brain)
Limbic system
(emotional
brain)
Three brains
One mind
Brainstem
(instincts)
(Paul MacLean, 1960’s)

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

27. Neocortex
(thinking
brain)
Limbic system
(emotional
brain)
Brainstem
(instincts)
Bottom-up
processing

28. 

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

29. 

Trauma overwhelms
Psyche splits
 Apparently normal
personality
 Emotional parts

30. Pre-trauma
personality
ANP
Attach cry
EP
Fight
Flight
Freeze
Submit

31. 
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

32. 
"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.

33. 


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

34. Measuring violence against women: Statistical trends (2013), Juristat, MaireSinha (Ed.)

35. 
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

37. 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

40. 

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

41. 
Decision-making based on
 Best available evidence
 Patient characteristics, situations and preferences

Recognizes that care is individualized and
ever changing

42. Best available
research evidence
Clinical Decision-Making
Patient’s
values, characteristic
s, and circumstances
Clinical
Expertise

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

45. 



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

46. 
Advantages
 Causal conclusions can be drawn
 Eliminates random causal findings
 Randomization ensures statistically
equivalent groups
 Typically focuses on pure diagnoses with
no comorbidity

47. 
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

48. 
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

50. 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

51. 


Pressure to provide brief interventions
Often lack expertise in trauma
Often view complex trauma survivors as too
difficult or beyond their scope of expertise

52. Best available
research evidence
Clinical Decision-Making
Patient’s
values, characteristic
s, and circumstances
Clinical
Expertise

53. 
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

54. 
If the wounds of trauma are
embodied, should treatment include a focus
on the body?

55. 
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

56. 


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)

58. 

Too many women are not getting the
treatment they need
Too many women are handicapped by their
trauma history and are marginalized

60. 






Powerlessness
Lack of control
Damaged goods
Unworthy
Unsafe
Fear of authority figures
Others are untrustworthy

61. 




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

62. •
•
•
•
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)

63. 
Patient-blaming
 Somatization, secondary gain


Emphasis on compliance
Misuse/overuse of power

64. … 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

65. 




Safety
Trustworthiness
Choice
Collaboration
Empowerment

66. 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/

67. A need for universal precautions

68. 





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

70. Catherine Classen, PhD, CPsych
catherine.classen@utoronto.ca
416-323-6041