Treatment of Seniors in Care with CPTSD/CRTR

[Kizzie]

IT'S NEVER TOO LATE: TREATING SENIORS IN CARE WITH A HISTORY OF COMPLEX TRAUMA

By Kizzie, March 10, 2023

I am a senior survivor of relational or interpersonal trauma and recently spent two months in hospital and an inpatient treatment program for what was diagnosed as anxiety and depression. During my treatment none of the professionals evaluating/treating me (including three psychiatrists), ever brought up the topic of past trauma. I brought it up with them, but it did not seem to resonate that my childhood abuse still impacted me greatly as a senior; that it is an important factor with respect to my current health, well-being, and treatment.  One reason for this is likely due to the lack of trauma training many mental health clinicians (and medical professionals) receive according to Kumar et al (2022). In their study "68% of participants reported feeling inadequately trained to assess trauma and 75% felt inadequately trained to treat trauma."

It was with great interest, therefore, that I read Monica Cations' (2023) article "Growing Old with Trauma: Elder Care Through a Trauma-Informed Lens" ‎in the International Society for Traumatic Stress Studies newsletter Stress Points in which she discusses the importance of providing trauma informed care (TIC) to seniors in care. Finally, here was research about people my age with a history of complex trauma in hospitals and care homes and their unique needs. 

I went on to read an earlier article by Cations and her colleagues (2021) in which they write, "To our knowledge, this is the first research study aiming to examine the impact of TIC in geriatric inpatient care settings."  I was surprised by this because there is a proliferation of data about childhood abuse/neglect which clearly demonstrates both mental and physical health effects of trauma that commonly extend to late in life (Afifi et al., 2016; Buhrmann & Fuller-Thomson, 2022; Cation, 2023; Dye, 2018; Felitti et al, 1998; Pfluger et al).

I personally can attest that trauma does not simply fade or go away with time and does indeed follow one over the course of one's lifespan if not recognized and treated effectively. I am not alone in this. I run a web site and forum (Out of the Storm) which I started with 3 members in 2014 and now has almost 11,000 survivors registered from 68 countries. Many are seniors who like me did not realize they suffer from Complex PTSD until later in life and have not received the treatment they need. Unfortunately, the lack of trained professionals, accessible care (cost-wise or geographic), and misdiagnoses are common complaints by these members. 

It was in 2014 that I read about Complex PTSD and realized that my mental health issues went beyond chronic depression and anxiety, and that I had been underdiagnosed and undertreated for decades.  As Brand (2016) suggests, it essential for those proving care to recognize the lasting impact of Complex Trauma and provide effective treatment:

....it is critical that clinicians are trained in the assessment and treatment of trauma-related reactions, and in particular, dissociative reactions. If dissociation and DD are not recognized, many of these patients will not be referred to psychotherapy, and even if they are referred, they are unlikely to optimally respond to treatment until the role of trauma in creating and maintaining their distress is addressed.

At least part of the lack of recognition/treatment of trauma in seniors may be because Complex PTSD was not recognized as an official diagnosis by the World Health Organization until 2018 and many, perhaps most, went untreated or were misdiagnosed and treated for other mental health issues such as dementia, borderline personality disorder, and/or anxiety and depression (Bailey & Brown, 2020; Powell, 2019). It is only recently that Complex PTSD has become more widely known allowing survivors to finally put a name to what has been plaguing them and to seek professional help and support from one another.  Powell (2019) describes finally receiving a diagnosis of Complex PTSD from her new therapist after years of looking for answers: "She took her time getting to know me for weeks before she suggested any diagnosis, and when she finally did, it was complex PTSD. As she explained what it is to me, I sobbed. Finally, someone understood me and, even more, I finally understood myself."

According to Cations (2023), TIC is not about treatment of trauma, but providing an environment that is as safe and non-triggering as possible. I was fortunate that although the inpatient program I spent time in did not provide actual trauma treatment, they were all about TIC and this allowed me and my fellow patients to feel safe and valued. We all had relationships with the staff that were very caring and supportive and that in and of itself was healing to a degree. The atmosphere in the program I attended was much like de la Perrelle et al (2022) describe in their study:

Staff behaviours demonstrated respect, fostered trust, and anticipated needs without unnecessarily imposing care. Staff consistently offered choices, used residents' names, sought permission before providing care, and offered reassurance. Staff reported high morale with a commitment to delivering high quality care, and feedback to management. Effective communication promoted information sharing and trust among staff.

I am left to wonder, however, just how much more recovery and healing would have taken place if the focus of treatment were on trauma with the same TIC approach were in place. Most of the psychoeducation groups in the program were about positive skills/resiliency building (assertiveness, Cognitive Behavioural Therapy, and relationship building), all good but tough trauma related topics (hypervigilance, dissociation and avoidance, low self-esteem, abandonment and rejection, isolation and relationship/ intimacy difficulties) were not addressed. According to the Jewish Centre on Aging and Trauma (n.d.), even seniors who have experienced past Complex Trauma and are coping well may become increasingly distressed as aging brings about unsettling events.

Traumatic stress symptoms can persist and re-emerge in older adulthood as this is a phase of social, financial, and physical change. These changes can trigger a traumatic stress response even for those who had previously been coping well. As trauma survivors age, their trauma symptoms can resurface and evolve as a result of major life changes such as retirement, emergence of health problems, loss of independence, loss of loved ones.

I learned from several of my fellow patients that they had been in the program previously and wondered if the reason was the treatment provided only dealt with part of the problem. I personally felt lost and anxious after being released from the program as I went from a lovely, safe bubble of care to struggling with my trauma symptoms on my own again. 

In that many (most?) patients in the program I attended had experienced Complex Trauma in childhood/youth, it seems a natural evolution of TIC to include the identification and treatment of trauma.  This might initially drive the cost of the program up because professionals with more extensive trauma training would be required (i.e., psychologists versus occupational therapists), and treatment would take longer, but in the long run would likely cost less because the same survivors would not return to the program a second or even third time (which was the case).

As a senior of 66 years, I would welcome trauma focused in-patient treatment. Given I may (hopefully) live another 15 to 20 years I would like to do so with a greater degree of healing, peace and yes fun in my later years. Dealing with Complex Trauma symptoms is not only emotionally exhausting, but physically detrimental as so many data have demonstrated, beginning with the Kaiser Permanent Adverse Childhood Events (ACEs) study in the 1990s (Felitti et al, 1998).  This well-known study demonstrated "a strong dose response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults".

TIC if done properly in hospital and care settings is important in that it provides safety, a sense of being valued and having a say in one's care.  Beyond care however, is trauma focused treatment which can help decrease symptoms associated with past abuse/neglect and let seniors live out their remaining years in less distress.  It is never too late to do so.   

References

Afifi, O. et al. (2016). Child abuse and physical health in adulthood. Statistics Canada Health reports, 27(3), pp. 10-18. https://www150.statcan.gc.ca/n1/pub/82-003-x/2016003/article/14339-eng.pdf 

Bailey, T.D., Brown, L.S. (2020). Complex trauma: Missed and misdiagnosis in forensic evaluations. Psychological Injuries and Law 13, 109–123.  https://doi.org/10.1007/s12207-020-09383-w

Brand, B. L. (2016). The necessity of clinical training in trauma and dissociation. Journal of Anxiety and Depression, 5(4). https://doi.org/10.4172/2167-1044.1000251.

Buhrmann, A. & Fuller-Thomson, E. (2022). Poorer physical and mental health among older adults decades after experiencing childhood physical abuse, Aging and Health Research, 2(3), https://doi.org/10.1016/j.ahr.2022.100088 

Cations, M. (2023). Growing old with trauma: Elder care through a trauma-informed lens, Stress Points, 37(1). International Society for Traumatic Stress Studies.

Cations, M., Laver, K., Couzner, L., Flatman, S., Bierer, P., Ames, C., Huo, Y., & Whitehead, C. (2021). Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol. BMC Geriatrics, 21(1), 492. https://doi.org/10.1186/s12877-021-02441-1   

de la Perrelle, L., Klinge, N., Windsor, T. D., Low, L. F., Laver, K., & Cations, M. (2022). Characterizing trauma-informed aged care: An appreciative inquiry approach. International Journal of Geriatric Psychiatry. https://doi.org/10.1002/gps.5802 

Dye, H. (2018) The impact and long-term effects of childhood trauma. Journal of Human Behavior in the Social Environment, 28(3), 381-392, https://doi.org/10.1080/10911359.2018.1435328 

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://www.ajpmonline.org/article/S0749-3797(98)00017-8/fulltext 

Jewish Center on Aging and Trauma (n.d.). Aging and trauma. https://cdn.fedweb.org/fed-42/2/AgingAndTrauma_FactSheet_CenterOnAgingAndTrauma_2fdbr.pdf   

Kumar, S. A., Brand, B. L., & Courtois, C. A. (2022). The need for trauma training: Clinicians' reactions to training on complex trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 14, 1387–1394. https://doi.org/10.1037/tra0000515 

Pfluger, V., Rohner, S.L., Eising, C.M. et al. (2022). Associations between complex trauma exposure in childhood/adolescence and psychopathology in older age: The role of stress coping and coping self-perception. Journal of Child & Adolescent Trauma 15, 539–551. https://doi.org/10.1007/s40653-021-00419-0 

Powell, T. (2019). Complex PTSD and misdiagnosis: It happens more than you know. Healthy Place. https://www.healthyplace.com/blogs/traumaptsdblog/2019/5/complex-ptsd-and-misdiagnosis-it-happens-more-than-you-know