Authored by Misty Boldt, LMSW at Lifespan of Greater Rochester
The Ursula Forem Domestic Violence Program Employment Fellowship Grant was created in 2015 honoring Ursula Forem, an employee of the New York State Office for the Prevention of Domestic Violence (OPDV). As the grantee for the 2016 –2018 Ursula Forem fellowship grant, and an employee of Lifespan of Greater Rochester, Inc.’s Elder Abuse Prevention Program (EAPP), I have spent the last two years researching trauma, trauma in later life, and the effects of trauma on older victims of domestic violence and elder abuse.
The first year of the grant project consisted of trainings through PESI, Inc. Behavioral Health Continuing Education; consultations with local trauma informed colleagues and their agencies such as Willow of Greater Rochester, Resolve of Greater Rochester, Coordinated Care Services Inc., and Tree of Hope Counseling; and numerous academic articles pertaining to the effects of trauma on the body and the brain. Armed with this trauma-informed knowledge, I set out to explore the connections between trauma and stress levels and the health and mental health status of elder abuse victims. In my work with older adults who have experienced elder abuse, I found that high stress was a constant for the older adults who also had high degrees of trauma across their lifespan. This level of stress is known as toxic stress, coined toxic for its lasting health risks.
Bessel Van der Kolk’s book The Body Keeps the Score: Brain, Mind, and Body in The Healing of Trauma (2014) and PESI, Inc.’s on-line training The Body Keeps the Score: Trauma and Healing with Bessel van der Kolk, M.D. were instrumental in obtaining a deeper understanding of psychological trauma and the correlation to poor health outcomes in later life. Continuing education training from PESI Inc. to become a Certified Clinical Trauma Professional online training course called Evidence-Based Trauma Treatments and Interventions taught by J. Eric Gentry, Ph.D., LMHC; Robert Rhoton, PhysD, LPC, D.A.A.E.T.S. also helped to solidify an empathic view of trauma and personal trauma histories when working with people who identify as having a lifespan of trauma.
The second year of the grant consisted of creating a trauma screening tool for older adults and attending conferences and trainings where I could share the trauma knowledge and screening tool. The idea for an adult screening tool came from wanting to delve more deeply into life stressors that might affect older adults across their lifespan. The tool was created using elements of the Life Change Index Scale, also known as The Stress Test, and the Holmes and Rahe Stress Scale. The screening tool was titled after a desire to want to learn more about life event stressors, naming it Life Event Screening Tool, also known as LEST. The LEST asks several questions using trauma-informed language with the intent to identify stressors, that could be seen as traumatic depending on the individual, across a person’s lifespan over the age of 18 years. Having a better understanding of toxic stress, trauma and the intersection of healthcare, it seemed reasonable to consider using the Adverse Childhood Experience questionnaire (ACE) in conjunction with the LEST. The reasoning for that decision was based on the strong correlation identified, during the Adverse Childhood Experience Study (ACES). The study, conducted by Kaiser Permanente and the Center for Disease Control in the 1990’s, resulted in the ACE questionnaire as a standardized instrument. The ACE questionnaire measured exposure to potentially traumatic events in childhood, such as abuse, neglect and household dysfunction, to name a few. The information gathered from the joint research identified that the higher the ACE score for children under the age of 18, the higher their risk for adverse health risks later in life. The ACE is still being used with children under the age of 18, but there has been no identified research to date that reviews the risk of adverse health in older adults who have been affected by a lifespan of adverse experiences.
Using a combination of the ACE questionnaire and the LEST, the need for older adults to have a more robust support system emerged. According to Danna R. Bodenheimer (2016), without these support systems, older adults may be at greater risk of abuse. If it is reasonable to believe that a child exposed to trauma and abuse should require a stable support system to learn healthy adaptive coping strategies, the same might be true for an older adult. In comparing an older adult’s ACE score with the LEST score, those with high ACE scores appear to have a correlation with a high LEST score. The older adult identifies an instability in their childhood through their ACE score, and high levels of stress throughout their adult lives through the LEST score. There is not, however, a reverse correlation of high LEST to high ACE. This correlation appears to be indicative of a lack of stable support systems throughout the older adult’s life. A support system seen as unpredictable or unsupportive, could alter ideas of relationships, leaving children who have experienced adverse trauma feeling insecure in themselves and the world they live in. Like children who experience childhood adversity without appropriate relationship supports, adults in later life might be susceptible to a continued cycle of trauma, mistrust and unsettled relationships. The lack of trusting relationships can leave an older adult at risk for loneliness and isolation.
This brings us to poor health. Kathleen Kendall-Tackett’s (2013) research examines health risks for children who are victims of childhood trauma. Kendall-Tackett shows the correlation of adverse health risks for children who have high ACE scores due to childhood trauma and poor health in later in life. The lines that are drawn link poor health with instability, loneliness, and isolation. The older adult’s health is poor and is at risk to become progressively worse if their stress levels remain high. In such instances adults with high levels of stress and undiagnosed trauma often have autoimmune diseases such as Rheumatoid Arthritis and Lupus (Kendall-Tackett, 2013). Other poor health outcomes are diabetes, high blood pressure, and somatic complaints.
Without regular medical appointments and opportunities for discussion of life events with healthcare providers, older adults sometimes blame their poor health on the aging process. The older adult does not understand the severity of their ailing health and might not be open to discussing some of the identified poor health for fear of being labeled with dementia, or unable to care for themselves and possibly forced into a nursing home. The person/people assisting the older adult might be playing a role in the older adults ailing health due to stress and years of difficult family dynamics. Older adults can be fearful of losing the only support they believe they have, the only caregiver the older adult believes they can rely on due to social isolation.
The LEST was designed to look at an older adult’s life through a trauma-informed lens. Currently, the LEST is being used by the Elder Abuse Prevention Program (EAPP) at Lifespan of Greater Rochester, Inc. During the case visit with the older adult, the EAPP Social Worker screens the older adult using the LEST. If the adult screens yes to five or more of the questions, the screen is given to the Trauma-Informed Care Professional (TICP) to conduct further screens using a trauma-informed approach. Depending on the older adult’s ability to form relationship bonds, the initial meeting with the TICP could last anywhere from one to two hours. If the older adult does not deflect and can talk about their past and present relationships, including childhood history, the biopsychosocial and additional screens can all be completed within an hour timespan. If the older adult perseverates on moments in time that are especially traumatizing to them, the TICP can assist the older adult to process the moment(s), allowing the completion of the biopsychosocial assessment.
Processing trauma can take a long time, and this Trauma Informed Screening Model is not meant as a long-term counseling process. The purpose of the Trauma Informed Screening Model is to assist older adults who find themselves in disrespecting and/or distrustful relationships. Talking through prior relationships and family dynamics can help highlight patterns of risk an older adult may have had throughout their lifespan. The biopsychosocial allows the TICP to have a strength-based conversation with the older adult to reframe their situation and look for alternative options, known as goal setting. As trauma is not something that can be resolved, but needs to be continuously worked at, the goals could be to find long-term treatment or identify ways to lower stress for a healthier life style. As goals for the older adult’s care plan is identified through the biopsychosocial assessment, it is also important that a holistic view of the older adult’s emotional state is assessed. The additional assessment used in conjunction with the biopsychosocial assessment are: Geriatric Depression Scale, Generalized Anxiety Disorder scale, PHQ-9, and the Mini-Cog to screen the older adult’s cognition. The screens and information gathering through the biopsychosocial can take six to eight visits depending on how much or how little the older adults wants to share and connect during the first meeting.
Using the screens helps the TICP and older adult identify traumatic moment(s) in the older adult’s life that could have occurred anywhere from early childhood to later in their life, or small moments throughout their lifespan. The biopsychosocial information gathering uses a motivational interviewing style to guide the older adult through possible difficult memories and realizations. The goals should be realistic and achievable, such as understanding the need for boundaries and how to effectively and safely establish them in relationships; forgiving themselves for what they see as failures within their lives; and understanding what a toxic relationship looks like. These goals work to empower the older adult to take back control of their lives and gives them permission say no and stop possible abusive behavior in their current relationships.
The completion of the screens and biopsychosocial includes a write up summarizing the older adult’s goals and the TICP recommendations the older adult can keep with them as a tangible tool used with their support system. The support system is identified through an Ecomap and Genogram that is built into the biopsychosocial assessment process. With the older adult’s approval, a copy of the report is then given to the older adult and their support system, such as medical providers, community agencies, supporting family members, and anyone else the older adult feels will play an important role in helping them achieve their goals.
The goal of the older adult working with a TICP is to allow for a relationship with a resilient and stable person in their life, which up to this point they may not have had and may not have been able to recognize as lacking in their life. The TICP is intended to help decrease the older adult’s emotional distress by lowering anxiety levels and depression symptoms using a trauma informed and strength-based approach. Research conducted using the ACE instrument identified the connection between stress and trauma and poor health outcomes. Having a TICP use specialized tools like the ACE and LEST can screen older adults for trauma across their lifespans. Assistance from the older adult’s medical providers can help the older adult and the TICP track the older adult’s goals such as a reduction in blood pressure, decrease diabetic symptoms, or ameliorate other adverse health conditions that could be exacerbated by undiagnosed trauma identified by the TICP.
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Kendall-Tackett, K. (2013). Treating the lifetime health effects of childhood victimization. Kingston, NJ: Civil Research Institute.