Module 5: Trauma, Violence, and Cultural Safety – Topic D Apply an evidence-informed awareness of the ongoing and potential health, emotional, behavioural, and relational impacts of trauma and violence including chronic pain, anger, unhealthy coping strategies, and mental health issues.

Learning Objectives

By the end of this topic, the student should be able to:

• Identify the ways in which trauma and violence shape poor health such as chronic pain, mental health, and unhealthy coping.
• Recognize the relationship between adverse childhood experiences and the development of unhealthy coping strategies.
• Explain how assessment can detect the association between trauma and violence and these health outcomes.

Key Concepts

• Social and environmental experiences early in life have lasting influences that continue into adulthood.
• Adverse childhood experiences (ACE) can have lifelong consequences and impacts across the life cycle.
• Trauma violence, the intentional use of force to inflict harm on another person, is now understood as a social determinant of health (Morris, 2016; World Health Organization, 2013) across the life cycle.
• Traumatic experiences are associated with both behavioural health and chronic physical health conditions, especially those traumatic events that occur during childhood. Substance use (e.g., smoking, excessive alcohol use, and taking drugs), mental health conditions (e.g., depression, anxiety, or PTSD), and other risky behaviours (e.g., self-injury) have been linked with traumatic experiences.
• The colonization and forced assimilation of Indigenous Peoples is considered a root cause of the elevated levels of mental distress.
• Trauma and violence at the societal or structural level inform personal experience, resulting in depression, chronic pain, and use of substances as a way of coping.
• Racial profiling by some health and social service providers can result in trauma and further stigmatization and become a barrier to effective treatment of chronic pain.
• Chronic stress as a result of structural violence such as oppression can be intergenerational, highlighting the importance of understanding the historical context of a person’s narrative/story.

Early Life Adversity and Stress

Research into early life adversity, also known as Adverse Childhood Experiences (ACEs), identify early experiences of stressful or traumatic experiences as strong precursors and predictors of negative outcomes later in life. ACEs are defined as experiences that include abuse, neglect or household dysfunction.

Examples of abuse

• physical
• emotional
• sexual abuse

Examples of neglect

• physical
• emotional

Examples of household dysfunction

• having an incarcerated parent
• witnessing domestic violence
• growing up with substance use, mental illness, parental discord, or crime in the home

Research findings link exposure to early traumatic experiences to problems people have developing healthy coping mechanisms later in life. Exposure to trauma and violence is directly correlated with altered neural development and impaired learning, as well as impaired coping mechanisms.

Relationship to Mental Health

In addition to the effects on learning and development, exposure to trauma has been linked to mental health issues that negatively impact emotional wellbeing and behaviour. Research reveals that prolonged exposure to adverse childhood experiences is a strong contributor to:

• depression,
• anxiety,
• posttraumatic stress disorder (PTSD),
• substance abuse,
• sleep disturbance, and
• suicidal ideation.

These mental health issues can manifest as an impaired ability to regulate behaviours and in the adoption of negative coping mechanisms, such as self-harming and taking substances.

“Repeated trauma can lead to anger, despair, and severe psychic numbing, resulting in major changes in personality and behavior.”

Trauma, Violence, and Chronic Pain

In a cross-national survey of adults from 14 countries, lifetime exposure to traumatic events, many of which involved violence, was associated with elevated odds of developing adult chronic physical conditions including chronic pain, heart disease, hypertension, asthma, and gastrointestinal conditions.

In this study, the most common chronic pain conditions listed as a result of trauma and violence included:

• frequent and severe headaches (26.8 percent),
• back and neck problems (11.8 percent),
• other chronic pain (6.0 percent), and
• arthritis (2.1 percent).

All pain conditions were more common among females than males.

Racial Bias in Pain Management

A 2016 study identified racial bias toward chronic pain management in Black people. The study revealed that white laypeople, medical students, and residents held false beliefs about biological differences between Black and White people and that these beliefs predicted racial bias in pain perception and treatment recommendation accuracy.

Pain Management in Indigenous Peoples

Trauma, Violence, and Mental Health

There is a mutual relationship between experiencing mental health conditions (such as depression and anxiety) and experiencing stigma, discrimination, and social exclusion. Likewise, stigma, discrimination, and social exclusion can be factors in the development of depression and anxiety.

© Course Author(s) and University of Waterloo

With growing evidence that discrimination and stigma are positively associated with adverse mental health outcomes among ethnic minority groups, ethnic discrimination is now considered a chronic stressor.

• Research indicates that, compared to non-Indigenous individuals, depression rates are higher for both Indigenous men and women residing either on or off a reserve.
• Data collected for the First Nations Regional Health Survey found that 26 percent of men and 35 percent of women living on a reserve felt depressed (First Nations Information Governance Centre, 2012).
• An examination of race, ethnicity, and depression in Canada found that Indigenous groups reported higher levels of depression symptoms and more episodes of major depression compared to Caucasian Canadians.

NOTE: Statistics related to Indigenous health need to be understood as variable; the impact of colonialism, neocolonialism, racism, and so on, has not been the same for all Indigenous Peoples or communities. Health and well-being have been shown to be associated with variation in acculturation histories, geography, protective factors, and so on (e.g., MacDonald et al., 2013, Napoleon, 2009).

Trauma, Violence, and Unhealthy Coping

It is commonly accepted that substances and substance use are a survival strategy for coping and mediating painful feelings.

Chronic stress as a result of victimization caused by colonization, war, family dysfunction, and abuse, among other reasons, can change an individual’s response mechanism to pain and painful feelings.

• The cellular and biochemical changes associated with stress may increase an individual’s post-stress susceptibility to substance use.
• Stress can change the microstructure of the brain in a way that predisposes a person to harmful drug use.

Questions

Chronic stress and trauma have been shown to result in which of the following health conditions?

a. Chronic pain

b. Heart disease

c. Hypertension

d. Asthma

e. Gastrointestinal conditions

f. All of the above

Correct! Chronic stress manifests into different health conditions, demonstrating that the impact of stress is systemic.

Incorrect. The correct answer is f. Chronic stress manifests into different health conditions, demonstrating that the impact of stress is systemic.

---

Can chronic or prolonged stress lead to physical and mental health issues?

a. Yes, but only if conditions last more than one year.

b. No, the link between stress and health is questionable.

c. It happens more so in some cultural or ethnic groups.

Correct! Groups of people who have been historically oppressed or who experience health inequities have higher prevalence rates of physical and mental health conditions.

Incorrect. The correct answer is c. Groups of people who have been historically oppressed or who experience health inequities have higher prevalence rates of physical and mental health conditions.

---

Can chronic stress and violence can lead to molecular changes in the body?

a. Yes

b. No

c. Evidence is not clear

d. Depends on the individual

Correct! Prolonged cortisol levels in the body from trauma and stress cause changes at the molecular level resulting in greater susceptibility to substance use.

Incorrect. The correct answer is a. Prolonged cortisol levels in the body from trauma and stress cause changes at the molecular level resulting in greater susceptibility to substance use.

---

Opioid use may have stronger associations with interpersonal violence and victimization.

a. Yes, this is true.

b. No, there is no evidence.

c. It is unclear.

Correct! Research indicates that all substance use, including opioid use, is linked to greater interpersonal violence. One proposition is that opioids used for pain tend to involve individuals who are in relationships that have become strained to the point of aggression.

Incorrect. The correct answer is a. Research indicates that all substance use, including opioid use, is linked to greater interpersonal violence. One proposition is that opioids used for pain tend to involve individuals who are in relationships that have become strained to the point of aggression.

---

References