Journal of Psychiatry Reform vol 9 #15
Caroline Giroux, MD, FRCPC
Professor of Psychiatry, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]
Trauma-informed care is now the standard of care. This framework aims to apply universal precautions when interacting with patients, staff, students, people who are institutionalized etc, by taking into account and keeping in mind the high likelihood that they might have suffered some form of trauma and therefore be triggered by elements of the interactions despite good intentions. In other words, we have to treat each person with compassion and attunement, assuming they have been victimized in the past, until proven otherwise.
The landmark study that propelled organizations and institutions into disseminating such practices was the ACE (adverse childhood experiences) study published in 1998, by Felitti et al , who through a survey made a correlation that would revolutionize the way we practice medicine: childhood toxic stress (categorized in 10 forms of abuse, neglect and family dysfunction at the time of the study) increases the risk of chronic and serious medical conditions, including cardiovascular disease, pulmonary disease, metabolic disorders, cancer, addictions, mental illness and suicide. Through chronic inflammation and other mechanisms of tissue damage, people who suffered ACEs are hence more likely to seek or need medical care, putting themselves at higher risk of being exposed to new trauma or triggers even during well-meaning and indicated interventions.
In order to mitigate the risk of traumatization and retraumatization in our systems of care, we need to keep in mind the trauma-informed principles. These principles include a foundation of safety (by being empathetic, gentle, cultivating trust, allowing patient to have a way to leave the space if they feel too uncomfortable etc), offering sufficient explanations before each procedure (screening test, exam…), giving each patient a voice and choice (such as honoring their “no”) and letting each person decide on the pace of the procedure or exam. It is about providing services that are welcoming and appropriate to the special needs of those affected by trauma and this framework of practice is applicable in all settings (on call, emergency, brief encounters, waiting room etc).
Trauma-informed care (TIC) also means validating and providing psychoeducation about the stress response systems and impact of trauma on the whole person. It encourages the cultivation of healthy coping mechanisms while fostering growth. Gradual exposure (to medication, and to stimulus in exposure therapy) is recommended as much as possible. By practicing TIC, we can also teach grounding and emotional modulation techniques as we coach patients in identifying and managing their triggers. It is culturally-sensitive, and is the standard of care.
The Substance Abuse and Mental Health Services Administration (SAMHSA) summarized the goals of this practice in 4 “Rs” . An organization that is trauma-informed:
- Realizes the widespread impact of trauma and understands potential paths for recovery;
- Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
- Seeks to actively resist re-traumatization.
Trauma-informed pharmacotherapy is a corollary of trauma-informed care (TIC). How do we apply the 4 Rs to safe medication prescribing? Mostly by resisting retraumatization since meds can be triggers through side effects causing somatic reactions reminiscent of prior activation of stress response systems or generate adverse events that can be potentially traumatic by themselves. I could not find extensive literature on this specific aspect of trauma-informed care, which is not surprising since it is still an emerging field. But here is an operational definition of trauma-informed pharmacotherapy which I developed based on my clinical experience and as I applied the trauma-informed care principles to pharmacotherapeutic interventions:
Trauma-informed pharmacotherapy is a set of medical acts including prescribing, administering, monitoring and adjusting (titrating, tapering, discontinuing) of:
1.Any medications for patients regardless of medical conditions, keeping in mind that the patient might have suffered trauma (developmental, medical, social etc) – this is trauma-informed;
2.Medications approved to treat trauma-related conditions –this is trauma-centered (more specific to trauma-related conditions, and a subset of trauma-informed pharmacotherapy). Derived from evidence-based medicine and current pharmacotherapy guidelines.
Trauma-informed is all encompassing and more generic. Trauma-centered is more specific. Trauma-centered implies being trauma-informed, but one does not have to be trauma-centered to be trauma-informed. For instance, psychiatry is one of the specialties that operates within the trauma-centered context, while the whole field of medical care, regardless of specialty, is within the realm of TIC. If we illustrated trauma-centered care by a circle, it would be placed within a larger circle called TIC.
Principles of Trauma-Informed Pharmacotherapy
It is patient-centered, with shared-decision making (which has a good therapeutic alliance as a pre-requisite) while providing sufficient explanations for informed decision-making. Once a new medication has been agreed upon, it is important to start extra low (half the dose in prescriber’s guides, for instance, 25 mg of sertraline), and go extra slow because trauma survivors are generally extra sensitive to side effects. It is also a good habit, since such a gradual titration ends up being gentler on any patient’s system. Gradual exposure is one of the principles listed earlier.
Reducing polypharmacy is also key, and should be achieved by:
- de-prescribing by removing harmful medications, medications that are no longer effective or indicated based on the patient’s evolution of symptoms;
- avoiding adding meds (or the “one symptom, one pill approach”);
- consolidating into less medications by removing some and optimizing doses of the remaining ones and/or finding multi-purpose ones (for instance, select one that targets both anxiety and depression)
In other words, trauma-informed prescribing is safe, rational and pragmatic. Below is a list of commonly prescribed medications for survivors of trauma.
Table – Classes of commonly prescribed medications in trauma-related conditions
|Class, type||Target symptoms|
First-line SSRI: sertraline (Zoloft)
Other SSRIs, SNRIs
Alpha-adrenergic medications: Clonidine (alpha 2 agonist) and prazosin (alpha 1 blocker)
Depression, anxiety (panic), impulsivity, eating disorders
Depression, anxiety, impulsivity
Autonomic hyperactivity (panic, hyperarousal); nightmares
bidirectional influence between pain and mood
Serotonin antagonists (i.e., second-generation antipsychotic agents) and benzodiazepine drugs are relatively contraindicated and should be used sparingly and with caution . In our clinical practices, we find that at times, some low-dose antipsychotic can have mood-regulating properties and help optimize anti-depressants. Just like in any other pharmacotherapy process, the risks-benefits analysis applies.
A key aspect to efficacy is sufficient dosage over a sufficient trial period of 8 to 12 weeks. If SRIs or SNRIs are ineffective, mirtazapine, nefazodone, vilazodone, tricyclic antidepressant agents, and monoamine oxidase inhibitors (MAOIs; specifically, phenelzine) should be tried [3,4].
Safety is an essential component and should be ensured by screening for and documenting substance use, as some medications may have additive effects with medications we intend to recommend.
Psychodynamic themes and other aspects
When facing challenges like adherence, medication misuse, medication-seeking or other counter-productive attempts for the patient to heal or reclaim their autonomy, we must try to decode these attitudes and behaviors. For instance, it is useful to consider what the medication represents to each patient (is it transitional object, a symbol of something meaningful, a “lifejacket”, or something good they ingest or internalize). One must pay attention to subtext, it is part of individualizing the approach, hence being trauma-informed. Some meds can be emotional triggers (for instance, in a patient whose parent committed suicide by overdosing on a medication). Therefore, a comprehensive assessment is key to maintain a trauma-sensitive approach. Finally, are there power dynamics at the root of non-adherence (for instance, refusing to take a medication may be the patient’s attempt at saying no to a perceived authority figure, as a way to heal a self-concept characterized by helplessness due to victimization in childhood). And of course, we have our own biases towards certain medications and it is important to remain aware of what they represent to us as well as we prescribe them to our patients.
-Be trauma-informed in all types of interventions and interactions. Practice universal precautions: it helps making everyone feel SAFE
-Treatment of trauma requires a focus on target symptoms more so than diagnosis
-Be aware that medications can have triggering effects
-Be realistic: meds are never the perfect solution. Be holistic, and encourage patients to develop a healthy lifestyle, including: mindfulness practices, healthy diet, regular sleep, exercise, social support, sense of purpose, spirituality, gratitude practices, lightness of being (joy and laughter).
-Trauma-centered psychotherapy is an effective adjunct to pharmacotherapy in treating trauma-related conditions
While we continue to do what we have been trained to do, we also need to make a paradigm shift. The role of a physician is not only to prescribe and de-prescribe medications, but also to discern the limits of our field, when medications are indicated and when they are not appropriate. And when medications have proven to be ineffective or insufficient, let us remind ourselves that our patients’ healing power often resides in their introspection, and our ability to catalyze their healing through “storylistening”.
“Stories are medicine… They have such power; they do not require that we do, be, act anything – we need only listen. The remedies for repair or reclamation of any lost psychic drive are contained in stories.”
–Clarissa Pinkola Estes, PhD
(American author, Jungian psychoanalyst and spoken word artist)
- Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Marks JS. 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. 1998 May 1;14(4):245-58.
- Huang LN, Flatow R, Biggs T, Afayee S, Smith K, Clark T, Blake M. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
- Limandri BJ. Prescribing with a trauma-informed perspective. Journal of Psychosocial Nursing and Mental Health Services. 2018 Aug 1;56(8):7-10.
4. Kobayashi, T.M., Patel, M., & Lotito, M. (2015). Pharmacotherapy for posttraumatic stress disorder at a Veterans Affairs facility. American Journal of Health-System Pharmacy, 72(Suppl. 1), S11-S15. doi:10.2146/ajhp150095