Dr. Carol-Ann Saari (biography and disclosures)
Disclosures: Honorarium by Reckitt Benckiser to present on “trauma, women and addictions” and on “adolescent brain development and youth concurrent disorders”.
Mitigating Potential Bias:
- Recommendations are consistent with published guidelines
- Recommendations are consistent with current practice patterns
- Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements
What I did before
Back in 2008, I became the Medical Director of the Provincial Youth Concurrent Disorders Program, a program specializing in concurrent mental illness and addiction in young people. Soon after, our team psychologist, Dr. Rosalind Catchpole, was awarded a grant to study this population. In retrospect, the results were not surprising. Virtually all concurrent disordered youth (94%) were reporting exposure to adverse experiences like physical and sexual abuse, serious illnesses or accidents, and other distressing experiences in their lives and 46% of young women and 31% of young men were meeting criteria for Posttraumatic Stress Disorder – and not just meeting criteria, but most were well above threshold. This triggered an immediate change in how we were approaching our patients It became clear that we had to become trauma informed. In the general population, approximately 75% of Canadians will report having experienced an adverse and potentially traumatic experience in their lifetime, with 9.2% meeting criteria for PTSD (M. Van Amerigan, 2008). Those with mental illness, substance use disorders and physical health complaints are even more likely to be affected.
To understand trauma, it helps to know the theories of how trauma can lead to chronic impairing symptoms. Porges’ theory outlines three different levels of response to trauma. The first is social engagement. When faced with fear, we tend to, as a species, turn toward our peers and families and look for support. After that, if we find ourselves alone in the face of trauma, the next step is to activate our sympathetic nervous system and prepare for fight or flight. Porges suggests that if we are not able to use “fight or flight”, and can’t dispel the energy of arousal, the fear response becomes “trapped” in our bodies. We become chronically hyper aroused. Physiologically this is seen as an elevated cortisol response, which stresses the body and can lead to immune disorders, physical health impairments, pain, headaches, and other disorders. It also leads to the hypervigilence and flashbacks we see so often. Finally, if the fight or flight response is not successful, a third response is to shut down the body to conserve energy. This is where dissociation comes into play. When you can’t escape the trauma, such as when a child is experiencing chronic abuse, you can mentally remove yourself for a time. This response can also become “disconnected” leading to uncontrolled dissociation. A fear response can occur when not warranted or not kick in when it’s needed.
As physicians we invariably see potentially traumatized patients all the time – the highly agitated young woman having a pap test, the man with the sleep disorder, the chronic pain patient seeking opiates. We may not always know the backstory or consider that their escalating behaviors may have developed as a means to get their needs met during abusive situations. This can lead to judgment, annoyance, that “heart sinking” feeling that comes when you see that patient’s name on your daysheet. What can we do? We can start by becoming trauma informed.
What changed my practice
Trauma informed practice (TIP) is a way of providing services that recognizes the need for physical and emotional safety, choice and control in decisions affecting one’s treatment and an environment where patients do not experience further traumatization. Principles include trauma awareness, understanding the impact of trauma on development, how trauma may present, how people cope with trauma and how trauma affects the emotional/physical and spiritual wellbeing of patients. TIP puts an emphasis on informed consent, confidentiality, transparency and consistency. It emphasizes choice, collaboration and connection, all things that are strikingly absent in experiences of trauma.
Nancy Poole, from the TIP advisory team, notes that “in practical terms, trauma informed approaches are incorporated as universal precautions. The strategies used to build a safe and trustworthy relationship will vary by type of practitioner, setting and length of the interaction, but can include how the person is contacted, how barriers to attending appointments are explored, how ideas for what makes accessing healthcare safe or unsafe are elicited, understanding which past strategies for self regulation have worked, and so on”. She reports that “key to these trauma informed approaches, as differentiated from trauma therapy, is that they are not based on disclosure, but are offered universally. As such, in settings other than mental health settings, screening for trauma is not recommended, rather creating an environment where a patient feels safe to access the care they need, and to disclose trauma if they choose. In therapeutic settings, trauma specific assessment can be done by trained practitioners.”
What I do now
When working with a person who is traumatized, it is important to recognize that the therapeutic relationship may be more important than getting a detailed history. Those details may come out over time; it is more important to create a relationship of safety, which will allow you to understand how the trauma is impacting their lives. Look around your office, does it support traumatized patients? Is there a space for people to go if they are feeling dysregulated? Can you guarantee confidentiality? Does the front line staff have an understanding of why the patients may be irritable and can they support the patient in a non-judgmental way? Can you support your front line staff if they become vicariously traumatized themselves? What will you do if the vicarious trauma happens to you?
EQUIP health care has a downloadable poster which summarizes tips for creating a welcoming environment: equiphealthcare.ca.
When a patient discloses trauma, it is important to acknowledge the information, express empathy and re-visit confidentiality. Recognize the courage it takes to talk about the trauma, address the time pressures you may have. If you don’t have time to sit with the person to ensure they are stable before leaving the office, ask a counselor or other staff to sit with them and support them. Respond to any immediate safety concerns and above all, offer hope. Depending on the setting, and the type of trauma experienced, a practitioner may wish to use the ACES (Adverse Childhood events) screener to explore the nature of early trauma experienced, and to explain how adverse childhood experiences are commonly linked to late life chronic health problems. If significant trauma is elicited and additional assessment is needed, referral to your local child and youth or adult mental health team or Foundry site may be a good first start. The Kelty mental health website also has a list of online resources keltymentalhealth.ca including information from Learning Links which is an online education module. Another great resource is the app PTSD Coach Canada developed by Veterans Affairs.
Treatments for trauma are mostly psychotherapeutic. They focus on teaching coping skills to manage the intrusive memories, to address distorted belief systems or to manage additional symptoms of anxiety, depression, panic or substance use. Some therapies try to decrease the power of the intrusive memories by using exposure and desensitization – these are modalities such as EMDR or trauma focused CBT. Pharmacologically we have a few weapons in our arsenal. Medications with level 1 evidence for symptom relief include fluoxetine, paroxetine, sertraline and venlafaxine. CANMAT has PTSD guidelines embedded in their Anxiety Guidelines, which review medications with level 1-3 evidence. One medication under review is prazosin, widely being used to decrease autonomic arousal that occurs in nightmares. This medication gets dosed starting at 1mg qhs and can be titrated up to 15 mg. Psychiatrist Dr. David N. Osser from Harvard medical school outlines a protocol with maximum dosage of 25 mg in men and 10 mg in women: psychopharmacologyinstitute.com. Benzodiazepines, largely seen as a “go to” medication for anxiety have been show to impair fear extinction and counteract therapy related learning. They also do not prevent PTSD in the post trauma period and may enhance development of PTSD.
The treatments we currently have can be very symptom focused, which makes a lot of sense. However, they may not be enough for full recovery. The rest may lie in what psychiatrist Dr. Viktor Frankl wrote about in his book Man’s Search for Meaning. Dr. Frankl lived through the horrors of Auschwitz and recounted his experiences soon afterward in this book. To make sense of it, he also presented his theory of Logotherapy. The crux is that we all need more in life than food, shelter and safety; we need to find meaning in and for our lives. Once experiencing a trauma that is so life altering, how does one find meaning in existence? That is the other necessary part of intervention – helping people find some meaning in their suffering so they can make sense of their world and move on with their lives. I believe trauma informed practice is one of the first steps in embracing a culture of acceptance and safety.
The Trauma Informed Practice (TIP) guide produced by the BC Provincial Mental Health and Substance Use Planning Council has a wonderful summary of trauma informed practice including how your organization and practice can adopt trauma informed principles: bccewh.bc.ca. CAMH also prints guides on how to work on the front lines of trauma and deliver first stage trauma treatments: https://www.camh.ca/en/health-info/guides-and-publications.
References and Resources
- Van Amerigan, M. et al., Post-traumatic stress disorder in Canada. CNS Neuroscience & Therapeutics, 2008. 14(3): p. 171-181. 2008 (View with CPSBC or UBC)
- Stephen Porges, PhD. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation (Norton Series on Interpersonal Neurobiology) 1st Edition (Request from CPSBC: UBC book can be requested or request from UBC)
- PTSD: National Center for PTSD Clinician’s Guide for Medications for PTSD. (View)
- Trauma Informed Practice Guide. May 2013 Provincial Mental Health and Substance Use Planning Council bccewh.bc.ca
- Bridging Responses: A Front Line Workers’ Guide to Supporting Women who have Post Traumatic Stress. CAMH publications, Centre for Addiction and Mental Health www.camh.ca
- First Stage Trauma Treatment: A Guide for Mental Health Professionals Working with Women. CAMH publications, Centre for Addiction and Mental Health 2003 www.camh.ca (Request from UBC Library)
- Women, Abuse and Trauma Therapy: An Information Guide. CAMH publications, Centre for Addiction and Mental Health 2004 www.camh.ca (Request from UBC library)
- Anxiety and Depression in Children and Youth – Diagnosis and Treatment (View)
- Major Depressive Disorder in Adults – Diagnosis and Management (View)
- Nancy Poole Contributor. Centre of Excellence for Women’s Health, Galvanizing Equity Group Inc., CanFASD Research Network TIP Project team. http://bccewh.bc.ca
Other
- Frankl, Viktor E.: Man’s Search for Meaning. An Introduction to Logotherapy. With a new Foreword by Harold S. Kushner and a new Biographical Afterword by William J. Winslade. Beacon Press, Boston, 1963-2007. (A revised edition of From Death-Camp to Existentialism). Hardbound: ISBN 0-8070-1426-5;
- Theory of Logotherapy by Dr. Viktor Frankl http://www.viktorfrankl.org/e/logotherapy.html
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I agree with this approach. The real challenge is lack of resources and time management in busy practice. I agree that non-judgemental empathetic approach can build the rapport and over the time patients will tell you their life experiences.