Ensuring a Safe, Trauma-Informed System of Care

Case Vignette

A 35-year-old woman was admitted to an inpatient unit for a suicide attempt in the context of depressive symptoms and heavy daily drinking, her fourth admission in the last two years. Her past diagnoses in the record were major depression, recurrent, severe; alcohol use disorder, moderate; and unspecified personality disorder with borderline traits. When the admitting psychiatrist attempted to ask her questions to screen her for trauma, she was reluctant to respond. Her only communication was to request some medicine to help her sleep and to stop what she described as her “shakes.” “Unable to screen for trauma” was documented in her previous admission notes.

As soon as the patient completed her detoxification from alcohol, she reported worsening anxiety, insomnia, nightmares, irritability, and anger. She asked the physician specifically for clonazepam for anxiety and zolpidem for sleep. She claimed that she “knew [her] body” and that it “really helps [her].” Her request was denied, though, as she had a history of active alcohol misuse and had previously overused those medications.

Five days after her admission, the patient yelled at a nurse, asking to be released immediately, claiming, “You guys don’t know what you are doing!” She denied any suicidal ideation and did not meet the medical necessity criteria for continued hospitalization.

A review of the patient’s records revealed that she was described by some staff as “difficult,” “hostile,” and “unmotivated.” Others described her as “anxious,” “afraid,” and “disengaged.” According to staff, she avoided the common areas and was reluctant to go to treatment groups. She preferred to speak to only certain staff members; when those specific people were not around, it was difficult to engage her.

The patient’s records also indicated that she usually did not keep her follow-up appointments and that she usually relapsed into drinking alcohol after being discharged.

Vignette Discussion

This scenario is not uncommon in an acute crisis stabilization unit. In such situations, one should suspect that the patient has a history of trauma. Some clues that a patient may be dealing with posttraumatic stress disorder (PTSD) are (a) reexperiencing, which can manifest itself as nightmares, flashbacks, or reactivity; (b) avoidance, which can present as denial, refusal to answer questions, social withdrawal, and even substance abuse; and (c) hyperarousal, which can take the form of irritability, insomnia, and verbal aggression. Given this patient’s presentation, one may have to broach the issue of a history of trauma at a later point in the treatment, once there is a greater therapeutic alliance, and with special sensitivity. Despite the sensitive nature of the topic, one should not disregard this important aspect of the patient’s history.

Avoidance can shield patients from experiencing shame, minimize emotional arousal, preserve self-esteem, and offer a sense of safety. Unfortunately, it can also hamper the healthy resolution of trauma (1). What is perceived as someone being difficult or unmotivated may simply be that person’s attempt to avoid troubling memories and feel safe. When professionals use such words or use a personality disorder lens to frame posttraumatic reactions, it can prevent them from understanding the reasons the patient may be acting in the way he or she is.

Questions

1. True or False: It is uncommon to discover a history of trauma in psychiatric patients.

2. True or False: Time alone heals all traumas.

3. True or False: The first stage of treating a patient with a history of trauma is to ask the patient to recall everything about the traumatic events of his or her childhood in detail.

4. True or False: If one addresses trauma when treating psychiatric patients, the overall costs of psychiatric care will increase.

5. True or False: It is best to take a paternalistic approach with patients with a history of trauma.

High Prevalence of Trauma

In a study of 100 psychiatric inpatients, 81% of the patients had experienced physical or sexual abuse, 60% had experienced two or more different types of assault, and 22% had experienced three or four types of assault (i.e., physical abuse as a child, physical abuse as an adult, sexual abuse as a child, or sexual abuse as an adult) (2). The authors recommended routine inquiries regarding patients’ trauma histories. Another study suggested that women with severe mental illness have rates of lifetime physical and sexual abuse ranging from 51% to 97% of cases, with a significant number of patients experiencing multiple instances of victimization (3). In yet another study, PTSD was reported in 43% of those with trauma exposure, but in only 2% of those cases was the diagnosis documented in the patient’s chart (4). If one were to examine patients who seek treatment for substance abuse, an estimated 50% would have lifetime prevalence of PTSD (5).

The Adverse Childhood Experiences (ACE) Study was a landmark study investigating whether there was a relationship between health risk behavior and disease in adulthood and the degree of adverse childhood experiences and household dysfunction during childhood (6). In a survey of 17,421 participants at Kaiser Permanente’s Health Appraisal Center in San Diego, the authors asked about eight categories of adverse childhood experiences: (a) psychological, (b) physical, or (c) sexual abuse; (d) violence against mother; or (e) living with household members who were substance abusers; (f) chronically depressed, mentally ill, suicidal, or in a psychiatric hospital; (g) ever imprisoned; and (h) parents were separated, divorced, or in some way lost to the patient during childhood. It was also discovered that ACEs are vastly more common than is commonly recognized or acknowledged. Twenty-eight percent of participants reported physical abuse and 21% reported sexual abuse.

ACEs tended to occur in clusters. Because of the difficulty of understanding their impact by studying individual effects, many later studies have instead looked at the cumulative effects of ACEs (7). ACEs are strongly associated with high-risk behaviors such as smoking, alcohol, substance misuse, and promiscuity, and they negatively impact safety; these effects increase with the number of ACEs experienced. ACEs are also correlated with unintended pregnancies, sexually transmitted diseases, severe obesity, heart disease, liver disease, cancer, lung disease, and a shortened life span. ACEs in any category increased the risk of attempted suicide two- to fivefold. Compared with persons with no such experiences, the adjusted odds ratio of ever attempting suicide among persons with seven or more ACEs (35.2% of the group with ACEs) was 31.1 (8). Patients with a history of ACEs are also known to engage in nonsuicidal self-injurious behaviors. These suicidal and nonsuicidal self-injurious behaviors serve different functions in regulating affective states. They may be experienced as a form of self-punishment, as a way of punishing others, as a means of control in interpersonal situations, or as a cry for help (9). They may also be used to end experiences of dissociation, to assert control or autonomy, to generate exhilaration or excitement, and even to feel real and alive again (10). The influence of trauma on a patient’s self-harm behaviors is often underappreciated. Repeated early trauma by caregivers causes extreme, overstimulating emotions that a child may have no comprehension of or ability to describe. The child often finds ways to manage such emotions through self-destructive means (11). Self-harm can also be way of reenacting specific abuse-related themes. These themes must be addressed for the patterns of self-destruction to resolve.

In a later commentary, Dr. Felitti, one of the lead architects of the ACE study, wrote that “time does not heal some of the adverse experiences we found so common in the childhoods of a large population of middle-aged, middle-class Americans. One doesn’t ‘just get over’ some things” (12). He concluded that psychiatrists are “comfortably focused on tertiary consequences of trauma far downstream” (12). He was critical of standard practices, writing, “We have limited ourselves to the smallest part of the problem: the part where we are comfortable as prescribers of medication” (12).

Trauma-Informed Care (System Level)

In 2001, the Institute of Medicine presented a very influential framework for a redesign of the American health care system in its report Crossing the Quality Chasm (13), which included six aims: a system must aspire to be “safe, effective, patient-centered, timely, efficient and equitable.” How can systems ensure safe and patient-centered treatment of patients?

Doctors taking the Hippocratic oath promise “to abstain from all intentional wrong-doing and harm.” It is doctors’ responsibility to proactively design systems of care that can promise a safe treatment journey that will not harm patients.

Interventions in hospitals such as seclusion and restraints; body searches; forced or threatened medications; nightly bed checks; boundary violations, such as walking into the patient’s room without knocking; forcing the patient to the floor; or interactions with patients that make them feel more powerless, vulnerable, and excluded can iatrogenically trigger or exacerbate crises and have the potential to retraumatize patients. Such interventions may also communicate to the patient that the patient is defective, hopeless, and worthless, and they have the potential to reenact aspects of the original trauma. Staff working on units that accept involuntary patients often appear focused on administering medication, ensuring that unit rules are followed, and conducting close observations, and they regularly use physical interventions in response to patient aggression and self-harm. This culture can be perceived by patients as being controlling and unhelpful, as opposed to one that focuses on psychological support and is perceived as being more caring and supportive (14).

In 2001, Harris and Fallot published Using Trauma Theory to Design Service Systems (15), which articulated the concept of trauma-informed care and provided the rationale and framework for creating such systems. They wrote, “Systems serve survivors of childhood trauma without treating them for the consequences of trauma; more significant, systems serve individuals without even being aware of the trauma that occurred” (15). They identified five principles to guide practice and create trauma-informed systems of care: safety, trustworthiness, choice, collaboration, and empowerment (15).

Trauma-informed care has been reported to reduce the need to use seclusions and restraints in hospitals (16). This improves safety not only for patients but for staff as well, who are prone to being injured during hands-on interventions. This kind of trauma-informed milieu also has emotional benefits for staff, who feel that the setting is trustworthy, collaborative, and empowering (14).

Education about trauma is necessary for all staff. They may need to be trained in de-escalation strategies, methods to help patients identify triggers, and calming strategies that reinstate a sense of control. They could also benefit from training on topics such as substance abuse and trauma; establishing, maintaining, and terminating relationships; and strength-focused care planning (17). Patients may need clear explanations of expectations for them; the opportunity to provide informed consent before tests, procedures, and interventions are conducted; maintenance of strict confidentiality; and respectful professional boundaries. Mental health professionals need to offer as much choice and control to patients as possible (14).

Trauma-Informed Care (Clinician Level)

Mental health professionals may be experts on treatment, but patients are experts on their own lives. The spirit of motivational interviewing, especially in addressing maladaptive lifestyle choices, includes evoking from patients what they already know, collaborating with them, and honoring the decisions they make (18).

Although all treatment settings need to provide such sensitive care, one might also need to have access to experts or settings that can provide trauma-specific interventions. If there is a shortage of psychiatrists, there is a much more acute shortage of providers who have expertise in providing trauma-specific services. Trauma is so pervasive that it may be expected to be the rule rather than the exception, thereby necessitating routine screens of ACEs and trauma in all health settings.

The current standard of care for treatment of psychological trauma is to provide a phasic or staged model of treatment (19). Professionals in all health care settings may have to learn to provide early-stage treatments that provide safety, stability, and engagement (20). Early-stage treatments, in contrast to other interventions that specifically address trauma, prioritize basic life and health and address and manage issues such as (a) dangerousness to self or others; (b) lack of food, clothing, or shelter; (c) substance use; (d) eating disorders; (e) lack of access to medical care; (f) high-risk behaviors; and (g) enmeshment in abusive or traumatizing relationships (11). Safety is an umbrella term that could signify various things, such as curtailing unsafe sexual practices, thereby reducing risk of infectious diseases; avoiding relationships that are unsafe; and controlling extreme symptoms, such as dissociation. Patients need help to move away from unsafe, self-destructive practices to instead embrace safe and life-affirming practices. Seeking Safety is an example of a well-researched integrated treatment model for patients who have comorbid PTSD and substance abuse, showing significantly better outcomes compared with treatment as usual (21).

It is also important to assess the effect of current trauma on the chronically traumatized patient. The occurrence of or exposure to current trauma may be concealed due to shame, amnesia, or an inability to link the current trauma to a current crisis. Clients often experience continued revictimization until the current trauma is actively addressed in treatment. Current relationships should be assessed for abusive or controlling interpersonal dynamics that evoke the patient’s prior traumatic experiences.

In addition to treatment for PTSD and dissociation, treatment for mood disorders, somatoform disorders, psychotic disorders, or personality disorders may also be required by the patient. The patient may benefit from learning symptom management techniques such as imagery, reframing, relaxation techniques, stress management, and journal-writing exercises (22).

Psychoeducational groups may be organized around trauma-related themes. Knowledge of posttraumatic reactions allows for more effective self-monitoring of levels of distress and a greater sense of self-awareness and mastery. Strategies such as grounding and sensory awareness may be taught in sessions and practiced as homework. The client may benefit from identifying internal and environmental cues that are associated with an increase in symptoms. The patient can also be coached in the use of techniques that facilitate the containment of distress (e.g., the development of a “safe place” image), which may be especially useful in managing acute distress. Clients may also benefit from modalities such as dialectical behavior therapy, which balances both acceptance and change-oriented approaches and emphasizes the development of distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness skills, which can be especially useful for traumatized clients (23).

Cognitive behavioral methods can be used to work with trauma-based cognitions. They can reduce distress and allow clients to differentiate past from present interpretations of events, which may become blurred as dissociative symptoms increase. Having the client write out cognitions and other adaptive ways of interpreting events can facilitate healing.

Ensuring a Safe Treatment Journey

When there is talk of population health and collaborative health care, ensuring trauma-informed care assumes an even greater relevance. Mental health care professionals must attempt to meet the aspirational goals set by the Institute for Healthcare Improvement within their framework of the Triple Aim—the simultaneous pursuit by systems of care of three interconnected aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care (24). We must redesign our systems to enable the path of our patients to shift from one of “continued victimization” or retraumatization to “one of effective self-regulation” (25). Unless we address these trauma-related issues in an integrated way at all levels of care, we will be unsuccessful in our transformational efforts to reach the Triple Aim. We need to improve the effectiveness and value of our interventions to ensure that our patients have a safe treatment journey and lead safer lives (26).

Answers

All of the statements are false.