In two previous posts here and here I’ve defined what’s meant by trauma, the effects adverse childhood experiences appear to have on the developing individual (particularly on the nervous system), and one form of treatment that’s intended to directly help people ‘recognise, disclose and process their traumas and conflicts’ to ‘face their experiences, experience them and ‘adaptively express’ them.’
Today I want to look at ‘trauma-informed’ therapy and consider the implications of this approach for pain management in general.
It’s not very easy to find a clear definition of ‘trauma-informed’ that everyone agrees with. As some authors point out, because trauma is everywhere, the effects of trauma vary widely, and because many chronic illnesses are influenced by early life experiences (along with genetics!) and life-long health behaviours, most clinicians will work with people who have histories of trauma. When we look at the definition of trauma that I used “an event(s) or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, and/or spiritual well-being.” (Valdez, chapter 2, p. 13 in Stromberg, 2023), and look at the definitions used in most epidemiological research such as DSM5 PTSD definition, or the ACES measure developed by Finkelhor et al., (2013), what we’re talking about in research might differ from what we talk about either in clinical practice or on social media. That is, both ACES and DSM5 PTSD describe significant events with a lasting impact.
At least part of the difficulty in this area is that structural or systemic discrimination might not feel like it’s traumatising to the dominant group with most power – and thus the experiences of people on the receiving end of such discrimination might not be accepted as real or having an impact. If you don’t have a voice that’s heard, it’s hard to speak up, right?
Back to therapy and a stance that might help us wend our way through this.
Trauma-informed therapy/care has been described as ‘a strengths-based approach… that understands and responds to the impact of trauma, and emphasises physical, psychological and emotional safety… and creates opportunities to rebuild a sense of control and empowerment’ (SAMHSA, 2014, paraphrased/edited by BLT). Essentially it’s an approach that looks to understand the effects traumatic experiences can have on people (both visible and hidden), aims to encourage respect for differences (e.g. cultural, neurobiological, gender, religious), starts by offering a sense of safety and dependability, is underpinned by compassion (not judgement), emphasises collaboration and choice, and fosters resilience. This kind of approach is relational rather than procedural.
There are many ways to ‘be’ trauma-informed and integrate these principles into therapy. One approach is the Four C’s – Calm (self, towards others, environmental, procedures/policies); Contain (don’t require detailed disclosure, behave reliably, monitor the person’s responses, use calming techniques, reduce opportunities for these experiences to be repeated); Care (practice self-care, support those disclosing trauma, destigmatise traumatic responses, be culturally humble, reduce power differences, enhance equity); and Cope (emphasise coping skills, ask about ways to help people feel more comfortable, include a coping/strengths list not just problems, help mitigate unhelpful coping strategies, connect people with resources, promote equity) (Kimberg & Wheeler, 2019).
I don’t know about you, but I would have hoped this is how we do healthcare. Of course if this was our routine approach to helping people, we wouldn’t need to spell it out quite so clearly, so perhaps it isn’t as fundamental as I’d thought. That we have to be so explicit about being respectful about individuals and their response to interacting within our health systems suggests strongly that we need to do some hard thinking about how health systems are established, who they are for, and how we train people who work in them. Basic rules: Don’t kick someone when they’re down, care for them when they’re unwell and make systems that do the job they’re there for – helping people who need help.
Two points I want to draw attention to in particular, though.
1. Contain – don’t require detailed disclosure. This is about ‘don’t poke bits that hurt’ and calls into question the suggestion that all people with a history of trauma ‘need psychology/counselling.’ If traumatic experiences are part of so many peoples’ lives, and we’re urged not to poke about if it’s increasing distress but instead offer coping and calming strategies, what can we all do in this area? What might it be like to the person who is feeling vulnerable to get passed on to yet another person to tell their story to? Can we all develop the competence to be calm, offer compassion and build on strengths? And do we need to call this ‘psychologically-informed’ or ‘trauma-informed’ or should we recognise and train to be full, responsive humans to work in health and make this our normal and expected way of working?
2. Everyone has a history. Everyone. We all learn to be who we are – and continue to develop into who we are right up until we die – throughout our lives. All the things we experience over life shape us. Some of those experiences might not be recalled consciously, while others can be seared into our personal narratives. Some of our stuff might be traumatic, some might just be distressing or uncomfortable. We all have opportunities to reconsider how we view events that have made us into who we are today. We can understand more about our current ‘self’ if we look at what we’ve been through over our lifetime. Sometimes this works best with a trained professional or at least someone who isn’t currently caught up in our ‘stuff’ – but it isn’t obligatory. This is why we have friends and family – and even ourselves, if we choose to figure stuff out in writing (or other individual pursuits). What matters is knowing that who we are isn’t fixed in stone, that change (to a certain extent) is possible, and that there are other perspectives. In clinical practice, having a professional supervisor (as mandated for occupational therapists here in NZ) can be a great way to stop, check in, review and process experiences.
To sum up, trauma-informed care should really be our routine approach to clinical practice. I’d like to remove the term ‘trauma-informed’ and replace it with ‘effective’ care. Gone are the days of knowing that ‘we know best’ because ‘we’ have been to healthcare training school. ‘We’ never know the person’s life and what has contributed to them being the way they are – just as we’re never completely aware of what has shaped our own life. This means clinicians need to take their judgements ‘oh she hasn’t taken the message on board’ or ‘they’re not motivated’ or ‘they’re just not helping themselves’ and shove them where the sun doesn’t shine. Instead, we need to bring compassion and curiousity to try to figure out – with the person – what might help them move towards what matters in their own life and aligned with their own values, and at the pace that fits them.
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (2021). Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2021.2669
Finkelhor, D., Shattuck, A., Turner, H., & Hamby, S. (2013). Improving the adverse childhood experiences study scale. JAMA Pediatr, 167(1), 70-75. https://doi.org/10.1001/jamapediatrics.2013.420
Kimberg, L., & Wheeler, M. (2019). Trauma and Trauma-Informed Care. In Trauma-Informed Healthcare Approaches (pp. 25-56). https://doi.org/10.1007/978-3-030-04342-1_2
Substance Abuse and Mental health Services Administration (SAMHSA). Definitions. SAMHSA News [Internet]. 2014; 22(2). Accessed 18 November 2024. Available from: https:// http://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/key_terms.html.