The National Council on Trauma Informed Care asserts that “knowledge about the prevalence and impact of trauma has grown to the point that it is now universally understood that almost all of those seeking services in public mental health have trauma histories.” A central tenet of trauma informed care is flipping the paradigm, from asking “what’s wrong with you?” to asking “what’s happened to you?”
But when traumatized people seek help at public mental health programs they often encounter a pronounced interest in identifying what’s wrong with them. This is primarily due to the continued reliance on the psychiatric Bible (DSM 4/5) to determine who is eligible for services and who is not. The frequent result is that the vast majority of these traumatized people receive diagnoses such as attention deficit, oppositional-defiant and conduct disorders (for children) and depression, bipolar and psychosis (for adults). In turn, these diagnoses spur the treatment towards psychotropic medications.
How does this diagnostic system, and the associated provision of medications potentially impact traumatized people? Setting aside the significant risks that the neuroleptics themselves can pose to many help seekers, how else can pharma focused interventions effect the treatment context?
The DSM 4/5 is largely concerned with nosology – the classification of diseases and categorization of “what’s wrong” (with the notable exception of PTSD). Through this lens, practitioners focus on assessing the symptoms, impairments and deficits – not on the etiological (study of causes) questions of why these difficulties may be occurring. The nosological approach of the DSM 4/5 could be characterized as the epitome of the “what’s wrong” perspective.
The emerging understanding of developmental trauma – referring to prolonged exposures to trauma and childhood maltreatment is described by Bruce Perry, M.D., of the Child Trauma Academy, as the “great imposter”. He makes the case that a great number of the DSM 4/5 diagnostic labels actually represent adaptations to high levels of chronic stress. Several recent studies have pointed out the relationship between psychotic disorders and trauma. This recognition and reframing of symptoms as adaptations is foundational to trauma informed care and can help people make sense of their seemingly senseless behaviors.
When children, young people and adults with these significant traumatic exposures present at mental health clinics, their adaptations (i.e. dissociation, impulsiveness, social withdrawal) are often seen as symptoms to be medicated. On the one hand, many people may experience great relief at being diagnosed (finally someone understands me and can help me!) The chemical imbalance narrative can override the trauma narrative of what happened to them. And medications can certainly provide welcome relief from distressing symptoms such as insomnia, anxiety and tension. In addition, we live in a culture that is deeply attached to quick fixes in the shape of pills (and other substances). The “what’s wrong” question gets a definitive answer; (you’re depressed) and a deceptively simple remedy (an anti-depressant).
On the other hand, trauma informed care can greatly expand our understanding, our compassion and the potential for healing and recovery. Most people can extract little meaning from the biological viewpoint that their dopamine is low or serotonin is high. Creating a sense of meaning from painful experiences, and restoring a sense of personal power are crucial goals of trauma informed care. By supporting and teaching traumatized people about ways that they can emotionally regulate and self-soothe, they can begin to develop a sense of mastery and control.
Taking medications can become a very passive act, demanding little effort and responsibility on the part of the help seeker (and the help provider). Trauma informed care requires a collaborative, empowering approach that is predicated on the belief that the person is the expert on themselves and has the capacity to heal. The Recovery Model states that diagnosis is not destiny. In trauma informed care, diagnosis may not even be the correct starting point.