The nurse practitionerâ€™s approach to the treatment of people with trauma
Treatment of people with trauma starts with a trauma-informed perspective which means that the PMHNP understands and acknowledges the widespread prevalence of trauma, and the effect trauma has on people (Sweeney et al., 2018). The approach to people with trauma is â€˜what happened to you?â€™ as opposed to â€˜what is wrong with you?â€™. The trauma-informed approach looks at problematic behavior and distress as a coping mechanism and adaptation to trauma. A patient may not intentionally be manipulative or attention-seeking but attempt to communicate distress and fear. The PMHNPs role is to connect with empathy instead of judgment (Sweeney et al., 2018). The goal is to build a collaborative relationship by empowering the patient to make choices and helping them feel safe emotionally, and physically.
Clinical parameters for identifying and assessing trauma
The trauma-informed provider can recognize the signs associated with previous trauma such as illicit substance use, extreme self-harm, or risk-taking behavior. If a patient uses primitive or immature defenses, they most likely have poor ego strength and early issues of trauma. Immature defense mechanisms include denial, projection, acting out, regression, somatization, and splitting (Wheeler, 2014). Providers need to ask about trauma and abuse. Research shows that many providers do not ask because of time constraints, fear of causing distress, fear of traumatization and lack of training (Sweeney et al., 2018). PMHNPs ask about trauma in initial assessments/psych evals. Trauma can be discussed in the context of a personâ€™s social and developmental history. Experts suggest prefacing trauma questions with normalization statements and reassurance that they do not have to disclose abuse or trauma if they donâ€™t want to. If they do disclose trauma experts suggest that it is important to reassure them that disclosure is a good thing, check current safety, and offer support and referral to treatment (Sweeney, et al., 2018). Screening tools such as the Adverse Childhood Experiences Study Score Calculator ask specific questions about adverse childhood experiences. When patients screen positive it is important to also screen them for suicidal thoughts and behaviors. Self-assessment tools and screening tools may be less threatening and help patients make a connection between trauma in their history and current patterns of behavior (NIH.gov, 2021).
Specific Nursing approaches that reflect trauma-informed care
Trauma-informed care experts teach that it is important to introduce yourself and your role to each patient as this avoids confusion and misunderstanding. Awareness of an open and non-threatening body position helps prevent threat detection areas of the brain from taking over. Anticipatory guidance helps the patient to know what to expect and decreases surprises and threat activation. Ask before touching a patient, protecting privacy, using plain language and teach-back techniques are specific nursing actions that reflect trauma-informed care (Fleischmann et al., 2019).
Psychotherapeutic strategies for trauma
Trauma affects brain structure and the wiring of neural networks. Brain areas affected by trauma include the locus coeruleus, amygdala, hippocampus, orbitofrontal cortex, cerebral cortex, hypothalamus, and anterior cingulate. Research studies show that changes in the brain occur in response to psychotherapy; psychotherapy approaches include mindfulness and EMDR which improve attention and tolerance of unpleasant feelings and CBT which helps inhibitory control and self-regulation (Wheeler, 2014). Research studies suggest that trauma-focused cognitive behavioral therapy, exposure-based therapy, and eye movement desensitization and reprocessing therapy (EMDR) are effective in the treatment of PTSD in adults (Stein, 2022). The choice of therapy includes shared decision-making and is based on patient presentation, preference, and the therapistâ€™s expertise. SSRIs are suggested as an adjunct treatment especially in patients with depression as they have low motivation and poor concentration. When these symptoms improve the patient has a better response to trauma-focused psychotherapy (Stein, 2022). Patients with PTSD and borderline personality disorder respond well to dialectical behavior therapy especially when self-harm and suicidal ideation are present (Stein, 2022). Psychotherapy helps persons who suffer from trauma develop strategies and skills that decrease sympathetic arousal by creating new neural pathways and new ways of thinking allowing dysfunctional material to be accessed and corrected by new adaptive networks (Wheeler, 2014).
Fleishman, J & Kamsky, H & Sundborg, S (2019). Trauma-Informed Nursing Practice. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-24-2019/No2-May-2019/Trauma-Informed-Nursing-Practice.html
NIH.gov (2021). Trauma-Informed Care in Behavioral Health Services â€“ Screening and Assessment. https://www.ncbi.nlm.nih.gov/books/NBK207188/
Stein, M (2022). Management of posttraumatic stress disorder in adults. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/management-of-posttraumatic-stress-disorder-in-adults?
Sweeney, A et al (2018). A paradigm shift: relationships in trauma-informed mental health services. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088388/
Wheeler, K (2014). Psychotherapy for the Advanced Practice Psychiatric Nurse. Second Edition. Springer Publishing Company.