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A Prescription for Trauma

 

How should we view trauma? We live in a society where we have a pharmacological agent for almost every ailment, real or imagined. When we are sick, we go to the doctor and we get a prescription for a drug. Prescriptions are usually written, but can be a verbal order. The drug is prescribed to heal an illness, or disease, or at least, to provide some relief. What happens, though, when an ailment is so deep within one’s core that it cannot be treated by any medication?

 As a seasoned pharmacist, I have always been intrigued by the manner in which therapeutic agents act on the intended targets. Drugs exert effects on cells and tissues within the body through varying biochemical ways. Some act at specific binding sites, through receptor activation or inhibition; some, through increasing or suppressing enzymatic activity. In the mind of a pharmacist, it all makes sense.  I remember well a time in my second year at the University of Illinois, at the Chicago College of Pharmacy, my Professor stating that it was our responsibility, as pharmacists, to make sure the right patient receives the right drug for the right disease. I had that down pat as I progressed through my career journey as a pharmacist. Through several different professional pharmacy settings - retail, hospital, and ambulatory care - I was motivated by that core concept – the right patient, the right drug, the right disease state.

One day I had a life changing moment - an epiphany. I was offered a contract position as a polypharmacy pharmacist for the Department of Defense. It was a pivotal moment in my practice. I began to look beyond the world of pharmacotherapy.  I began to look at each patient’s disease beyond the molecular level in which their medication exerted effects on their moods, sleep, and well-being. In my epiphany, I began to ask myself what could be done at a deeper level – deeper to the core of the whole person – than just at a molecular level?  To explain a little further, for context, my job description as a contract pharmacist was to assess military service members medication profiles to determine if the medications that they were prescribed were effective and if there was any duplication in the medications they were being prescribed, and, also if the patients were experiencing any adverse effects. While meeting with those valiant men and women service members who had been exposed to combat, there was one underlying resonating consistency. In my sixty-minute interview assessment sessions with them, the singular common denominator was a history of being exposed to serious trauma.  

Trauma is a deeply disturbing or distressing and injurious event or series of events. Trauma results in profound physical and emotional harm that has long term effects on an individual’s ability to function. Examples of common trauma that occurs frequently include:

  • Acts of domestic violence, including witnessing domestic violence, whether physical or emotional, or both
  • Community neighborhood shootings, including, mass gatherings and school shootings
  • Sudden or violent loss of a loved one, either to an accidental incident or an intentional act of violence
  • Physical or sexual assault, such as being wounded by a knife or firearm, or sexually molested or raped
  • Living in a chaotic environment, e.g. homelessness, and, possibly, living for a period in a shelter

 Soon, after leaving my contract position, I began to reflect on my own experiences within my native city, Chicago. I began to appreciate with greater understanding and conviction the similarities between experiencing combat engagements in war arenas and the violence that is occurring in the most distressed cities in the United States. Tragically, our youth are the most vulnerable to those acts of violence and are most likely to henceforth become violent themselves, in the future, after having been exposed to violence. Yes, it is a self-regenerating cycle.

Some cities in the United States are reporting escalating rates of violent crimes and ever-increasing involvement of deadly weapons among our youth between the ages of 15-24. The National Center of PTSD revealed that 77 percent of children exposed to school shootings and 35 percent of urban youth exposed to violence develop Post-Traumatic Stress Disorder (PTSD), a rate far greater than soldiers deployed to combat areas, largely due to those youth being in the formative and, hence, more vulnerable developmental stage of their lives. The rates of youth violence are disproportionately higher in impoverished communities, ones that are underserved by healthy lifestyle recreational facilities and programs and lacking in social, psychological, and clinical medical providers and services, standard retail stores, restaurants, and food markets, and that are lacking a sound and healthy economic base.

Demographically, homicides among the youth population in inner cities of the United States has taken more lives than suicides, heart disease, HIV and unintentional injuries. We, as a society, must no longer continue with the same approaches and attempts at solutions and expect to get different results. As Susan B Anthony said,” organize, agitate, and educate must be our war cry.”

Ultimately, I began to ask myself what my role as a pharmacist should be. I had witnessed the effects of overmedicating adults who had been exposed to trauma. Could that also be occurring with our children? How are we treating those who have been exposed to the trauma of neighborhoods shootings, police brutality, gang violence, and poverty? A pill is not the answer – it never was. If we are going to find ways to break the cycle of violence in our communities, we must begin to look at the root causes of violence. As a Robert Wood Johnson Clinical Scholar, I have joined the movement to treat trauma as an health issue; and continue to develop a model with interventions that recognize the significance of treating the whole person - the mind, the body, and the spirit.

 Lachell Wardell Pharm.D.

Creighton University MPH Candidate 2018

 

 

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I really appreciated your story Lachell and have made similar changes to my own views. I hadn't realized how fully RWJ seems to be embracing the science of trauma and its effects in so many aspects of life. I'm thrilled to hear it!

What an interesting professional and spiritual evolution you describe. I’m amazed how it sometimes feels like all roads eventually lead to the same destination regardless of the point of origin. As a criminologist focused on juvenile justice and community violence, I have spent a couple decades thinking about the communities you describe - and the last 10 through the lens of trauma - I’d like to add a critical layer that I’m sure you’re aware of but didn’t include - and that is the impact of historical oppression and racism. We cannot talk about trauma without talking about racism - it’s one of the most pernicious forms of trauma for a segment of our population disproportionately affected by trauma - particularly, as I know you know, in those communities you describe above. Centuries of oppression and subjugation have created communities that have no “sound economic base” due in large part to redlining and obstruction of wealth accrual and property ownership, yes? 

I like to share a phrase from the RYSE Youth Center in Richmond, CA that reminds us: ‘It cannot be trauma informed unless it is racially just.’ When we think about examining the root causes of violence and addressing the whole person in the communities you describe, it would be woefully incomplete to do so without anchoring racism at the heart of the inquiry. I would be glad to be in touch to share more of you’re inclined. 

I completely disagree that only prevention works. It's everything that works....we need it all: intervention, healing, treatment, rehabilitation, and recovery.

e.g, If you don't create work places that aren't toxic, if you don't provide paid parental leave, if you don't provide well-paying employment so that both parents don't have to work two jobs to put food on the table, if you don't provide safe places for families to play and exercise, if you don't provide social services that  help families recovery from trauma....all the messaging aimed at parents will be like building sand castles at the low-water mark.

all that is well and good, Karen, but what's even more important is the ability to think, reason, critique, and contribute to the practice of science, and not be just consumers of technology derived from science -- a much rarer ability -- one which does not permit the apotheosis of buzz words, however politically popular or seen as necessary those buzz words may seem, in some quarters, or by some "organizations".

I love science and am amazed at how it is continually evolving.  Looking back, five or ten years ago I never imagined how rapidly ACE's science would evolve, especially when compared to our evolutionary timeline!   When I think of all the pioneering researchers who bravely explored "fringe science", I feel gratitude.  Today we understand epigenetics, the neurobiology of ACEs,  and fMRIs  provide insight into blood flow and neuronal activation - and so much MORE!

What I am trying to say, is that yes, EBP are the gold standard - AND we need to keep pushing that edge using emerging science to inform our efforts.   

For those interested in SAMHSA's National Registry of Evidence-based Programs and Practices list,  click HERE   

NREPP Newsroom

This page compiles the latest NREPP-related news, including announcements on recently added program profiles, SAMHSA press announcements, Federal Register notices, NREPP Learning Center news, Open Submission periods, and more.

This EBP summary demonstrates how emerging science continues to inform our work and push us forward - 

This approach represents an important shift from a previously widespread understanding of adolescence as a tumultuous period, in which youths are prone to or at risk of unhealthy or maladaptive behavior, especially as a result of biological factors. Under this model, optimal development meant the avoidance of unhealthy or maladaptive behaviors—for example, not using drugs or alcohol, engaging in unsafe sex, and participating in crime or violence (Lerner et al., 2005). This deficit model of development focused on deterring problematic behavior and reducing risk exposure by regarding adolescents as “problems to be managed” (Roth & BrooksGunn, 2003, p. 172).

However, as Hilliard and colleagues (2014) pointed out, mounting evidence did not support the deficit model; most youths develop along different trajectories. In fact, even those who have experienced trauma or other adversity can avoid negative outcomes as a result of protective factors, such as involvement in positive activities, support from caring adults, and economic opportunity (Development Services Group, 2013).

It is now understood that successfully transitioning to adulthood requires more than avoiding problematic behavior (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004). For, as Pittman, Irby, Tolman, Yohalem, and Ferber (2003) noted, “problem-free is not fully prepared” (p. 6). Since societies have a vested interest in ensuring that young people grow to lead healthy, satisfying, and productive lives as adults, they need to help today’s youths navigate the many obstacles they face, which include “time-crunched parents, dangerous substances and behaviors, overburdened schools, and a more demanding job market” (Roth & Brooks-Gunn, 2003, p. 170).  

Last edited by Karen Clemmer

I came across a very interesting drug study recently (see NEI's webinar on psychosis and parkinson's) where 40% improved on the drug, and "only" 26% on placebo. Guy raved about the drug's effectiveness. My take: you can talk yourself into almost anything, but don't get your hopes up too much.

And then separating out what works for most v. what works for a few, but is effective. And separating out "evidence-based" that works for some segments of the population but very obviously not for many others.

Science has to become more nuanced in this area; the community Patients Like Me is taking a good stab at it.

Regarding root causes...

Treating the symptoms of polio does not cure it or prevent it.  Only a vaccine can prevent it.  Similarly, intervention, healing, treatment, rehabilitation, and recovery will not stop adverse childhood experiences.  Only primary prevention can accomplish that.  Visit advancingparenting.org to read about what we do, why we do it, and our plans for the future.

Read the bridgework/riverwork allegory too.

Cheers!

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