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Trauma Informed

Medication Education 23rd Annual Northeast Regional Psychiatric Nursing Conference

4.4.2019

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Contact Information

Kathryn Kieran, MSN, PMHNP-BC:

kkieran1@partners.org; 617-855-2468

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Off-label use may be discussed.

Thank you, Patricia

Mangones, NP, Stephanie

Brunet, & Rose Sajjabi.

Support for this work has been

provided by the Anonymous

Women’s Health Fund.

Discuss 3 commonalities between deprescribing and trauma-informed models

Give 3 examples of how trauma can result in over- and under- medicating behaviors

Propose 3 nursing interventions for harmful trauma-related medication behaviors

Learning Outcomes Content Acknowledgement

Trauma Exposure

Preexisting

Occupational

Vicarious

(Boulanger, 2018; Cohen & Collens, 2013)

https://youtu.be/1eziF7t9CcE

Video: Misty

https://maketheconnection.net/ U.S. Department of Veteran’s Affairs

Last summer she self-discontinued her sleep medication, and had poor outcomes.

Misty presents asking to discontinue her sleep medications.

What are some major discussion points?

Case Study

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- Richard Chefetz, 2015, p.131

“Avoiding responding has potential serious negative

consequences in a repetition of past neglect or dismissiveness”

Mind-Body Connections in Trauma

bio psycho social

(Mintz & Belknap, 2011; Karp, 2006)

Placebo and Nocebo

expectation

misattribution

learning

(Hodgkins, et al, 2018; Webster, Weinman, & Rubin, 2016)

Trauma & treatment resistance:

Trust & relationship

Meaning of Medication

“…symptoms serve many functions: to substitute for missing memories, to communicate distress, to

symbolize crucial relationships, to contain internal conflicts, to manage interpersonal issues.”

(Lowenstein & Goodwin, 1999, p.83)

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Medication in Trauma

numb

stigma

body

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Medication in Trauma

ritual

control

avoid

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Medication in Trauma

sleep

anxiety

mood appetite

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Exercise 1: Pick a Problem

Weight gain/ loss Bruising at injection site

Sexual side effects Swallowing liquids

Tremor Changes to libido

Nausea Jittery

Headaches Dreams more vivid

Can’t swallow Cognitive dulling

“Against medication” Shortness of breath

Sensations in mouth “Feel controlled”

Shape of pills Insomnia

Color of pills/liquid Sedation

Under-and-Over-Prescribing

Threading the needle (Davies & Frawley, 1994)

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Irrational Pharmacology

Cognitive challenges

Accentuated power

dynamics

Comorbidity

Self-care deficits

Impacts on Prescribing

(Karlamangla, Tinetti, Guralnik et al., 2007; Kessler, Sonnega, Bromet, Hughes & Nelson, 1995; Resnick, Acierno & Kilpatrick, 1997)

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Exercise 2 (Leonard, Graham, & Bonacum, 2004)

Situation

Background

Assessment

Recommendation/ Request

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Deprescribing Model:

Review medications

Identify targets

Plan a regimen together

Communicate

Frequent review and support

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(Gupta & Cahill, 2016, p.2)

•Universal precautions

•Maximize choices & control

•Collaborate on treatment & recovery

•Safety, respect, & acceptance

•Minimize retraumatization

Trauma-Informed Care:

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(Anai-Otong, 2016)

(Anai-Otong, 2016)

(Gupta & Cahill, 2016, p.2)

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Trauma Informed Medication Education

Review medications

• Universal precautions

Identify target medications

• Collaborate on treatment & recovery

• Maximize choices & control

Plan a regimen

• Communicate

• Frequent review and support

• Safety, respect, & acceptance

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Examples of Communication

expectations

practicalities

treatment interfering

communication

Examples

Review

Ask about specific side-effects

Identify Targets

Assess for stockpiling, agreement with regimen

Offer Reminders or Cues

Printouts, med organizers, set alarms together, post-its

Frequent review

& support

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Examples

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Key Points Medications have meaning

Assess for meaning at every opportunity

Historical trauma beliefs may be guiding current behavior

Mis-taking medications often important ways of coping

Make the medication contract explicit

Discuss a harm-reduction plan

Questions?

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References

Antai-Otong, D. (2016). Caring for trauma survivors. The Nursing Clinics of North America, 51(2), 323–333.

Boulanger, G. (2018). When is vicarious trauma a necessary therapeutic tool? Psychoanalytic Psychiatry, 35(1),

60-69.

Chefetz, R. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. NYC, NY: W.W.

Norton & Co.

Cohen, K., & Collens, P. (2013). The impact of trauma work on trauma workers: A metasynthesis on

vicarious trauma and vicarious posttraumatic growth. Psychological Trauma: Theory, Research, Practice and Policy,

5(6), 570-580.

Elwyn, G., Dominick Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E.,

Tomson, D., Dodd, C., Rollnick, S., Adrian Edwards, A., & Michael Barry, M. (2012). Shared decision

making: A model for clinical practice. Journal of General Internal Medicine, 27(10):1361–7.

Gupta, S., & Cahill, J. D. (2016). A prescription for “deprescribing” in psychiatry. Psychiatric Services , 67(8),

904–907.

Davies, J.M., & Frawley, M.G. (1994). Treating the adult survivor of childhood sexual abuse: A psychoanalytic

perspective. NYC, NY: Basic Books.

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References

Groopman, J. (2007, October). What’s the trouble? How doctors think. The New Yorker. Retrieved from

https://www.newyorker.com/magazine/2007/01/29/whats-the-trouble on November 2, 2018.

Hodgkins, G.E., Blommel, J.G., Dunlop, B.W., Iosifescu, D., Mathew, S.J., Neylan, T.C., Mayberg, H.S., &

Harvey, P.D. (2018). Placebo effects across self-report, clinician rating, and objective performance tasks

among women with Post-Traumatic Stress Disorder: Investigation of placebo response in a

pharmacological treatment study of Post-Traumatic Stress Disorder. Journal of Clinical Psychopharmacology,

38, 200-206.

Karlamangla, A., Tinetti, M., Guralnik, J., Studenski, S., Wetle, T., & Reuben, D. (2007). Comorbidity in

older adults: nosology of impairment, diseases, and conditions. The Journals of Gerontology. Series A, Biological

Sciences and Medical Sciences, 62(3), 296–300.

Karp, D. (2006). Is it me or my meds? Cambridge, MA: Harvard University Press.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder

in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060.

Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective

teamwork and communication in providing safe care. Quality and Safety in Health Care, (13)suppl 1, i85-i90.

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References

Mintz, D. & Belnap, B.A. (2011). What is psychodynamic psychopharmacology? An approach to

pharmacological treatment resistance in Eric M. Plakun, (Ed.), Treatment resistance and patient authority:

The Austen Riggs reader (pp. 42-65). NYC, NY: W.W. Norton & Co.

Resnick, H..S., Acierno, R., & Kilpatrick, D.G. (1997). Health impact of interpersonal violence 2: Medical

and mental health outcomes. Behavioral Medicine , 23(2), 65–78.

U.S. Department of Veteran’s Affairs. (n.d.) Misty found healing for MST in a women's group. Retrieved

from https://maketheconnection.net/stories/642 on August 10, 2018.

Webster, R.K., Weinman, J. & Rubin, G.J. (2016). A Systematic review of factors that contribute to nocebo

effects. Health Psychology, 35(12), 1334-1355.