Society and Culture Health And Wellness

Trauma Informed Care

TIC’s place in pharmacy for better Indigenous health care

  • Dr. Gezina Baehr
  • 21 June 2021

Originally published in the Winter 2020 The Mortar & Pestle magazine.

Canada’s colonial history has caused deep historical and intergenerational trauma in its Indigenous communities across the country. Colonial practices – like residential schools, which saw an estimated 150,000 Indigenous children forcibly removed from their homes and families to assimilate to European practices and religion – caused massive group trauma. Even though the last residential school closed in 1996, the generational repercussions are immense.

Today, Trauma Informed Care (TIC) or Trauma Informed Practice (TIP) is gaining popularity in healthcare – especially in serving vulnerable populations. The British Columbia TIP Guide defines historical or intergenerational trauma faced by our Indigenous communities as “cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma, such as residential schools”. In response to the traumas, coping and adaptation patterns are developed and passed from one generation to the next.

Understanding Canada’s colonial history means we need to be mindful that Indigenous peoples have experienced this historical trauma and act accordingly. As health care professionals, we have a responsibility to care for our patients in the best way possible. This includes educating ourselves on Indigenous history, practicing empathy, and learning better ways to treat diverse populations. Though this article only skims the surface of the essential skills of TIC, I invite you to learn more, access the resources provided to deepen your understanding, and continue implementing these skills in your practice.

What you can do.

Be Trauma Aware: TIC begins with an awareness of trauma and a realization that pharmacists have a potential to ease or exacerbate a person’s capacity to cope with trauma.

  • Action: Be aware of the commonness of trauma; how the impact of trauma can be central to one’s development; the maladaptations people make to cope and survive trauma and the relationship with substance use, physical health and mental health. Be culturally aware of the devastating impacts of residential schools, where Indigenous children were subject to loss of family, language, culture and exposed to ritualized abuse, including neglect, physical and sexual. Parents and other community members also dealt with the trauma from the incredible loss of their children.

Safety and Trustworthiness: Safety, including physical, emotional and cultural, is central to TIC, as trauma survivors often feel unsafe, are likely to have experienced abuse of power in important relationships, and may be in currently unsafe relationships or environments.

  • Action: Establish safety and trustworthiness by adapting the pharmacy space to be less threatening; ensuring informed consent; explaining why you are asking sensitive questions; demonstrating predictable expectations; and being consistently empathetic towards your patients.

Choice, Collaboration and Connection: Safe environments foster a sense of self-determination, dignity, and personal control for those receiving care. The goal is to level the power differential between pharmacist and patient and create a meaningful sharing of power and decision-making.

  • Action: Foster collaboration by communicating openly and using open-ended questions so patients can tell their story in their own words. Allow the expression of feelings without fear of judgement, provide choices regarding treatment preferences, and work collaboratively with patients. Use a shared decision-making model and goal-setting with the patient to determine the plan of action they need to heal and move forward. If someone refuses a medication or test, or if they are upset about something (like vaccinations), respond with compassion and work with them – do not attempt to force them or become annoyed. Put effort into understanding the ways in which Indigenous peoples’ choice and voice have historically been diminished and were often recipients of coercive treatment, such as with Indian hospitals.

Empowerment and Strengths Focused: Focus on individual’s strengths and experiences. In TIC, there is an inherent belief in the importance of serving people, in their resilience, and their ability to heal from trauma. Pharmacists should act as facilitators of health and recovery, instead of controllers of it.

  • Action: Motivational interviewing, a technique to elicit behavioural change, is a great way to empower patients in making behavioural/medical changes. Affirming your patients acknowledges their effort and strengths, offers appreciation and understanding, and recognizes success. You can affirm patients on medication adherence despite challenges, for their prioritization of their health when they are making health decisions with you, or a patient’s tendency to be doubtful of medications as a sign of trying to be health literate on what they are taking. There are many ways to affirm your patients.

What you can avoid.

Fixing Someone: Avoid the attitude of wanting to “fix someone”. This is disempowering to the patient and can be overwhelming for both of you. Realistically, these problems are bigger than you, and you can only do so much. See Principle 4.

Experts Only Attitude: Acting only as “the expert” loses pharmacist-patient collaboration. Rigidity forms when there is a belief that there is a “right” way for people to recover. Remember that information alone does not always cause change. See Principle 3.

Vicarious/Second-Hand Trauma: Be aware that working in a space with vulnerable populations can create something called vicarious or second-hand trauma in staff, as well as burnout. Whether or not you have experienced trauma yourself, vicarious trauma or burnout can be triggered by patient responses and behaviours. Therefore, a key part of TIC includes resources for pharmacist self-care. A TIC approach seeks to resist the re-traumatization of staff, as well as patients.

Indigenous peoples have experienced a lot of trauma over generations. Making healthcare a safer place, where it has traditionally failed, is a major step towards reconciliation. Trauma Informed Care expands beyond Indigenous peoples as well, into traumas faced by death of loved ones, displacement, homo or transphobia, sexism, and racism. Therefore, every healthcare professional can do their part to become more trauma informed when dealing with their patients. Be aware of trauma, make a safe and trustworthy space for patients, collaborate with your patients to give them choice in their care and empower them to make those decisions. Readers have already taken the first steps to becoming trauma informed in their practices.

Reading List

How you can learn more.

Please be encouraged to take the time to seek out these resources, listed from shortest to longest read. They can help you learn more about Trauma Informed Care, Indigenous History, and better your patient care.

About the Author

Dr. Gezina Baehr (PharmD 2020) is a recent Faculty of Pharmacy and Pharmaceutical Sciences alumna. She is passionate about advocating for the betterment of Indigenous health in Canada and reclaiming Indigeneity in healthcare settings.



Footnotes
1,3,5 British Columbia Provincial Mental Health and Substance Use Planning Council; Trauma Informed Practice Guide; May, 2013; http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf
2,4 J.R Miller; Residential Schools in Canada; 10, October, 2012; updated 15, January, 2020; https://www.thecanadianencyclopedia.ca/en/article/residential-schools
6,7,8 SAMHSA’s Trauma and Justice Strategic Initiative; SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach; July, 2014; https://store.samhsa.gov/system/files/sma14-4884.pdf
9 Canadian Centre on Substance Abuse; Trauma-informed Care (The Essentials of…Series); 2014: https://www.ccsa.ca/trauma-informed-care-essentials-series
10 Nova Scotia Health Authority; Trauma-informed practice in different settings and with carious populations: A Discussion Guide for Health and Social Service Providers; March, 2015; https://novascotia.ca/dhw/addictions/documents/TIP_Discussion_Guide_3.pdf
11 Alberta Health Services; Trauma Informed Care; 2020; https://www.albertahealthservices.ca/info/Page15526.aspx
2 Venner, Feldstein & Tafoya; Native American Motivational Interviewing: Weaving Native American and Western Practices: A Manual for Counselors in Native American Communities; 2006; https://www.integration.samhsa.gov/clinical-practice/Native_American_MI_Manual.pdf