Trauma-Informed Care in Addiction Treatment

0:00:16 William Moyers
Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to us, the issues that we know matter to you, too. Substance use prevention, research, treatment of addiction and recovery management, as well as education and advocacy. I'm your host, William Moyers, and today my guest is my colleague Dr. Kristen Schmidt, an addiction psychiatrist at Hazelden Betty Ford in Minnesota. Welcome, doctor.

0:00:44 Dr. Kristen Schmidt
Thank you.

0:00:45 William Moyers
You are an expert when it comes to all things addiction. How did you get into the field of addiction medicine?

0:00:52 Dr. Kristen Schmidt
Yeah, so I'm actually in recovery. So I have now twelve years in recovery.

0:00:56 William Moyers
Congratulations.

0:00:58 Dr. Kristen Schmidt
And yeah, thank you. That's the reason I actually went to medical school. I put it right there on my admissions essay. And you know continued on with residency and then fellowship and addiction psychiatry.

0:01:12 William Moyers
And how does that work when you're actually seeing patients?

0:01:14 Dr. Kristen Schmidt
So, you know, we're always supposed to do everything in the best interest of the patient. So, in terms of my own disclosure—

0:01:22 William Moyers
Mmm-hmm.

0:01:23 Dr. Kristen Schmidt
I try and make sure that the reasons I'm disclosing my recovery is really for the patient rather than for myself. I do find specifically with females that it can be very positive. Them knowing that there's a female out there in recovery who's been able to achieve after becoming sober. I think it goes a long way.

0:01:49 William Moyers
We have seen this evolution of awareness around the role that trauma plays both in addiction and how we treat addiction. Talk to us about the role that trauma plays in addiction.

0:02:01 Dr. Kristen Schmidt
Yeah so trauma can be defined a lot of different ways. And I think sometimes it's a trap when we get too caught up into specific criteria especially as psychiatrists. A simple definition is trauma is really an event that has an effect on somebody psychologically, spiritually, emotionally, where they have experienced some kind of threat, some kind of harm. I see patients all of the time almost minimize their trauma because they don't feel that it's big enough to warrant them even discussing about it. And I think that is a piece of the shame that comes along with the trauma—

0:02:44 William Moyers
Mmm-hmm.

0:02:46 Dr. Kristen Schmidt
And the concealment and so, I really try and advocate for my patients that whatever has affected them is of import and they need to talk about it.

0:02:58 William Moyers
The correlation between trauma and a substance use disorder is off the charts.

0:03:02 Dr. Kristen Schmidt
Oh yeah.

0:03:02 William Moyers
Does everybody who has a substance use disorder also have some sort of traumatic experience in their background that contributed to it?

0:03:10 Dr. Kristen Schmidt
Well what we know is the CDC has basically put out some statistics in the general population. So we know that one out of four children suffers from some kind of an abuse. Physical, sexual, emotional.

0:03:24 William Moyers
And that's a trauma?

0:03:25 Dr. Kristen Schmidt
That's a trauma. We know that one in four women has suffered from domestic violence. And we know that one in five women has had some kind of sexual assault or rape. And that's in the general population.

0:03:38 William Moyers
Hmm.

0:03:39 Dr. Kristen Schmidt
So when I'm seeing patients in a substance use setting, I would say that nearly 75 percent and that would be a modest estimate have suffered some kind of a trauma of the sort that the CDC has talked about. So physical, sexual, emotional abuse. There are other sorts of traumas that my patients have suffered. So, recently just yesterday, I had a patient talk to me about the fact that they found out that they had a half-brother that they never knew about. And how that that had significantly impacted them because the world as they knew it—and this was a 50-year-old man—but the world as he knew it had changed. And it was different. And that's the piece about trauma. There's something about trauma that changes the nature of your expectations. And that's why it's so impactful for our patients.

0:04:35 William Moyers
And it can happen decades ago as a child or it can happen as you said in a 50-year-old man who's a—who's just recently learned of something that he didn't know before.

0:04:45 Dr. Kristen Schmidt
Absolutely.

0:04:46 William Moyers
So you have this remarkable incident 75 percent you said roughly in a treatment setting at Hazelden Betty Ford that have had a traumatic experience. How do you incorporate that reality, that truth, into the treatment of a patient?

0:05:02 Dr. Kristen Schmidt
Yeah. It's a good question. So one of the things we try to do most is not re-traumatize the patient. So, that is one of the biggest efforts in a trauma-informed approach. Is really realizing that the majority of your patients are going to have experienced trauma. Recognizing what those symptoms and signs look like, so things like numbing, things like hypervigilance or hyperarousal, and then really reacting and responding to that and not re-traumatizing people. So, we know substance users tend to try and avoid the hospital, avoid treatment settings, and there's a variety of reasons and some of those are because they don't wanna be re-traumatized. So in a treatment center, what we do or an example of this is really even looking at detox. So, back in the day they used to just send substance using patients to centers and use a behavioral modification approach that we'll just let you seize from your alcohol withdrawal or your Benzodiazepine withdrawal. We don't do that anymore. Because it's a—it's a trauma and it's actually life-threatening.

0:06:15 Dr. Kristen Schmidt
[continued]
Another thing that we're careful about is you know our lab draws. So we have heroin addicts, meth addicts, who, you know, triggering anytime you get a lab draw and you're drawing from that vein, it's a major triggering event. So what I try and do is be mindful of that. We want phlebotomists that know what they're doing. I was actually at a treatment center and there was a phlebotomist that you know was consistently almost blaming my patients that their veins weren't good or they weren't hydrated enough and I made sure that we got a different phlebotomist because that's a really triggering thing for a patient. In psychiatry residency, I remember sitting with a patient as she got a blood draw because she was scared. And that's another thing, you know? I have patients who've been using IV drugs and then, they think it's silly to admit that they're actually afraid of needles, right? But there are a lot of people who are. And who are using IV drugs. So, one of the things I did was I actually just sat with the patient. She wanted me to be there when she got her blood draw. And that's what I did as a physician, that was the best thing I could have done. And so it's really incorporating measures like that in our care that you know is a cornerstone of trauma-informed approach.

0:07:41 William Moyers
Is there a role for trauma group in a treatment setting where patients can come together to talk about their trauma? Or is that not a good idea?

0:07:50 Dr. Kristen Schmidt
No that's a—that's a very good idea. So, one of the principles of trauma care is actually peer support and peer recovery. So, having a place where the experience, even though it's individual, there's still a universal sense—

0:08:07 William Moyers
Ahh.

0:08:08 Dr. Kristen Schmidt
That, you know, we are all weak, we are all human beings and things have happened to us. And being able to have a space to talk about that that's safe—

0:08:17 William Moyers
Mmm-hmm. Mmm-hmm.

0:08:19 Dr. Kristen Schmidt
—Is really important for our patients. And that we have several trauma groups in our treatment centers as a result.

0:08:26 William Moyers
Talk more about that safety strength and worth that are key to trauma-informed care.

0:08:31 Dr. Kristen Schmidt
Right. So one of the things about trauma is really this adverse power differential. So, people who have experienced trauma whether it's a tornado, whether it's a sexual abuse, there's been a power differential where that—that person feels that they have no control. So one of the best things we can do is to give our patients a voice and empower them.

0:08:56 William Moyers
Mmm.

0:08:57 Dr. Kristen Schmidt
When I'm doing an interview, I'm not even doing a physical exam, but even when I'm asking questions, those can be just as invasive as a physical exam. And it's asking your patient permission and it's letting the patient lead you when they're talking about their traumatic experiences. And it's—it's trying to make sure that you're not re-traumatizing a patient by having them discuss it time and time again when they're not ready.

0:09:25 William Moyers
Interesting. So you've gotta be able to address it. The patient has to be able to talk about it, but you have to be careful about the frequency in which you do it or the environment in which you do it.

0:09:36 Dr. Kristen Schmidt
Correct. Absolutely.

0:09:37 William Moyers
But not everybody who's had trauma is necessarily gonna end up with a substance use disorder, correct?

0:09:42 Dr. Kristen Schmidt
Mmm-hmm. Mmm-hmm. And not everyone who's experienced trauma is going to end up with a stress reaction to it. So just like we don't know the real piece in recovery as to why do some people recover and why do others not recover, right?

0:09:59 William Moyers
Right, right.

0:10:01 Dr. Kristen Schmidt
It's the same thing with trauma. We don't understand why there are some people who are able to withstand the most horrendous things. The things that I have heard as a psychiatrist. And—and they're resilient. And they it seems not to have affected them in the way that it might affect somebody else. We don't have the answer to that. But what we know is that the patients we see are very resilient because they're still there. So I, you know, often times people will ask me how do you—how do you do it? Right?

0:10:40 William Moyers
Yeah. Yeah.

0:10:40 Dr. Kristen Schmidt
How do you go in day in and day out and hear these stories? And for me, I can focus on these traumatic events. And these awful things that have happened to people. Or I can look at them and understand that they're sitting in my office and they're survivors. So, I try and focus on the resilience and I try and shore up the strengths in my patient and help continue to empower them as they continue their journey.

0:11:08 William Moyers
What about trauma that occurs later on, after treatment? To say the patient comes to you, they're treated, they're successfully treated, they leave treatment and six weeks later, they're home is destroyed by a tornado. Or a year later, they're involved in a mass shooting. What is the role that trauma plays in recovery post-treatment and how should people who have experienced trauma be aware of it and deal with it?

0:11:34 Dr. Kristen Schmidt
Yeah. It's a wonderful question. So, any kind of post-treatment trauma is going to be a huge trigger for relapse. We know that even fights, even something as simple as a domestic, you know, dispute—verbal dispute—can trigger people to relapse. So, if there is a trauma what happens biologically is suddenly their cortisol and their stress response kicks in and you have this hyperarousal, hypervigilance, and what we know is that can lead people to relapse to substances to try and calm that neurocircuitry down. So it's so important for patients. Just like I advocate if they're going to get a surgery, that they need to be very mindful if some event like that happens, they need to call their sponsor. They need to reach out to the people in their community that know them and they need to make sure that their sobriety is protected and they get help for that trauma.

0:12:35 William Moyers
Or they may need to go even a step further and go see a professional.

0:12:39 Dr. Kristen Schmidt
Absolutely.

0:12:40 William Moyers
So how does that work? Would it be your counsel to an alum of Hazelden Betty Ford, for example, to make sure they disclose to a therapist or to an addiction psychiatrist that they've had a history of addiction in their lives? When they're going back to get some more care for trauma?

0:13:00 Dr. Kristen Schmidt
Oh, absolutely. It's so important that the patient brings that information to their treatment provider so that we're completely aware of what the story is. I've had lots of patients say to me that, you know, what they love about recovery is that they finally get to have a free flow of communication with their providers.

0:13:23 William Moyers
Mmm-hmm.

0:13:23 Dr. Kristen Schmidt
Because they've always been hiding, right?

0:13:24 William Moyers
Of course! Right! [chuckles]

0:13:25 Dr. Kristen Schmidt
They've been hiding that thing. So, the same goes if there is a traumatic experience. I mean, the sobriety and the history of addiction needs to be on the table so that, you know, the patient is safeguarded against relapse and, you know, so are their loved ones.

0:13:44 William Moyers
We have about two minutes left. I wanted to ask you before we close what is the role of medical professionals in trauma? Not everybody has that level of experience that you have. Pediatricians or gynecologists or gerontologists—what should they know about trauma as it relates to how it might present itself in their own patients and what should they do about it?

0:14:10 Dr. Kristen Schmidt
Right. So, the most important thing they can do is ask the patient if they had any experience that might impact their care. They need to again ask for permission, they need to explain what they're doing. So if they wanna do an exam or they need to do a lab draw, they need to explain what the rationale is. And they should ask the patient to be a collaborator in their care and ask them, you know, what is the most comfortable way that we can do this? Because again, the goal is not to have the patient avoid care. It's actually to have the patient access the care more fully.

0:14:56 William Moyers
Dr. Kristen Schmidt, thank you for bringing your remarkable medical expertise to our listeners and our viewers today. And thank you for sharing and disclosing a little bit of your own experience that is obviously apparent in the work that you do as an addiction psychiatrist for the Hazelden Betty Ford Foundation in Minnesota. Thank you very much for joining us today.

0:15:15 Dr. Kristen Schmidt
Absolutely.

0:15:16 William Moyers
I'm your host William Moyers and on behalf of our Executive Producer Lisa Stangl and all of us at Hazelden Betty Ford, we thank you for joining us for another edition of Let's Talk. And we'll see you another time.