Using Principles of Trauma-Informed Care to Address Structural Racism in Psychiatric Care
In early 2020, Mr. A, a middle-aged Black man, presented for an intake appointment with his court-assigned outpatient psychiatrist, Dr. B, a White woman specializing in public psychiatry. Mr. A was involved in a robbery while intoxicated several months prior and was found not guilty by reason of mental disease or defect. As part of his terms of release, he was mandated to receive psychiatric treatment in the community and was connected with Dr. B upon discharge. Mr. A’s discharge summary from the Department of Corrections indicated that he had major depressive disorder, severe alcohol and cocaine use disorder, and antisocial personality disorder. The report indicated that Mr. A was physically abused and neglected as a child, but did not specify whether he met criteria for posttraumatic stress disorder (PTSD).
As Dr. B began treating Mr. A, he was reserved and disengaged. He frequently offered brief answers such as “Everything’s fine.” Dr. B recognized his initial guardedness because it was similar to that of her other patients who received court-mandated treatment. Given his legal status, he was required to attend all appointments, take all medications as prescribed, and submit urine or blood for drug tests, which could be included in Dr. B’s quarterly reports to the court. She suspected it would take time to gain his trust. His urine drug screens came back diluted, so she couldn’t assess whether he used substances during their outpatient treatment.
Despite these limitations, Dr. B used trauma-informed care principles to gently establish rapport with her patient. She focused on building an alliance with him whenever possible. When Mr. A alluded to past trauma, Dr. B stayed present-focused to nurture his trust and resist retraumatization. She focused on Mr. A’s present psychological state, his physical well-being, his response to medications, and whether he experienced side effects. She expressed curiosity when he shared details of his life. He walked with a limp and she inquired about it and expressed concern for his chronic pain.
Mr. A opened up about an assault that occurred several years earlier when he got into a dispute over money he owed for drugs. He was subsequently fearful and hypervigilant and avoided going out. She moved slowly, acknowledging his distress whenever possible, and being aware of trauma symptoms when they arose within the session or afterward. Initially, she focused on containing his symptoms rather than exploring the incident.
In the spring of 2020, given the regulations limiting in-person visits during the COVID-19 pandemic, their sessions continued by telephone, and Mr. A opened up more about his childhood. Dr. B suspected that he was able to share more now that they were no longer face-to-face, as she’d heard colleagues describe similar experiences. Mr. A’s mother was mentally ill and used substances when Mr. A was a child. She would leave the children home alone for days at a time without food. Mr. A remembered feeling bewildered as he waited for his mother to return. Strangers stayed in the house while his mother was away and occasionally were physically violent with the children.
Dr. B diagnosed Mr. A with posttraumatic stress disorder. She helped him understand that the distress he experienced on a daily basis was in part due to traumatic experiences as a child and more recently in his neighborhood. They explored how much of Mr. A’s substance use stemmed from an attempt to manage the intense flashbacks and dysregulation associated with the trauma. Dr. B suggested that Mr. A was more sensitive to quarantining in his apartment because it was reminiscent of being left home alone as a child. This point resonated with Mr. A.
As Dr. B learned more about Mr. A’s childhood, she saw how the early trauma had an impact on his behavior patterns and his tendencies in relationships. He routinely gave away clothes, money, and food. Dr. B speculated that Mr. A may be trying to keep people from leaving him and repeating the cycle of abandonment he experienced as a child. Dr. B gently made observations such as, “It seems like someone else’s needs often come before your own.” In those moments, he would pause and then say, “I have to think about that.” For a period of time, Mr. A improved. He sounded brighter on their calls together, and he terminated an unhealthy romantic relationship.
In the summer of 2020, 6 months after Mr. A began treatment, Dr. B noticed that he was slurring his words on their calls together. Eventually Mr. A stopped attending appointments altogether. He eventually returned to care for several sessions, during which Dr. B encouraged him to be transparent about his substance use so they could explore it together. After working with Dr. B for several more weeks, Mr. A left treatment again.
In the case described here, Dr. B used a trauma-informed care approach to help Mr. A understand his history of trauma and its impact on his current mental health. Trauma-informed care emerged from a need to consider what happened to a person in the past. What if we zoomed out further and considered how systemic racism affected a patient throughout their life? What if we used trauma-informed care principles to guide our systemic interventions to address structural racism’s impacts on our individual patients?
Dr. B provided trauma-informed care at the individual level, as she had been trained to do, yet her harm-reduction approach also contradicted the punitive ethos of court-mandated treatment. She worked within a system where her patient had little autonomy. Despite this, Dr. B was able to build an alliance with Mr. A in which he gained an understanding of himself and his symptoms. Her individualized approach helped situate his substance use within a lifelong history of trauma. How can we widen the lens further and understand his substance use through a structural lens? What would a structural approach look like and what would it mean for Mr. A’s recovery?
Just as we are trained to take a family history or assess early childhood experiences, we also have to consider our patients’ encounters with various inequitable structures. Mr. A’s experiences of trauma were individual and specific to him, but they were tied to the structures he interacted with. If his childhood neglect is the tip of the iceberg, then policies and institutions that overdetermined his neglect—the lack of support for his mother, the lack of institutional protections for him as a child—are the remainder of the iceberg submerged in the water (1). A traumatic experience such as an assault, for example, occurs to an individual, but the drivers of this event are rooted in neighborhood or community-wide policies. As Metzl and Hansen suggest (2), in order to understand illness, we must understand the upstream structural forces acting on our patients.
Mr. A was raised in South Bronx in the 1970s, a time of major demographic change in the city. In the 1970s and 1980s, city officials and developers actively sought to clear Black and Latino neighborhoods of inhabitants by divesting resources from those areas (3). Fire stations were closed, which contributed to 40% of the housing stock in the South Bronx burning down and giving way to mass displacement of residents (3). This was followed by South Bronx reporting the highest cumulative drug deaths per capita of any New York City borough and an uptick in psychological trauma and PTSD symptoms (4, 5). In Mr. A’s case, the tip of the iceberg was his mother’s substance use and neglect; underlying that was the breakdown of social networks and mental health sequelae across the community—a shift that was not due to individual choices but to systemic racism and divestment from communities of color.
After the age of 7, when Mr. A was removed from his mother, he was absorbed into the foster care system. Such family separation is a form of trauma with structural inequities, demonstrated by the fact that Black children are two to three times more likely to be removed from their parents than White children (6, 7). Mr. A’s mother needed the very structures of support and community health care that had been divested from her neighborhood.
We recommend presenting this structural assessment of the patient to the entire team when discussing his substance use and potential relapses. This discussion can help the entire clinical team caring for this patient to situate the neighborhood breakdown and crack epidemic within the trajectory of Mr. A’s substance use and criminal record. Next, Dr. B and her staff must have a framework for counteracting the systemic impacts of trauma in their patient.
Trauma-informed care principles can guide a systemic analysis of the impact of structural racism on our patients because they indicate that the environment around the patient must change to enable healing. The six principles of trauma-informed care at the individual level are safety, trustworthiness, transparency, empowerment, collaboration, and peer support (8). We suggest that during rounds, practitioners go through each principle and consider how they can leverage a system-wide change in order to advance each principle.
When the team meets, they can first focus on initiatives to increase a sense of safety for Mr. A. They can begin by getting a sense of where Mr. A feels safe, and then build this into his treatment plan. Is it a garden he connects to? A spiritual group? Classes? If Mr. A has constantly experienced a fracturing of family and community, how can the clinic help to restore a sense of continuity? They could connect him with a place such as Baltic Street, in Brooklyn, which partners with people with a lived experience of mental illness and connects them to housing assistance or skills training (9).
To improve trustworthiness, the clinic could consider locating treatment within trusted organizations within the community, with staff and clinicians from that community. For example, one collaborative group of religious leaders and mental health professionals in New Haven, Conn., launched a program called the Black Church Project to locate substance use treatment in Black and Latino churches, provided by clinicians and people with lived experience of substance use (10). The clinic may connect Mr. A with programs that help formerly incarcerated people build a life and network (11). Connecting with others who have been incarcerated could help Mr. A gain a consciousness about the systems he’s been embedded in and learn to push back against them. To increase a sense of transparency, the team can become curious about how much their patient understands of the court-mandated nature of their treatment. They could partner with organizations run by people with lived experience of psychiatric diagnosis, and have a democratized structure to draw people in.
We need to make an effortful shift beyond putting the blame on the individual and instead draw attention to the system and neighborhood-level factors that acted on the patient. To improve outcomes for patients like Mr. A, clinician practitioners can be trained to see and intervene in structural drivers of health through collaboration with patients, community organizations, institutions, and ultimately with policy makers, using approaches such as structural competency.
Dr. B made tremendous strides in building rapport with Mr. A despite the structures working against them. However, Dr. B was also operating within a system where she was confined to using medications to treat her patients and urine drug tests to track their progress. Mr. A was court-ordered to this treatment within a context where city policies had acted to deprive him of neighborhood and community support that he needed to thrive. His substance use emerged within a crack epidemic targeting his neighborhood. Dr. B optimized the tools that she was trained to use to help him recover.
A combination of factors contributed to Mr. A’s psychiatric illness, substance use, and illegal behavior, including trauma at the individual level, and structural racism at the community and institutional level. Therefore, it will also require a combination of factors at the individual, community, and institutional levels to foster his recovery.
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