Most psychiatrists are trained to diagnose symptoms and treat patients with medication, psychotherapy, or a combination of both. Unfortunately, while we may have an appreciation of family, social, and cultural contexts, the understanding of these factors are not our strong suit. As physicians, we are focused on disease states and, unfortunately, are less familiar with issues of resiliency and strength- or asset-based approaches to patient care. In addition, we are less familiar with how protective factors minimize the impact of traumatic experiences.1 Psychiatrists need to understand how living in violent families and neighborhoods increases the likelihood of trauma and the psychiatric sequelae associated with it as well as how to respond in the aftermath.
Prevalence of exposure to trauma and violence
Because interpersonal violence is a major problem in the African American community, it is not surprising that children are frequently exposed to violence in their homes and in their communities.2,3 Several epidemiological studies have shown a high prevalence of exposure to trauma in a variety of cultural, racial, and ethnic groups as well in various socioeconomic classes.4-6 In addition, because the contexts of epidemiological studies are often radically different, my colleagues and I have always thought it was a good idea to study patients in our clinical practice.
Of the 330 patients currently being seen for medication monitoring at the Community Mental Health Council, 18 (5.5%) have extensive histories of childhood trauma.7,8 Our center provides mental health services to both high– and low–collective efficacy communities; it is clear that there are either higher rates of trauma in the low–collective efficacy community and/or there are fewer protective factors in that type of community.9 Compared with patients from the high–collective efficacy community, those from the low–collective efficacy community are more likely to have been exposed to violence, either as victim or as witness—or both.
Not only are members of communities that have low collective efficacy more likely to see violence, but also families that are isolated and that lack access to social supports are more likely to be under stress and the children to be traumatized. Trauma has the potential to result in a variety of psychiatric sequelae no matter where it comes from—the family or the community. Accordingly, clinical psychiatrists need to be facile in talking to patients about childhood trauma during the initial psychiatric evaluation.
? The article places a great deal of emphasis of getting a trauma history from all patients and reminds us of the victimization questions that were developed by Jacobson and Bell/Jenkins. Advice is provided on how to help persons who have been traumatized—by treating them as people, not as neurochemical machines.
? The information provided will help psychiatrists to be more responsive to issues of childhood trauma in adult patients. Although not all persons who experience childhood trauma automatically have a stress disorder as an adult, it is still important to include questions about childhood trauma when obtaining a history of an adult patient with a stress disorder.
Exploring childhood trauma in the initial psychiatric evaluation
Considering the prevalence of childhood and adult trauma, initial psychiatric evaluations should include a history of childhood and adult trauma but should take no longer than 30 minutes. Our experience is that childhood trauma histories are especially important in middle-aged women who have an early history of substance abuse or who present with generalized anxiety, panic attacks, and symptoms of depression.
The 30-minute investigation may need to be adjusted depending on the patient’s ability to relate his or her childhood and adult traumatic experiences (Sidebar). Wise and well-trained psychiatrists do not open “Pandora’s box” without knowing they can close it before the session is over, so the patient’s tolerance for these questions needs to be carefully gauged. You can always delve deeper in a future session—my experience is that the majority of patients tolerate these questions well and are relieved to finally meet someone who has enough compassion and courage to ask the questions in an empathetic manner.