TRAUMA INFORMED HEALTHCARE
Joy Lo, MD, FAAP
SAMHSA defines trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”1 What we are increasingly learning is that there is a strong tie between early trauma and a person’s overall long term health, including not only the emotional, psychological and mental, but also the physical. The adverse childhood experiences (ACEs) study has clearly illustrated this effect.2 For this reason, to fully care for a patient, we need to be aware that they may have had some level of trauma in their past life. Trauma-informed care takes this into account and changes the dialogue with a patient from “What’s wrong with you?” to “What happened to you?”3
The ACEs study was conducted at Kaiser Permanente from 1995-1997 and administered questionnaires to over 17,000, mostly white, individuals in California. The questionnaire asked about abuse and neglect, violence, substance abuse, mental illness, parental separation/divorce, and household member incarceration during an individual’s childhood, and assessed their correlation with adult mental and physical illness. The results are highly significant. ACEs are common across all populations. Almost 2/3 of participants reported at least one ACE, and 87% had more than 1. The more ACEs an individual reports, the worse the outcome in adulthood in terms of chronic disease, depression, suicide and/or violence.4
Trauma-informed care acknowledges that no matter a person’s socioeconomic status, race, age, gender, or ethnicity, they may have experienced trauma, which affects how they interact with the world, and affects how their bodies react. In order to be effective healthcare providers, we need to understand that there may be more than meets the eye. Trauma-informed care leads to better provider-patient relationships, health outcomes, and treatment adherence.
According to SAMHSA, the 4 key assumptions and principles of trauma-informed care are: Realize the widespread impact of trauma and understand its need to be addressed for healing; recognize the signs of trauma; respond by applying the principles of trauma-informed approach in all aspects of care; and resisting re-traumatization.
How do we accomplish this? Trauma-informed care can be applied to practically all walks of life, from medical care to behavioral health and social work, from schools to governmental institutions and public organizations. For those of us in the healthcare setting, an organizational buy-in will be critical for full implementation of caring holistically for our patients while being trauma-aware. Every person in the healthcare facility, from front desk and security to the heads of departments should be trained and aware. Universal screening for childhood trauma would be one step in the right direction.
From an individual standpoint, awareness is the first step. In addition, being aware of our own biases, experiences, and vulnerabilities is essential to our ability to stay mentally healthy while treating others with their trauma. Perhaps the 42-year-old female with diabetes, anxiety and chronic pain isn’t showing improvement partly because her past trauma has not been acknowledged, even by herself. Maybe the difficult young man who argues with everything and smokes marijuana daily needs a different approach. We are not all called to be therapists but acknowledging that a patient may have had traumatic experiences that shape the way they think and interact can help us see them more compassionately and patiently; also, acknowledging these past traumatic experiences can affect our patients’ physical health increases our likelihood of improving their overall health.
What does trauma-informed care look like in our busy practices? Creating a safe environment for both patients and staff is critical. Train clinical and non-clinical staff on the effects of trauma on the brain and in the body.5 Understand that listening can be healing, and that although healing from trauma can take time, it can lead to better health outcomes and better patient compliance. As health care providers we feel pressure to “fix” something; consider partnering with your patients and families to help come up with solutions. Communicate often and well. Don’t be afraid to ask about past trauma. Research has shown that providers are often not comfortable bringing up past trauma, but that a large percentage of patients would like to talk about their experiences. They are waiting for us to ask. Having a robust referral process is instrumental in this process. And always practice self-care.6
Some examples of trauma-informed practices in cases of sexual trauma/exploitation/trafficking are:
Interviewing your patient alone
Using a facility-approved interpreter if needed
Explaining the limits of confidentiality (e.g., as in mandatory reporting)
Establishing privacy and safety
Mirror their language
Active listening
Giving agency and control to your patient
Meeting their basic needs (food, clothing, etc.)
Asking questions on a need-to-know basis
Being non-judgmental; being open to unfamiliar narratives
Staying calm
Being culturally aware
Explaining each step, letting your patient control the pace of the exam
Explaining to your patient that they can say “no” to any part of the exam
Asking permission to touch them during the exam
Sitting at the same level of your patient or below them
Reassurance on the parts of the exam that are normal
When trauma-informed care is implemented into healthcare practices, everyone wins. To be sure, this is hard work, but will be paid off with better patient outcomes; stronger relationships amongst patients, their providers, and staff; and more thorough and holistic care of our patients – and ourselves.
References
Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. U.S. Department of Health and Human Services Publication No. (SMA) 14-4884. Rockville, Maryland.
https://acestoohigh.com/got-your-ace-score/
https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/
https://www.nationalcouncildocs.net/wp-content/uploads/2018/07/Trauma-Informed-Care-for-Primary-Care-Literature-Review.pdf
