This is a fictitious story but shows how the medical field recognizes trauma…treats trauma….
This does not cover trauma as a spiritual issue but for those who read this with spiritual eyes you will see the different kinds of trauma and can use this medical info to help people get set free.
Sora a 21-year-old, Japanese-American woman, is visiting a physician’s office for an initial appointment. The staff member at the front desk is taking a phone call when Sora arrives, and quickly hands her a clipboard of paperwork to fill out. Sora sits next to her friend in the crowded waiting room with chairs lined up against the perimeter of the room. She fills out the intake paperwork, detailing her family health history, her medical history, and her own health concerns, including experiencing GI symptoms, severe anxiety, migraines, and generalized muscle pain. All her symptoms contribute to missing work frequently and not spending a lot of time with friends.
A nurse calls her name, asks for her date of birth, and instructs her to go to room 3. The nurse asks her to take a seat on the exam table and begins to ask her questions about her presenting concerns, family health history, and previous medical history. Sora appears tense and avoids eye contact. The nurse then instructs Sora to change into a cotton robe so the physician can perform a physical exam, and then she leaves the room. After a few minutes of Sora’s being left alone, the physician enters the room, and asks Sora about her symptoms and previous medical history. Sora appears distracted and sits with her arms and legs tightly crossed. She is visibly tense during the physical exam and jerks away when he touches her.
Based on the physical and records from collateral examinations and tests, the physician informs her there is no reason she should be experiencing the muscle pain or GI symptoms. He prescribes an analgesic for her migraines, tells her to avoid dairy and gluten, and tells her to come back in a month.
Sora does not return for a second visit.
Effects of Trauma on Healthcare
Healthcare professionals increasingly are recognizing the long-term effects of trauma on health.1 Many traumatic events involve violations of a person’s body integrity, and experiencing trauma can affect general attitudes regarding medical care.2 As rates of trauma exposure in primary care patients are estimated to be between 65% and 88%, it is critical that healthcare professionals understand the relationship between trauma, adversity, and health. They also need to understand approaches to create clinical environments that are less traumatic for everyone, and promote recovery and healing through the services they provide.3,4 (Level A)
Beginning research has demonstrated that Trauma-Informed Care (TIC) has the potential to increase patient engagement in treatment and preventive care, improve the patient experience of care and health outcomes, as well as promote genuine healing.1,2,5 Trauma-informed approaches align with person-centered care to provide a framework for healthcare professionals to interact with patients and coworkers in a way that embodies safety, trustworthiness, choice, collaboration, and empowerment.4,6
What Is Trauma?
According to the American Psychiatric Association (APA), “trauma is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives. Psychologists can help these individuals find constructive ways of managing their emotions.”7 In 2012, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Trauma and Justice Strategic Initiative expanded the definition to include any event, series of events, or set of circumstances perceived by a person as harmful or threatening that also has lasting adverse effects on the person’s functioning and well-being.8 Conceptualizing trauma involves looking beyond just the event or circumstances that occurred. SAMHSA proposes three components of trauma: events and circumstances, experience, and effects.9
Events and circumstances. Trauma can be caused by a single event that is often referred to as acute or simple trauma, such as an assault or a bad car accident. When people experience multiple traumas during their life, or prolonged trauma, such as childhood neglect or domestic violence, it is referred to as complex trauma. Physical injuries, as well as sudden and unexpected health-related events such as a diagnosis of terminal cancer, can be associated with psychological trauma.5
Experience. In addition to the event or circumstances, a person’s perception and meaning-making of the experience ultimately determines whether it is traumatic or not. Everyone can be affected by trauma, regardless of race, ethnicity, age, and sex; however, the same event may be traumatic for one person, but not for another.5 Trauma overwhelms a person’s ability to cope and is usually associated with fear, helplessness, and vulnerability.5
Effects. Trauma is more than just one moment in time; it includes everything that happens afterward. Trauma can affect a person in a negative way behaviorally, emotionally, physically, socially, and/or spiritually. The effects of trauma may occur immediately after the traumatic incident or may be delayed, and they can be short-lived or long-term.
Acute Stress Disorder and PTSD
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the two primary diagnoses that relate to trauma are acute stress disorder (ASD) and PTSD.10 Both diagnoses require criterion A, which is “the exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways”:
- Directly experiencing the traumatic event(s)
- Witnessing, in person, the event(s) as it occurred to others
- Learning that the event(s) occurred to a close family member or close friend (cases of actual or threatened death must have been violent or accidental)
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
Additionally, the event(s) must affect the person in a certain number of symptom categories, such as intrusion, negative mood, dissociation, avoidance, and arousal.10 The primary difference between the two diagnoses is the time that has elapsed since the event. If symptoms are present in the time period immediately after the event until four weeks later, the person may be diagnosed with ASD. If symptoms persist for longer than a month, the person may be diagnosed with PTSD.
The majority of people who have experienced trauma do not get diagnosed with PTSD.11 Further, the criteria of PTSD does not match fully and account for the effects of complex trauma, and the literature reflects that the clinical presentation of complex trauma is more persistent and impairing.5,12,13 Patients may still have a trauma history, even if they do not have a diagnosis of ASD or PTSD.
Diagnostic criteria for PTSD also do not account for the intergenerational transmission of trauma within communities.14 There is increasing evidence that there are not only epigenetic changes resulting from experiencing trauma individually, but that those changes may also be transmitted across generations.15Historical trauma refers to complex trauma experienced collectively by people who share a group identity such as religious affiliation, nationality, and ethnicity, and the subsequent psychological, physical, and social effects across generations.14,16,17 Examples of groups affected by historical trauma are Holocaust survivors in Europe, Japanese Americans during World War II, and African Americans and indigenous populations throughout the history of the United States. These groups were subjected to massacres, concentration camps, slavery, violence, discrimination, and forced removal from their land and homes. While all of these occurrences were likely considered traumatic at the individual level for those who experienced them, research is beginning to show the clear effect they collectively have on health and identity over generations.14 An additional element of historical trauma is that contemporary members of the affected group can experience trauma-related symptoms, even if they themselves were not present for any of the past trauma(s).18 Patients and colleagues may experience trauma-related symptoms as a result of their affiliation with groups affected by historical trauma.
Adverse Childhood Experiences
The Centers for Disease Control and Prevention (CDC) and Kaiser Permanente collaborated in a large research study with more than 17,000 adult participants that looked at adverse childhood experiences (ACEs).19 Participants completed a physical examination, as well as a retrospective survey in which they were asked about 10 categories of adversity in their childhood: physical, sexual, and emotional abuse; physical and emotional neglect; growing up with a parent who was incarcerated, had a mental illness, or abused substances; growing up with a parent who was a victim of interpersonal violence; and having divorced parents.19 (Level B) Every adverse experience equals 1 point in an ACE score, with a minimum score of 0 and a maximum score of 10.
One study found that ACEs were very common, and almost two-thirds of participants reported having an ACE score of at least 1.19 Additionally, results of the study showed that as the ACE score went up, so did the risk of negative health outcomes such as:
- Severe obesity
- Physical inactivity
- Depressed mood
- Suicide attempts
- Alcohol and illicit drug use
- Chronic lung disease
- Liver disease
- Number of sexual partners and STIs
- Chronic bronchitis or emphysema
- Skeletal fractures
- Poor self-rated health
- Ischemic heart disease
- Premature mortality
Since the original ACEs study, subsequent literature has shown evidence of the dose-response relationship between childhood adversity and negative health outcomes. Various studies have found similar results looking at other categories of child adversity such as homelessness, growing up in poverty, and witnessing community violence.20 Although experiencing adversity does not necessarily mean the individual will find the experience traumatic, adverse events can be considered traumatic.
Adversity, Trauma, and Poor Health
Sora was sexually abused by her uncle from the time she was 5 until she was 10 years old, although she did not disclose this to the healthcare professionals. When she told her parents, they did not believe her, and her father secluded her in her room for “making up such a horrible story” about his brother. She never again talked to anyone about what happened to her. From Sora’s earliest memories, she can remember her mother as having depression and frequently drinking alcohol until she would black out. Sora’s parents divorced when she was a sophomore in high school.
Adverse or traumatic experiences in childhood are associated with the increased risk of unhealthy behaviors, disease, and disability.21 Additionally, studies have also demonstrated that both interpersonal violence and PTSD as adults have been correlated strongly with many of the same health outcomes as childhood trauma and adversity.4 Research continues to show that trauma and adversity are associated with an increased risk of being hospitalized with an autoimmune disorder such as rheumatoid arthritis, fibromyalgia, and chronic fatigue, as well as an increased risk of type II diabetes, and digestive, cardiac and neurological disorders, sleep problems, and cancer.22-26
Sora experienced headaches throughout middle and high school, managing them with an OTC analgesic. After her parents’ divorce, she started experiencing severe anxiety, and GI symptoms such as bloating, constipation/diarrhea, and abdominal pain. Sora also had increasing muscle aches and pains all over her body, and her headaches began turning into migraines. Her father brought her to various physicians and specialists, such as a neurologist, cardiologist, and gastroenterologist, and each time she was asked to talk about her presenting concerns and symptoms. All of her tests came back normal. With each visit, the physician informed her there was nothing wrong with her, and her father kept telling her that her symptoms were just in her head.
The relationship between adversity, trauma, and poor health is complex, but there is increasing evidence that experiencing trauma or adversity has a negative effect on brain circuitry and development, as well as on the sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis.2,13,20,27Complex trauma especially can cause both the sympathetic nervous system and HPA axis to become overactive, resulting in too much cortisol in the short term, which suppresses the immune system, and too little cortisol in the long term, leading to an unnecessarily prolonged inflammatory response.2,20
Sora’s experience of chronic pain and GI distress may have in part been caused by her chronically overactive stress-response systems. Further, having chronically elevated stress hormones is linked with memory and attention problems, sleep disorders, headaches, unexplained pain, and can also contribute to many long-term health issues previously discussed, depending on which body system is most vulnerable in any given individual.13 Brain studies have also shown evidence of the amygdala, hippocampus, and prefrontal cortex being particularly affected by experiencing trauma and adversity, with the amygdala typically being larger and overactive, and the latter two smaller and underactive.13,20
There is growing literature to support the idea that groups affected by historical trauma have a higher prevalence of disease and greater health disparities.14,15,18,28 For example, Native Americans living on reservations have higher mortality rates from tuberculosis, alcoholism, and diabetes, and experience a lower life expectancy than other groups in the United States.15 More research is needed to better understand the effects of historical trauma on health. As such, ramifications of experiencing trauma or adversity on the body are likely only a piece of the whole picture. Historical trauma is a type of complex trauma that occurs over generations. Those affected may experience chronic stress levels and additional adversity or trauma through discrimination and other social consequences of historical trauma, which may lead to the chronic activation of the body’s stress systems.15 There is also evidence of the physical effects of historical trauma being passed onto subsequent generations epigenetically through physiological adaptations, gene expression, and genetic mutation.15,28
Trauma and adversity can also affect an individual’s health by influencing behaviors in addition to an individual’s biology. Someone struggling with feelings of anxiety, depression, and difficulty trusting others as a result of their experiences may turn to unhealthy behaviors, such as smoking and drug use, overeating, and unprotected sex as a means of coping with their difficult feelings.2 Having a trauma history may affect medication adherence, as an individual may fear losing control, being aware of bodily sensations, or being numb as a result of taking their medication.2 Furthermore, experiencing trauma is associated with greater use of healthcare services, such as sick visits and emergency care, and avoidance of preventive medical care.2,25 Healthcare professionals need to be aware that various unhealthy behaviors and noncompliance may be related to an individual’s history, or an attempt to cope with history. Healthcare professionals who are aware of this will be better prepared to intervene, increase positive health outcomes, and help individuals heal.2,29
Individuals who have histories of trauma may experience interactions, protocols, and procedures as “triggering” because they replicate the dynamics of their experience.5 Retraumatization is any situation, environment, or interaction that mirrors an individual’s trauma either literally or symbolically and triggers difficult feelings and cognitions associated with the original experience.5,30 For example, a patient who was sexually abused may feel triggered when having her yearly gynecologist examination. However, interactions that are retraumatizing may not appear obvious, nor do they have to replicate the original trauma exactly.6,30 Protocols or interactions that mirror the dynamics of an individual’s trauma can be just as retraumatizing.
Individual experiences with trauma can be replicated in healthcare service delivery by feelings such as:30,32
- Being unseen/unheard
- Being blamed and shamed
- Being trapped
- Being controlled
- Being sexually violated
- Being unprotected
- Being threatened
- Being discredited
- “Crazy-making” (manipulative behavior)
The Connection Between Trauma and Retraumatization
When considering Sora’s history of trauma, adversity, and current symptoms, it is clear that some of the above trauma dynamics were mirrored by the healthcare professionals and system. This may have been a contributing factor to why she did not return for a follow-up appointment.
|Analysis of Sora’s Traumatic Experience and Recent Healthcare Visit|
|Trauma Dynamic||Sora’s Experience||Healthcare Visit|
|Parents did not believe Sora’s disclosure of sexual abuse.||Sora filled out intake paperwork and answered similar questions from both the nurse and physician about her concerns and history.
[Sora had to re-tell her story each time she saw a new physician/specialist.]
|Sexually violated||Sora was sexually abused by her uncle.||Sora was required to change into a cotton robe and was touched by the physician (male) performing the exam.|
|Isolated||Father sent her to her room by herself as a punishment for disclosing her abuse.||Sora is left alone in the small exam room while waiting for the physician.|
|Crazy-making; blamed and shamed||Sora’s father told her that her symptoms were “in her head.”||The physician says there is no reason for the majority of her symptoms because there is “nothing wrong with [her].”|
|Powerless; controlled||Sora was unable to prevent being sexually abused by her uncle.||The physician prescribes a painkiller, instructs her to avoid dairy and gluten, and to come back in a month without eliciting her input for treatment.|
Less apparent means of retraumatization can include specific smells or sounds, having relationships with healthcare professionals disrupted by a change in shift, and feeling that control of the patient’s well-being is in the hands of the healthcare professional.6,32 Messages that are implicit in communication of care delivery can also be retraumatizing.33 For example, disregarding a patient’s valid request can indicate “you don’t matter,” and telling a patient “no progress is expected” can prompt feelings of being defective and/or hopeless.33 Retraumatization is usually unintentional, but the potential to retraumatize patients exists in all systems and levels of care.
Patients who experience retraumatization often have exacerbated trauma-related and physical health symptoms, increased rates of self-injury, decreased willingness to engage in treatment, and a loss of trust in healthcare professionals.5,30,34
Medical care can often involve invasive, painful and/or frightening procedures, rendering treatment itself stressful or even traumatic for anyone.29 However, trauma survivors often report concerns about not having control, having their body exposed, feeling powerless, being alone with an unknown provider, being touched, and being unconscious while in medical settings.2 Therefore, procedures, policies, and interactions mirroring these concerns and trauma dynamics will likely be seen as retraumatizing. When healthcare professionals are not sensitive to trauma and the potential of retraumatization, patients may feel revictimized and be less likely to seek help from the healthcare system in the future.35
Had the healthcare professionals and systems that interacted with Sora been more aware of how their interactions and procedures could be retraumatizing, she may have returned for a second visit.
Trauma-Informed Care (TIC)
Trauma-Informed Care (TIC) is a framework that is patient-centered, acknowledges the broad effect trauma and adversity can have on individuals and has the goal of promoting healing and growth while actively preventing retraumatization.4,6 TIC requires a system-wide paradigm shift from thinking, “What is wrong with this person?” to “What has happened to this person?”6 Although TIC is a multifaceted approach, SAMHSA delineates the following key components of trauma-informed systems of care:9
Realization. All staff members have a basic understanding of trauma, how it can affect individuals and that it is integral to systems of care. Behaviors are understood in the context of a person’s experience and are seen as an attempt to cope.
Recognize. Professionals recognize the signs of trauma in both patients and other providers. Screening and assessment tools are used to help recognize trauma in patients.
Respond. The system applies TIC to all aspects of organizational functioning by making changes to language, interactions, policies, and procedures. The system is sensitive to the possibility that trauma affects everyone.
Resist retraumatization. Professionals and systems actively seek to prevent retraumatization by teaching staff how to recognize and address practices that are inadvertently retraumatizing to patients.
TIC does not require healthcare professionals to know if a person has a trauma history, but rather to change practices that are used with all patients and staff.2,29 As such, TIC is a “universal precaution” for retraumatization, similar to how a healthcare professional would use universal precaution for bloodborne pathogens. All staff, including support staff and administration, are trained on the effect of trauma and adversity on health, to recognize the potential for retraumatization, how to use the principles of TIC in their specific roles with patients and one another, and how staff can be affected negatively by working with individuals who have trauma histories.4,6,29 Both patients and staff are engaged actively in all aspects of the organization, and there is deliberate engagement with referral sources and partner organizations for making cross-sector trauma-informed decisions.1,4,9 In healthcare organizations, TIC also involves a continual analysis of health benefits versus the emotional costs of continuing procedures and examinations (i.e., possibility of retraumatization).36
|Key Components of Trauma-Informed Care31|
|TIC = Trauma-Informed Care.|
Guiding Values/Principles of TIC
TIC has five guiding values that provide a framework for how healthcare systems and professionals can reduce the risk of retraumatization, as well as promote healing and growth in patients.6 The values become principles as healthcare professionals and organizations implement them within the context of the work, and they become a natural part of organizational functioning.
The five values of safety, trustworthiness, choice, collaboration, and empowerment define an organization’s culture and are applied to all interactions, relationships, physical settings, and policies.6
Consider how the healthcare professionals/systems who interacted with Sora could use the five values/principles to prevent retraumatizing her.
Safety has physical and emotional dimensions. Physical safety includes considerations about where and when services are offered; security measures in place; the physical appearance of waiting rooms, exam rooms, and offices; whether bathrooms are accessible easily; and if there is adequate personal space for patients.6 For example, healthcare professionals can assess their office or waiting/exam rooms for welcoming qualities such as artwork, photos, and informational posters on the walls, plants, and child-friendly materials if appropriate.
Emotional safety includes welcoming, respectful, and engaging interactions between healthcare professionals and patients/other staff, and being sensitive to patient/staff discomfort or unease.6 A healthcare professional can simply ask a patient what can be done during a visit or procedure to make them feel more comfortable, and, if possible, stop procedures/protocols when the patient is overwhelmed.2,36
Trustworthiness includes providing clear information and expectations for both patients and staff in advance — who, what, when, where, and under what circumstances — as much as possible.6 For example, before a healthcare professional performs a physical exam, they can review which parts of the body will be involved and what will occur before doing it.2,35 Healthcare professionals and systems take informed consent and confidentiality seriously and provide information to patients to obtain their consent.6
Choice is given actively to patients with regard to various aspects of the services they receive, as well as to the healthcare professional in the way they provide services.6 How are healthcare professionals and systems incorporating small choices that make a difference to patients and staff? Can unnecessary procedures be skipped? Can necessary procedures be modified on an individual basis to provide patients with choice and control?36 For example, a physician can give a patient the choice to move a piece of their clothing out of the way instead of putting on a gown if only a small section of the body needs to be seen.2 An occupational therapist may offer the patient the choice of which area of their life they would like to talk about first. Does the organization allow for patients to choose the sex of their provider, time of their visit, or the way they prefer to be contacted?6 The principle of choice also considers whether concerns and issues of importance to patients are made a priority in care.6 Finally, to what extent are healthcare professionals fully informing patients of their choices with regard to their care?
Collaboration involves the healthcare organization embodying a model of doing “with” rather than doing “to” or “for” in all healthcare professional interactions with patients, as well as leadership interactions with staff.6 All individuals are considered the experts in their own experiences and history, and patients know what has worked for them in the past, what makes sense for their care in the present, and which health goals they want to achieve. Collaboration involves healthcare professionals giving patients a significant role in the planning and delivery of their own care, as well as planning and evaluation of the services provided by the organization.6 Does the agency have a patient advisory board? How do healthcare providers elicit feedback from patients around the services they are receiving? Patient care should be a two-way conversation, with both the patient and the healthcare professional bringing valuable experience and knowledge to the table.
Empowerment considers how all interactions and procedures within the healthcare system are affirming, validating, and build on strengths and skills of patients and staff.6 Do healthcare professionals ask about patient strengths and what is going well in addition to eliciting details around the problem or concern? For example, when the provider is talking with a patient who has weight concerns and is focusing on actions contributing to weight gain, the healthcare professional can ask what the patient is already doing that is helpful or what has been helpful in the past with regard to weight loss. Healthcare professionals and organizations can also empower individuals by emphasizing healing and growth rather than maintenance and stability.6
Cultural competency involves the organization’s implementation of policies and protocols that are both sensitive and responsive to racial, ethnic, sex, and cultural needs of their patients and staff.9 For example, does a female patient have the option to pick a female provider? Do healthcare professionals ask about and incorporate cultural traditions, values, and beliefs about health and healing into practice when possible? Are wall decorations such as artwork, signs, or posters representative of patient cultures and language? Is written information provided in other languages if the organization works with patients whose primary language is not English? Recognizing and acknowledging the presence of historical trauma and its potential effect on the presenting symptoms is also an important consideration.9 [The Harris and Fallot model of TIC assumes cultural competence is interwoven into the five values/principles, whereas SAMHSA delineates cultural competence as a sixth principle of TIC.6,9]
Levels of Trauma Care
Much like primary, secondary and tertiary prevention approaches to health, trauma care can also be broken down into three levels: trauma-informed, trauma-sensitive, and trauma-specific.
|Levels of Trauma Care31|
|TIC = Trauma-Informed Care.|
TIC is the overarching “umbrella” that anchors the guiding values/principles described previously in all organizational interactions and functioning. Staff has received basic training on trauma, understands the effect of trauma on patients and coworkers, and is aware of signs of potential stress responses.6,37Trauma-informed practices are used universally and do not require knowing whether an individual has a trauma history.
In the case of Sora, the physician’s office and other healthcare systems she was involved with would be trauma-informed by ensuring staff has a basic understanding of the effect of trauma on health and behavior, and how they can use the values/principles of TIC in their roles. The staff member at the front desk, nurse, and physician would recognize Sora’s lack of eye contact, increased muscle tension, closed-off body language, and responses to being touched as possible signs of discomfort, and inquire about what would make the visit more comfortable for her. The nurse and the physician would recognize her severe anxiety, GI symptoms, isolation, and difficulties going to work as potential effects of her trauma, and may refer her to a psychiatrist or mental health professional, a gastroenterologist, and an occupational therapist for a team-based approach to care. The physician would also work together with Sora to create a treatment plan based on his or her own expertise on the symptoms, and knowledge about what already works and what makes sense to Sora.
Healthcare organizations that are trauma-sensitive make the deliberate decision to address trauma by using evidence-based screening and assessment tools, making changes to their physical environment, policies, and procedures to address the potential for retraumatization. The ACE questionnaire and a primary care PTSD screen are two examples of tools commonly used in healthcare settings to screen for adversity and trauma.2 However, simply screening for trauma and adversity is not enough.
Healthcare professionals who decide to screen also need to define next steps with regard to a negative screen, and disclosures of trauma or adversity.5 The services provided onsite and services of referral sources will determine ultimately what steps healthcare professionals should take after a patient discloses a history of trauma or adversity.4 Especially in cases where interventions to process and treat trauma are not available onsite, healthcare professionals in a trauma-informed setting create and maintain a list of agency partners that do provide those trauma-specific interventions, to provide patients with referrals if needed.2
Sora’s physician’s office would be trauma-sensitive by looking at their day-to-day policies and procedures to assess for any mirroring of common trauma dynamics. Any that are identified could be changed to prevent the possibility of retraumatization. For example, multiple professionals asking the same or similar questions during the intake process may result in patients such as Sora feeling unheard and unimportant. The office could change its protocol to ensure that nurses and physicians read the patient’s intake paperwork before meeting with the patient, and briefly check in with the staff member who talked with the patient earlier to minimize repetition. Additionally, because of the long-term relationship between a patient and physician, the physician’s office may decide to take steps to become a trauma-sensitive organization by implementing ACE screening as part of the intake process for all patients. In Sora’s case, the nurse and physician would be aware that Sora has an ACE score of 4 (childhood sexual abuse, having a parent with a mental illness, having a parent who used alcohol, and having divorced parents). The physician could collaborate with Sora to make small modifications to the physical exam, such as letting her know before she would be touched, to help her feel more safe and comfortable during the process.
Trauma-specific refers to evidence-based interventions designed to process and treat trauma directly, such as cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and trauma-focused cognitive behavioral therapy (TF-CBT). Professionals must be trained in these models to be qualified to provide these interventions for treatment. Because only providers trained in an evidence-based trauma treatment should deepen a conversation around a patient’s trauma, healthcare professionals need to be cautious when a patient discloses a trauma history. Instead of eliciting more details, healthcare professionals can validate the disclosure; thank the patient for sharing; ask what they can do to make their appointment, examination, or procedure more comfortable for them; and refer out to a partner agency that provides trauma-specific treatment as appropriate.2,37 A positive experience after disclosing a trauma history to a healthcare professional may prompt a patient to seek further supports.37
Cross-sector collaboration and team-based care are very important for professionals and organizations looking to become trauma-informed — especially those who do not provide trauma-specific services on site. For example, a physician’s office that has a patient who disclosed a trauma history but does not provide treatment for trauma would provide a referral to a licensed clinical social worker or other mental health professional who is trained in a treatment like EMDR. Thus, effective cross-sector collaboration requires an up-to-date list of referrals that offer trauma-specific treatment and other services that may be helpful to address the effects of trauma on the patient, such as Sora’s severe anxiety and difficulties going to work. Additionally, it is also essential for healthcare professionals to be aware of how trauma-informed, trauma-sensitive, and trauma-specific their referrals are. A referral to a provider or organization that is not informed or sensitive to trauma may retraumatize the patient and possibly hinder their recovery and healing.9
Since Sora’s physician’s office does not provide trauma-specific treatments onsite, the healthcare professional should validate her disclosure, provide information regarding the possible role of trauma in her current symptoms, provide information on the treatment options for trauma, and offer a list of referral possibilities that provide appropriate evidence-based treatments for trauma.
Healthcare professionals and organizations are encouraged to consider their level of contact with patients (short- versus long-term) and their role when looking at which level(s) of trauma care to implement.2 For example, it may not make sense for a specialist such as a dermatologist to screen for trauma or offer trauma-specific treatment interventions onsite, but it is appropriate to use trauma-informed approaches as a universal precaution, knowing that their patients may have a history of trauma.2 However, if a health center has long-term relationships with their patients and a licensed clinical social worker or psychologist on staff who is trained in an intervention such as EMDR, it may make more sense for the center to implement trauma-informed, trauma-sensitive, and trauma-specific levels of care.
Trauma-Informed and Patient-Centered Care
Trauma-informed approaches align with and build upon patient-centered care.4,36,37 Both approaches apply to all patient interactions and have a focus on cultural competence.36 Healthcare professionals using patient-centered communication seek to increase their understanding of the patient’s individual needs and perspectives to reach shared understanding and decision making, much like the trauma-informed value/principle of collaboration.38-40 Patient-centered care also involves providing the information patients need to participate in their own care, while respecting their needs, wants, and preferences by encouraging patients to make informed decisions — mirroring transparency in the value/principle of trustworthiness as well as providing choice.39 Validation of the patient’s perspective is key to both patient-centered care and empowerment.38 (Level A)
The Health and Medicine Division (formerly the Institute on Medicine) states that ensuring safety from any harm caused by the care system is a priority in patient-centered care.40 TIC is a framework that has safety as one of the guiding values/principles, but also has the overarching goal of minimizing retraumatization that inadvertently can be caused by interactions, policies, and procedures within the healthcare system. Healthcare professionals and systems of care that have an awareness and understanding of the effects of trauma and adversity on patients, as well as how they can incorporate the values/principles of TIC, are in a better position to be patient-centered in their work. Although the link between TIC and patient-centered care has not been well investigated, one research study evaluated the effect of a six-hour course called “Trauma-Informed Medical Care” on primary care provider interactions with patients.41 The course included information on understanding trauma and PTSD, the effect on patients, ACEs, RICH relationship feelings and skills (respect, information sharing, connection, and hope), and the role of self-care in mitigating the possible negative effect of working with patients who have a trauma history. Findings from the study showed primary care providers who completed the course had more person-centered interactions.
Secondary Trauma, Vicarious Trauma, Compassion Fatigue, and Self-Care
An additional component of TIC is ensuring that all staff have an understanding of their own history, as well as reactions to interactions and/or environments that may trigger feelings and thoughts associated with their history.6 Medical settings often do not encourage healthcare professionals and staff to consider their own history; however, doing so is important when providing TIC, as it is difficult to be empathic when they themselves are overwhelmed with emotions.2In trauma-informed healthcare systems, all staff are aware and have received training on the potential effect of working with patients who have trauma histories, which may affect staff in the form of secondary trauma, vicarious trauma and compassion fatigue.
Secondary trauma refers to healthcare professionals experiencing trauma-related stress symptoms themselves as a result of their exposure to a patient’s traumatic experience; the symptoms can often develop quickly and are usually associated with a particular event.5,42 Exposure can include interacting with, witnessing, and hearing about the trauma and struggles of others.43
Vicarious trauma is the cumulative effect of witnessing others’ trauma and adversity.43 Vicarious trauma results in a negative change in the healthcare professional’s own worldview — their sense of themselves, the world, and others. Common signs of vicarious trauma can include experiencing pessimism, cynicism, and/or a loss of hope; distancing from others; numbing; shame; anger; irritability; a loss of idealism; and physiological symptoms such as headaches, GI concerns, and fatigue.5,42,43
Compassion fatigue is the combination of secondary trauma, vicarious trauma, and/or burnout. There are various tools that can be used both personally and in supervision for healthcare professionals to assess their level of any of these negative effects. One example is the Professional Quality of Life Scale (ProQOL), which assesses an individual’s level of compassion fatigue (including burnout and secondary trauma) and compassion satisfaction based on their experience during the past 30 days.44
Similar to the effect of retraumatization on staff, secondary trauma, vicarious trauma, and compassion fatigue can also result in high job turnover, low morale, absenteeism, and job dissatisfaction.45 Further, compassion fatigue is associated with healthcare professionals having decreased capacity to respond empathically and professionally, increased likelihood of making medical errors and inappropriate prescribing practices, as well as decreased patient treatment adherence and satisfaction with care.29
The first step in addressing the potential of healthcare professionals being affected by their work is increasing awareness and understanding of secondary trauma, vicarious trauma, and compassion fatigue through staff training.5,45 Healthcare professionals can use various self-care assessments and resources to increase their own awareness of what works best for them and help develop a plan for how they will take care of themselves to manage any negative effects.
Additionally, organizations that increase awareness, and encourage and provide opportunities for the use of good self-care strategies can help healthcare professionals mitigate the negative effects of their work.2,45 Healthcare systems can also implement organizational supports for healthcare professionals such as incorporating 5-minute “check-ins” at the beginning of team meetings, providing ongoing supervision, and promoting a psychologically healthy workplace through the provision of orientation and continuing education training. Recognizing and involving staff in decision making, and providing opportunities for onsite health and wellness activities is also helpful.45 While engaging in self-care is the responsibility of each healthcare professional, it is also the role of a trauma-informed organization to set the expectation that staff members are taking steps to care for themselves, as well as provide the resources (time, space, etc.) for them to do so during the work day. Healthcare professionals who actively take care of themselves and feel supported by their organizations will be better positioned to provide TIC for their patients.
Practices in the Workplace
TIC builds upon patient-centered care by providing an extra dimension focusing on healthcare professionals. Trauma-informed approaches apply to leadership and administration interactions with staff in the same way as they apply to staff interactions with patients. Trauma-informed methods can promote resilience in staff and combat the negative effects the work can have.
Trauma-informed approaches ask healthcare organizations to consider how their policies, procedures, environment, and other aspects of organizational functioning may possibly retraumatize staff.6 Screening and assessment tools are used to help recognize trauma in patients, while education, workforce development, and supervision are tools used for recognizing trauma in staff.
Retraumatization of healthcare professionals is associated with higher turnover, random absences and illness, decreased job satisfaction and treatment compliance, low morale, increased stress levels, and an increased risk for secondary and vicarious trauma.30 Such conditions are not conducive to healthcare professionals being patient-centered in their work.
Leadership can establish emotional safety with staff by completing a simple “check-in” to see how staff are at the beginning of each shift or meeting. It can encourage and respond to staff feedback, ideas and suggestions in ways that communicate their opinions are valued, even if their ideas cannot be implemented.6 For example, if completion of a new form is required during patient visits, leadership should let staff know there is a new form, and ask for thoughts about how best to incorporate it. Supervisors can provide choices to healthcare professionals with regard to factors affecting their jobs, such as vacation time and the way their office/space looks.6
Both healthcare professionals and systems are continuing to recognize the effect trauma and adversity have on health. Given the high prevalence of trauma and adversity, healthcare professionals can assume that many of their patients and coworkers have a history of trauma or adversity.
All professionals and systems of care have the potential to retraumatize both patients and staff. It is crucial that to provide effective care, organizations commit to integrating TIC into their practices, policies, and interactions. The values/principles of safety, trustworthiness, choice, collaboration, and empowerment assist healthcare professionals in being person-centered and promote healing, growth, and resilience in both patients and coworkers. TIC is truly an opportunity to transform the experience of care for everyone in the health system.4
American Academy of Pediatrics recommendations for ACE screening:
Centers for Disease Control (CDC)
Substance Abuse and Mental Health Services Administration (SAMHSA)