Treating patients who have suffered trauma in their past is a complex and delicate endeavor at any time. Then external events such as the Kavanaugh hearing and #MeToo movement can make things even more difficult, potentially triggering survivors of sexual violence and further complicating interactions with their physicians.
“With an inherent power differential between patient and physician, healthcare services can be retraumatizing for survivors," said Eve Rittenberg, a primary-care internist, in a recent article in the New England Journal of Medicine. Potential triggers for patients during an exam include physical touch, removal of clothing, lack of privacy, and personal questions, Rittenberg writes.
How can physicians best treat patients that have suffered trauma? A new approach – “trauma-informed care" – looks to offer guidance. The intent is to acknowledge the widespread impact of trauma and promote a culture of safety, empowerment, and healing in interactions with patients.
Many patients once written off as problematic or difficult because of their idiosyncratic or noncompliant responses in the care setting can now be recognized as potential trauma sufferers. Even those patients without trauma in their lives are likely to benefit from care encounters that give a sense of security, control, and compassion.
“The idea is deeply rooted in the ideology that many patients live in an environment that is traumatizing, or what's called a toxic environment, particularly as it relates to adverse childhood events," explains Kemi Alli, M.D., CEO of Henry J. Austin. Her organization implemented trauma-informed protocols in 2010, and the program is now part of a wider effort to address environmental health problems among its patients.
“We've been dealing with the behavioral health crisis among individuals who have chronic disease," says Alli. “What we want to do is get below the surface to understand how those individuals come to have that crisis or come to have the chronic disease, and how can we avoid that?"
Tenets of trauma-informed care
The movement is being driven by recent studies that show a startling prevalence of abuse and violence in the United States.
A recent CDC report estimated that one in four children experiences some sort of maltreatment (physical, sexual, or emotional abuse). And data from the National Coalition Against Domestic Violence show one in four women has experienced domestic violence, with one in five women and one in 71 men having experienced rape at some point in their lives. Twelve percent of these women and 30 percent of these men were younger than 10 years old when they were raped.
According to Substance Abuse and Mental Health Service Administration (SAMSHA), the concept of trauma-informed care
- realizes the widespread impact of trauma and understands potential paths for recovery
- recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system
- responds by fully integrating knowledge about trauma into policies, procedures, and practices, and
- seeks to actively resist retraumatization.
In practice, trauma-informed care means offering patients choice (by, for example, asking patients if they would like the door open or closed while they wait) and control (by explaining what the physician is about to do and why it is necessary; and by asking patients if there’s anything that would make them feel more comfortable).
Claudia Gold, M.D., pediatrician and faculty member at the University of Massachusetts Boston Infant-Parent Mental Health Program, says that such an approach can not only avoid retraumatizing patients during clinical encounters, but can actually help heal traumatized patients by building their confidence through their relationship with their physician.
“Both our physical and emotional wellbeing throughout our lives grow out of the moment-to-moment interactions in our primary care-giving relationships," Gold says.
Addressing deep trauma
At Jefferson University Hospital, Diane Abatemarco, Ph.D., then vice chair of Pediatric Population Health Research, helped implement a trauma-informed care program known as Maternal Addiction Treatment Education & Research (MATER) for new mothers that addresses the impact of opioid addiction post-delivery.
Many of the women in the MATER program have experienced deep trauma in their past, which can get in the way of effective parenting.
“Women who are in treatment for opioid addiction are very good physical caretakers for the most part, but what they don't do is access their own emotions," Abatemarco says. “If you can't be self-compassionate, you really can't be compassionate to another, including your child."
Jefferson University recently completed the first federally funded study on the impact of trauma-informed parenting classes, which showed mothers who participated in the 12-week program significantly improved the quality of their parenting.
Early adopters rising
At the Henry J. Austin Health Center, CEO Alli says long-term results are still years away, but the organization has achieved significant short-term goals. The number of patients that are screened for depression has increased fourfold, she says. The number of patients who are receiving care for depression, substance use disorder, or anxiety has tripled, and the number of patients who have their hypertension under control has doubled.
Alli believes the concept of trauma-informed care will spread because it moves healthcare further upstream to address the origins of ill health.
“With any new change, there's a bell curve of early adopters," Alli says, “and we're just now on the uptick of that bell-shaped curve."
Rod Moore is a writer based in Nashville, Tennessee.