What is Trauma-Informed Care?
There is not one way to be a trauma-informed provider, just like there is not one way to practice medicine.
The goal is NOT to find the hidden trauma (or traumas) experienced by every patient, but to understand how trauma can impact an individual's health, life style choices, and life story.
In this blog post I discuss 5 strategies to become an effective trauma-informed health provider. I have then included some patient interactions where my conversations have led to a greater understanding of their journey with trauma. All patient's identities have been de-identified to protect their personal health information.
How to be a Trauma-Informed Provider:
1. Develop a Relationship Founded on Trust
This is one of the most difficult but most important steps of any relationship, and is imperative between a patient and their healthcare provider. For an individual who has gone through trauma, commonly someone or something has betrayed their trust. This could have been a parent, partner, or even a group in society. Therefore, in order to help an individual to take the bold step in trusting someone, they must first feel safe in that relationship.
Counter to some people's belief, you don't have to work with an individual over multiple sessions or years to develop a trusting relationship. Trust can be formed as quickly as the first couple minutes of an interaction through sharing statements demonstrating that you hear them and value what they have to say. Some example statements include:
"I hear you" "I can't imagine what you are going through" "That sounds so painful"
"I appreciate what you are saying"
Sometimes, even just sharing a common interest, background, or history can have a profound impact on gaining an individuals' trust. I recognize that this is not appropriate or ethical for all patient interactions, nor should any provider be urged to disclose their personal experiences. However, being able to break down the barriers of patient-doctor dynamic to humanize the provider can have a profound impact on the relationship. Especially when working with individuals who have gone through trauma, breaking down that power dynamic can be another avenue to help them feel safe in sharing their story.
Trust is a very fragile and malleable concept which can be lost as quickly as it can be formed. Therefore, one must be particularly patient and transparent with their patient to make sure that one doesn't damage that trust.
2. Demonstrate a judgement free zone
Actions speak louder than words.
Even though one can voice that it is a "safe space" an individual who has been through trauma can become very hyper-aware of minute facial changes and body language. If they sense that one doesn't have the time or doesn't care to listen, they will easily shut down. This could happen if one glances at their watch or clock, holds their arms across their chest, or has their full body turned away from them and towards the computer.
Instead one can practice having an open body language which non-verbally demonstrates that they are not judging them. One can do this through keeping their arms down, sharing eye contact, nodding one's head, and using sounds of universal understanding like "uh-hmm."
In addition, tilting one's head to the side demonstrates that you are interested, non-threatening, and are trying to form a connection. This is actually a sign that is seen across animal species!
A straight head can be an automatic sign of danger. In the wild, a predator does this right before attacking a prey.
3. Have Comfort with the Expression of Emotions
Dealing with medical conditions and trauma can bring up an array of emotions. As a trauma-informed provider one needs to practice feeing comfortable letting a patient express various emotions. Sometimes it can feel like one is experiencing whip lash when individuals express an array of emotions in one session.
It is also important for the provider to remind themselves that the emotions expressed by patients are not directly caused by the provider. Even if a specific situation leads any individual to feel upset, like waiting a long time for a provider to show up, a history of trauma compounds subconscious emotions which may come out when they feel vulnerable.
Individuals who have been through trauma commonly have difficulty understanding and interpreting their bodily sensations and emotions in relation to the world around them. This is because when an individual goes through a traumatic experience, the brain region called the amygdala (located in the temporal lobe) is intensely activated. The amygdala is responsible for producing and remembering intense emotions surrounding fear and distress. Trauma leads the amygdala to become hypersensitive and doesn't properly communicate with the pre-frontal cortex, an area of the brain that processes higher functioning like comprehension and analytics. Therefore, when an individual is faced with a situation that triggers the amygdala, their emotions take over and they can not use the logic center of their brain (pre-frontal cortex) to adapt and extinguish the extreme emotions.
One proposed mechanism for this response is when an individual feels trapped, in a "non-controllable" or "inescapable stress," there is an enhanced presynaptic glutamate release (an inhibitory neurotransmitter) from the prefrontal cortex to the amygdala (Liu et al., 2020). This means that the cognitive center of the brain communicates less when an individual has a significant emotional event which activates the amygdala.
This dysregulation has been seen through multiple animal and human studies looking at the neuronal brain connections during and after trauma. For an in-depth look at the "synaptic, biochemical and genetic changes" in the brain and research done visit "The amygdala and medial prefrontal cortex: partners in the fear circuit."
To bring it full circle, emotions are complex, and as trauma-informed providers it is meaningful to be a stable presence when an individual is experiencing this rollercoaster of emotions. The act of just providing tissues or asking to hold their hand can be a huge comfort and also further strengthen the trust in the relationship.
4. Understand the various types of trauma & their impact on health
There are a significant variety of traumas that one can experience across a lifetime. Originally medicine focussed on the 10 Adverse Childhood Experiences (ACEs) as significant events impacting an individuals long term health and life. These 10 ACEs are seen here:
However, recently there has been a lot of research on how additional traumatic experience can occur across a lifetime and also have an impact on health.
Additional traumas include living through war, natural disasters, housing instability, or a lower Social Economic Status. Following, struggling with discrimination based on your race, heritage, language, sexual orientation, gender identity, disability, or country of origin are traumatic.
Increased levels and numbers of traumas (including ACEs) have been correlated with multiple medical conditions and unhealthy lifestyle choices. Therefore, when a provider learns that their patient has experienced trauma one needs to provide increased follow up and support to prevent the development of the medical conditions.
5. Collaborate with an Inter-professional Team
Individuals who have been impacted by trauma commonly have more complex health and social needs, so it is monumental to connect them with resources early on through collaborating with an inter-professional team.
Relevant individuals of this team can include:
Primary Care Provider, Medical Specialists, Mental Health Therapists, OT/PT/Speech/Behavioral Therapists, Nutritionists, Case Managers, Counselors, Religious Leader/Chaplain
No one needs to know the details of the trauma but that the individual is a trauma survivor. It can also be helpful to share the category of trauma so one can develop a person-centered treatment and support system tailored to that individual's needs.
Examples of Patient Interactions:
Teenager female patient suffering from obesity and an ovarian cyst.
1 hr clinic visit later and the list of differential (potential) diagnosis included:
• Hypertension (High Blood Pressure)
• Depression with Suicide ideation
• Possible PTSD from childhood sexual abuse
How did we get from talking about obesity in a teenage well-child check to trauma & possible PTSD? Here was the natural flow of conversation I had while interviewing the patient.
• Talked about school: no friends outside of school
• Talked about sleep: difficulty falling asleep, 3 hr naps after school
• Talked about Diet: eats a lot of calories, fast food, & soda
Next, asked the parent to step out for a private conversation with the patient
• Talked about menstruation: inconsistent periods
• Talked about Birth control options
• Talked about sexual orientation & identity: patient opened up about their identity
• Discussed current sexual activities
• Showed patient their weight chart: there was a significant increase in weight at age 10, inquired about what happened in that child’s year
• Discussed connection of weight and feeling sad: over eating, over sleeping and suicidal thoughts
• Trauma: Then sexual abuse history naturally came out which they had never told anyone…
Provided a box of Kleenex and held space for her to cry and express her emotions
Went to get Resident & Attending to finish visit and prepare plan.
ASSESSMENT (how doctors synthesize the interaction): This patient is a teenage female patient with a history of ovarian cyst and childhood obesity presenting for a well child visit. Upon discussion with parent and alone with patient, she is struggling from significant depression post childhood sexual abuse which has lead her to have a metabolic syndrome.
Patient doesn't have active suicidal ideation or a plan but her thoughts of "dissapearing" have impacted her sleep, mood, appetite, and social and academic life. Her struggles with sleep and reuminating with guilt overnight with possible flashbacks and nightmares increases her risk
for PTSD. In addition her history of a ovarian cyst with over 99% BMI leads her to be at an increased risk for PCOS and menstrual problems.
• Refer for Nutrition Counseling for family
• Education on link between mood and eating and excess mobility
• Previous high HbA1C so Reorder HbA1C
• Order CBC to check Glucose level
• Nutrition and health counseling
HTN (High Blood Pressure)
• Two high BP at two different visits so recheck at home and at next f/u
• Order blood CMP and Lipid panel
• Most likely has PCOS, history of irregular periods, increased weight gain, history of cyst
• Restart birth control pills after manage HTN
Depression post childhood sexual abuse
• Refer to Psychotherapy with Cognitive Behavioral Therapy (CBT)
• Consider SSRI medications in future after a couple therapy appointments
• Consider PTSD diagnosis and refer to with psychiatrist
• Educate family in future on Suicide Ideation and worry signs to look for
• Sleep Hygeine education
THIS ^ is why I love medicine, one doesn’t have to just be a psychiatrist to ask about trauma & diagnose & treat mental health conditions. From there we provided referrals to therapy, social support, a nutritionist, & multiple follow up apts
Elderly patient with Aphasia (difficulty speaking)
He asked me when would need to move to a higher level of care – to assisted-living. I sat down with him and explained to him with simple sentences about the assisted living facility and what was different and the same compared to his current living situation in independent living.
He mentioned he was scared and started crying and I comforted him. He said that he had never asked the question before and instead ran away when someone brought it up. I told him he was very wise to even contemplate the question because a lot of people have to be pushed into a new situation before contemplating it. I told him it was smart of him to contemplate what it would feel like to move because it is a scary new thing.
Elderly female patient who is here for annual primary care visit and struggling with mood.
• While in bed experiences thoughts racing, worries a lot "worry"
• Fall asleep between 2-3am
• Feel exaughsted during day
• Had COVID (not vaccinated) hospitalized 4 days, worsened sleep
• This Summer stayed in bed for long times
What do you worry about? crossing street, defending self, shootings in neighborhood, getting hit by cars
What happens when you worry or have "worry attacks?"
• a lot over the summer, every day
• clostraphobic in elevators
• don't like crowded places
What types of things do you enjoys: drawing and reading inside the house but difficulty focussing & mind wanders
What is your Appetite like? No appetite, cookie & coffee in morning, rarely lunch
Have you ever thought about hurting yourself, not waking up from sleep, or committing suicide? Previous suicide attempt in teenage (OD on pills, didn't work)
More questions for Review of Systems:
Musculoskeletal: Positive for myalgias.
Psychiatric/Behavioral: Positive for depression. The patient is nervous/anxious.
Attention and Perception: Attention and perception normal.
Mood and Affect: Mood is anxious and depressed. Affect is labile.
Behavior: Behavior normal. Behavior is cooperative.
Thought Content: Thought content normal. Thought content does not include current suicidal ideation. Thought content does not include current suicidal plan.
Cognition and Memory: Cognition normal.
Judgment: Judgment normal.
Elderly female patient who is here for f/u for GAD & Depression. Since she was a teenager patient has experienced generalized anxiety on every aspect of her life, difficulty with sleep, and bouts of depression. This summer she has been more anxious which has prevented her from falling asleep and going outside. She is not currently experiencing suicidal ideation but she has in the past and had a suicide attempt with pills as a teen. Patient stated she "just deals with the worries" and describes herself as a "worry wort." She is fearful of being in large crowds or even going outside because of risks to her life and health. This has led her to remain inside and mostly in bed all summer.
Patient expressed multiple occasions of episodes of intense sweating which correspond to anxiety attacks. All symptoms represent her diagnosis of Generalized Anxiety disorder, Agoraphobia, and Dysthymic Depression Disorder. Patient expressed multiple concerns throughout the visit regarding her multiple medical conditions and life.
Differential Diagnosis: Generalized Anxiety Disorder, Depression, and Insomnia
• Worse Anxiety affecting sleep, social outings
• Continued Depression affecting sleep and decreased appetite
• Continue looking for a mental health therapist and support group.
• Anti-Anxiety & Depression medications - Consider SSRI and later Buproprion because good for dual mental diagnosis and smoking cessation
It is interesting that lowering (deepening) your voice and slowing down your speech can truly affects the attitude of elderly individuals.
I once worked with an elderly patient whom most caregivers hated because she was always very grumpy. However, through sitting down and talking to her I learned that she was a vocal performer, and now could only hear individuals when talking deep and slow. Higher pitch voices triggered her because the difficulty understanding them led her to feel inferior.
<10 year old girl in the ER with multiple months of vomiting on and off.
While interviewing the patient she randomly made comments about her weight and what foods her family should and shouldn't be eating. Then through speaking with her parent we learned that her mother had recently had a miscarriage which had a significantly impact on the family. However, the parents were surprised that the patient never seemed to show signs of sadness similar to the rest of the family members. Could her vomiting and stomach aches be a manifestation of her grief, and could she be starting to develop an eating disorder?
Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
Marek R, Strobel C, Bredy TW, Sah P. The amygdala and medial prefrontal cortex: partners in the fear circuit. J Physiol. 2013 May 15;591(10):2381-91. doi: 10.1113/jphysiol.2012.248575. Epub 2013 Feb 18. PMID: 23420655; PMCID: PMC3678031.
www.cdc.gov/vitalsigns/aces/index.html
Liu, WZ., Zhang, WH., Zheng, ZH. et al. Identification of a prefrontal cortex-to-amygdala pathway for chronic stress-induced anxiety. Nat Commun 11, 2221 (2020). https://doi.org/10.1038/s41467-020-15920-7
Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune diseases in adults. Psychosom Med. 2009;71(2):243-250. doi:10.1097/PSY.0b013e3181907888
Liu YZ, Wang YX, Jiang CL. Inflammation: The Common Pathway of Stress-Related Diseases. Front Hum Neurosci. 2017;11:316. Published 2017 Jun 20. doi:10.3389/fnhum.2017.00316
Harris HR, Wieser F, Vitonis AF, Rich-Edwards J, Boynton-Jarrett R, Bertone-Johnson ER, Missmer SA. Early life abuse and risk of endometriosis. Hum Reprod. 2018 Sep 1;33(9):1657-1668. doi: 10.1093/humrep/dey248. PMID: 30016439; PMCID: PMC6112577.
ACE Provider Training: https://vetoviolence.cdc.gov/apps/aces-training/#/#top
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5233668/
https://www.cdc.gov/violenceprevention/pdf/brfss_adverse_module.pdf
To Learn More on Trauma-Informed Care visit the Collections Tab and check out my other Writings and Presentations on this topic at the My Work Tab
***This Blog Post is for educational purposes only and is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. This does not imply a doctor-patient relationship. All opinions are the opinions of the writer and not reflective of any institution or employer. Please follow up with your health provider and therapist for any additional questions or support.***