Trauma Informed Care Improves Approach to Mental Health

Margaret Paccione-Dyszlewski, PhDBy Margaret Paccione-Dyszlewski, PhD

Those of us who work in health care are intimately familiar with trauma. Medical trauma appears on our doorstep as the car accident survivor presenting with a fractured pelvis or serious burn, the soccer player describing the neurological symptoms of a head injury or the young man in pain resulting from an industrial accident hemothorax.

But what of the other trauma – the one that is less visible, painful and always present in health care settings – psychological trauma? Above the water line are the emotions that often accompany a medical visit: anticipation, worry, fear, loss. Less noticeable are the feelings resulting from financial insecurity, domestic or community violence, and natural or human-engineered disasters. 

In brief, psychological trauma can be defined as any adverse experience that affects a person’s ability to function. Having individuals in our health care system who have experienced trauma has always been true.

What has changed, however, is that we now know the consequence of prolonged exposure to stress is universal and impacts all major domains of human development and functioning. As documented by the landmark Adverse Childhood Experiences (ACE) study (Felitti, et.al. 1998)1 and other subsequent research (Shonkoff 2012; Public Health Management Corporation 2013)2, exposure to abuse, neglect, family mental illness, discrimination, parental incarceration, violence and other adverse experiences increase an individual’s lifelong potential for serious health problems and engaging in health-risk behaviors.3

"Trauma is personal. It does not disappear if it is not validated. When it is ignored or invalidated, the silent screams continue internally, heard only by the one held captive. When someone enters the pain and hears the screams, healing can begin." 

As many traumatic events erode the dignity and safety of the individual, they often influence a survivor's attitude toward medical care and the provider of that care. Many health care procedures, especially those which involve a patient being alone with a provider, placed in a physically vulnerable position or touched in intimate areas, may be re-triggering for traumatized patients. Depending on the nature of their trauma, many individuals may be reluctant to trust providers with critical information or may avoid the health care system altogether.

A concept termed trauma informed care (TIC) has invited evolutionary change in a variety of settings including schools, health care organizations, prisons, and social service agencies. This shift in culture has resulted in improved care to individuals who have histories of traumatic life events or toxic stress.

According to the Substance Abuse and Mental Health Services Administration, a program, organization or system that is trauma informed4:
  • Realizes the universal impact of trauma
  • Recognizes the signs and symptoms of trauma in individuals involved with the system
  • Integrates knowledge about trauma into policies, procedures and practice 
  • Seeks to actively resist re-traumatization

Although the concept of trauma informed care can take many forms as it is applied to health care, studies suggest that TIC in our delivery system consists of two major domains: universal trauma precautions and trauma-specific care (Raja et.al. 2015).5

Employing universal trauma precautions assumes that every individual receiving services in that system has a history of trauma. With this foundational culture shift in place, the stage is set for the provider to establish trust and rapport with survivors of traumatic life events, encourage patients with undisclosed trauma histories to reveal their vulnerabilities, and creates a more therapeutic environment for the small percentage of individuals who have escaped life trauma.

Awareness is the first step. If a patient presents with challenging behaviors, an enlightened provider views the behavior through the lens of trauma. Brain science informs that dysregulated behaviors, emotion dyscontrol and cognitive interruptions are hallmark trauma reactions. In a trauma-sensitive culture, if a patient raises her voice, a parent forgets his child's birthdate or a visitor pushes past a provider, trauma would be considered as a root cause of the behavior. Trauma research provides the back story behind many patient behaviors that challenge our health care system. Armed with nuanced knowledge and interpersonal skills – especially de-escalation skills – health care providers can vastly improve the patient experience for all populations. 

Once the patient has revealed a history of trauma or toxic stress, specific strategies can be utilized to support the needs of the patient. These techniques may involve targeted screening to determine the health effects of the trauma, interdisciplinary collaboration, and provider education concerning the risks and prevention for vicarious traumatization.

According to author and trauma survivor Danielle Bernock, "Trauma is personal. It does not disappear if it is not validated. When it is ignored or invalidated, the silent screams continue internally, heard only by the one held captive. When someone enters the pain and hears the screams, healing can begin." 

If health care environments recoil from validating damaging trauma experiences, the toxicity of trauma will corrode the very potential of healing. A shift in culture to become more trauma informed will set the stage for maximum healing to take place. Our Lifespan facilities can be that place of healing for trauma survivors.

Sources

1V.J. Felitti, R.F. Anda, D. Nordenberg, D.F. Williamson, A.M. Spitz, V. Edwards, et al. “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study.” American Journal of Preventive Medicine, 14, no. 4 (1998): 245-258.

2J. P. Shonkoff, A. S. Garner, and the Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; and Section on Developmental and Behavioral Pediatrics. “The Lifelong Effects of Early Childhood Adversity and Toxic Stress.” Pediatrics, 129, (2012b): 232–246.

3Public Health Management Corporation (2013). Findings from the Philadelphia Urban ACE Survey. Available at: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf407836.

4Trauma-Informed Approach and Trauma-Specific Interventions online at https://www.integration.samhsa.gov/clinical-practice/trauma-informed

5S. Raja, M. Hasnain, M. Hoersch, S. Gove-Yin, C. Rajagopalan. “Trauma Informed Care in Medicine”. Family Community Health, 38, no. 3 (2015): 216-226.