Trauma Informed Care

As an introduction to today’s post, take a couple of minutes and watch this music video from the band Simple Plan. Or, if you can’t, read through the lyrics. The first verse is included in this post, the rest is at the link below.

 

Welcome to My Life

By Simple Plan

Do you ever feel like breaking down?
Do you ever feel out of place?
Like somehow you just don’t belong
And no one understands you

Do you ever want to run away?
Do you lock yourself in your room?
With the radio on turned up so loud
That no one hears you screaming

No you don’t know what its like
When nothing feels alright
You don’t know what its like to be like me
To be hurt, to feel lost
To be left out in the dark
To be kicked when you’re down
To feel like you’ve been pushed around
To be on the edge of breaking down
And no one there to save you
No you don’t know what its like
Welcome to my life

What is Trauma Informed Care?

An organizational approach to understanding how trauma affects a person’s life . There are three important pieces to trauma informed care:

  • Realizing the prevalence of trauma
  • Recognizing how trauma affects all individuals involved in the organization
  • Responding by putting this knowledge into practice

Psychological trauma is not rare. Some studies suggest that as many as 50% of men and 60% of women in the general population have been exposed to some form of trauma. In clinical samples, this rate can soar to 90% .

Trauma is linked to common mental health disorders including PTSD, depression, anxiety, personality disorder, dissociative disorder, substance abuse, psychosis, and somatic complaints. Trauma is also associated with increased lifetime risk for a number of medical conditions including asthma, hypertension, diabetes, obesity, cardiovascular disease, GI problems, arthritis, and chronic pain .

Trauma disrupts functioning while ongoing trauma disrupts functioning in an ongoing way. In addition, growing up in a chronically traumatic environment, with an ineffective interpersonal context interferes with basic aspects of functioning developing adequately in the first place. Theses deficits in basic aspects of functioning impair the capacity of survivors to cope with routine daily stressors including things like making and keeping appointments, paying bills, finding work, or taking medication .

Because of these inabilities to handle daily stressors, survivors of trauma are more likely to have “trauma-related behaviors” when stressed or anxious including becoming angry, irritated, upset, verbally abusive, losing the ability to concentrate, etc.

It is important to recognize that trauma-related behaviors are adaptive in that they have helped the individual survive up to this point. These behaviors should be viewed as a form of resilience . Examples of these types of adaptive behaviors include veterans of the war in Iraq or Afghanistan who, upon return home, swerve to avoid litter while driving, or only drive in the left-most lane. Without understanding the context in which this behavior developed, some might consider this behavior bizarre. When one realizes that in Iraq and Afghanistan roadside bombs are a significant threat, and that many veterans of these wars have lost friends to IED, the driving behavior makes sense and can be viewed as an adaptive behavior.

Likewise, a patient who become loud and verbally abuse at the front desk is likely doing so because they have learned through experience that the best way to get what they need to to be loud and demanding until those that they view as standing in their way give in.

How does this impact primary care? Ask yourself who you see in your clinics. I  made a list of the types of traumas I have seen in my clinic:

  • Refugees
  • Veterans
  • Homeless individuals
  • Chronic poverty
  • Domestic violence
  • Child abuse/neglect
  • Accident survivors
  • Victims/witnesses of violent crime
  • Torture survivors
  • Cultural trauma (Native Americans, Asian American, African Americans, etc.)
  • Survivors of natural disasters
  • First responders

When we understand that 90% of the patients we see have been exposed to one or more of these types of traumas, the realization can be quite sobering.

Staff can increase can help by remembering a few basic skills. They should be reminded to avoid assuming malicious intent, watch for areas of deficiency, learn to distinguish “right” from “appropriate” behavior, and teach missing information/skills. Healthy, every day interactions can help survivors of trauma improve their functioning . The experience of an authority figure, such as a physician, providing choices and validating those choices has a powerful, positive impact on the person . As staff and providers model appropriate interactions and interpersonal skills, and create an environment of safety, survivors trauma related behaviors will reduce .

Emphasize safety.

The clinic should be a safe place for our patients. We should become aware of potential triggers and work to reduce or eliminate them. We should establish clear roles and boundaries and model these appropriately. Having a clear understanding of who does what can do much to reduce anxiety in clinic. It’s important to be clear about what services the clinic provides. For example:
  • We offer Behavioral Health as part of primary care, but not extended psychotherapy
  • We do not treat chronic pain with narcotic pain medicines (new patient)
  • We do not treat chronic anxiety with controlled medications
  • Even if we help diagnose ADHD in adults, we do not treat this with controlled stimulants

Anytime a patient is asking about something like this, they should be getting a clear and consistent answer.

Whenever a transfer between personnel must occur, make sure that it occurs as a warm hand off whenever possible. Many individuals with a history of trauma have concerns about being abandoned. By introducing the patient to the next provider or staff member who will work with them, we can reduce feelings of being dumped off onto someone else.

Validate personhood.

One of the most insidious results of trauma is the perceived loss of personhood. Trauma informed care is about treating each person like a person and not just a number. A key is giving each person your full attention, making eye contact, and speaking authentically with them. It is important to use reflective listening and validate the person’s experience and emotional response.

Dr. Gottman’s relationship technique of “Turning Toward” can be helpful in out relationship with out patients. Use each interaction with the patient as a chance to provide small, unrelated validation. Comment on their nice scarf, ask them about their drive/ride to the clinic and respond genuinely. Gottman suggests that we keep those positive to negative interactions at a 5:1 ratio in order to increase collaboration and strengthen the relationship .

Empower.

The easiest way to do this is to provide choice and respect the patient’s choice. Does the patient prefer to keep the exam room door open? Would they like to have a friend or family member with them? Is there a way to make that happen ? Accept and respect the diversity that comes into the clinic and ensure that staff is trained in culturally competent practices. For example, some patients may prefer to work with a provider of the same gender. Others may speak English, but would still benefit from having an interpreter in the room, especially during long medical discussions.

Try to avoid jargon. Use of jargon can become a barrier to understanding and puts patient and clinician on different levels. In my clinic we use a lot of abbreviations. A new patient, or non-English speaking patient can easily become confused by these terms. What is the difference between the CSR[1]Client Services Representative. This is the title of our Patient Navigators, a position created and funded by the Affordable Care Act. These individuals help patients sign up for, renew, or troubleshoot problems with their insurance. and a CSA[2]Controlled Substance Agreement. These documents are renewed annually for patients in our clinics who are prescribed controlled substances including narcotic pain medications, benzodiazepines, stimulants, and Ambien. They outline the general conditions under which controlled substances will be prescribed to a patient, the conditions under which the prescriptions would be stopped, and the treatment plan for managing the underlying disorder(s). During the annual CSA renewal visit with a member of the behavioral health team, the patient and the behavioral health provider review the patient’s progress toward their functional goals from last year and sets new ones for the coming year.? And does it have anything to do with the CIA[3]Central Intelligence Agency. No comment.? What are “refills?” What is a “sliding scale” and why do you need to know about my income and household size?

Ask questions! Dr. Steven Gold reminds clinicians to approach their patients form the the stance that they don’t understand what a patient is experiencing, because, because you don’t. He says that we need to be willing to be educated by the client by having her/him explain their rationale or beliefs to you. He encourages us to take a one-down position, and say, “I don’t understand…” or “Please explain that to me.”

The bottom line: provide positive regard, clarity, compassion, and validation.

Self Care.

An important part of Trauma Informed care is to care for yourself and each other on the clinic team. There are a hot of different ways that one can do this, but certainly it is important to have regular, consistent self care habits in place including:

  • Eating a healthy breakfast
  • Regular exercise
  • Regular relaxation activities

In addition, there are some strategies that can be useful during the work day, or even during a difficult patient interaction. One way is to use Linehan’s IMPROVE the moment skills:

  • Imagery: see self coping well, holding a child, going to a peaceful place, having a soothing picture near computer.
  • Meaning: “I am a professional” affirmation.
  • Prayer: Ask God or higher power for support. “Radical acceptance.” Trust it will work out.
  • Relaxation: breathing, respond to stress in the body.
  • One thing in the moment: I only have to get through this moment.
  • Vacation: Take a super-brief vacation to stretch, go to the bathroom, look out the window, regroup.
  • Encouragement: Say to yourself what you would say to a friend, “I can handle this.”

Another useful tool is to identify one or two “de-stress” buddies. Use an agreed upon keyword (e.g., “Code Purple”) to indicate need to de-stress. Briefly explain cause of stress. Your buddy then helps you breathe, calm down, remember skills. It is important to balance venting (and listening) with positive regrouping and self-regulation reminders.

Remember:
  • It’s not personal
  • Take a deep breath
  • Step away, take a break

As you implement trauma informed practices into your daily clinical practices. You’ll help reduce barriers to good mental and physical health for your patients. Further, your will be improving the functioning of those patients with trauma histories that come into your clinic. Finally, you’ll reduce the risk of inappropriate patient behavior in your clinic which will increase both patient and staff safety.

What i’ve talked about here is just a very high level overview of trauma informed care. Feel free to read through the resources listed in the notes, paying particular attention to TIP 57 from SAMHSA. This treatment guide is available for free directly from the SAMHSA Store. I’ve also uploaded the slides I use for this when I present on this topic. Feel free to download them, but make sure you give credit and provide a link back here.


References

 

____________________________________________________
Cite this article as:
Robert Allred, "Trauma Informed Care," in Robert P. Allred, PhD, October 8, 2015, http://doctorallred.com/2015/10/trauma-informed-care/.

or

APA 6th:
Allred, R.P. (October 8, 2015). Trauma Informed Care [Weblog post]. Robert P. Allred, PhD. Retrieved September 21, 2017 from http://doctorallred.com/2015/10/trauma-informed-care/

Notes   [ + ]

1. Client Services Representative. This is the title of our Patient Navigators, a position created and funded by the Affordable Care Act. These individuals help patients sign up for, renew, or troubleshoot problems with their insurance.
2. Controlled Substance Agreement. These documents are renewed annually for patients in our clinics who are prescribed controlled substances including narcotic pain medications, benzodiazepines, stimulants, and Ambien. They outline the general conditions under which controlled substances will be prescribed to a patient, the conditions under which the prescriptions would be stopped, and the treatment plan for managing the underlying disorder(s). During the annual CSA renewal visit with a member of the behavioral health team, the patient and the behavioral health provider review the patient’s progress toward their functional goals from last year and sets new ones for the coming year.
3. Central Intelligence Agency. No comment.

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