The Heart of Trauma-Informed Care

A couple of years ago, I came to the end of a long primary care visit with a well-known patient. “It’s time for your next Pap!” I announced blithely. She froze, looked at me, and silently started to weep. I was taken aback; after several minutes she explained that she had been sexually violated in the past. The mention of a Pap triggered anxiety and fear – and I was caught completely off-guard.

In this era of #MeToo, gun violence, and family separation at the border, trauma has assumed center stage in our national conversation. At home, trauma can invade the lives of our patients in insidious and catastrophic ways. As clinicians, we are often unaware and ineffective.

“Trauma-informed care” is a framework for responding to this often-hidden epidemic. SAMHSA offers the most widely accepted set of principles that comprise a trauma-informed approach. Yet among clinicians, I continue to hear a familiar refrain: “What is trauma-informed care?” They yearn for something more concrete.

In that spirit, I’ve outlined one interpretation of trauma-informed care for providers. It is by no means comprehensive, but I hope it serves as a starting place.

1.) Trauma-informed care is healthcare in which we bring awareness of the prevalence of trauma and its long-term effects on physical and emotional health to every patient encounter.

Fifty-nine percent of children in the US have experienced at least one adverse childhood experience (ACE). ACEs are associated with long-term health problems such as COPD, ischemic heart disease, depression, and substance use. Among adults, one in five women has experienced rape, and many more sexual violence.

Trauma comes in many other forms. Trauma-informed providers are familiar with the pervasiveness of trauma and educated about its lasting effects. As a result, they assume universal exposure until proven otherwise.

2.) We recognize patient resilience, and also take into account how trauma may influence behavior and engagement in care.

While watching an inpatient yell at staff and refuse the majority of her care, a wise friend taught me to ask not, “What’s wrong with this patient?” but “What has happened to this patient?”. Trauma-informed providers see “difficult patients” not as people with character flaws, but as survivors in whom trauma has shaped behavior in both adaptive and maladaptive ways. They celebrate the resilience that has brought survivors this far rather than blaming or labelling them.

3.) We prioritize safety, choice, and collaboration, while working to build trust.

Given the prevalence of trauma, we take universal precautions. To help patients feel emotionally and physically safe, try introducing sensitive questions with a preamble, like, “I’m now going to ask some sensitive questions that I ask all my patients; please let me know if you would prefer not to answer.”

We ask permission before moving to sensitive parts of the exam. We give trauma survivors choices, like,“Would you prefer to keep the door partly open?”

We seek to collaborate toward the goal of health, for example by saying, “How can I help make the Pap a less frightening experience for you?” Building trust is fundamental.

4.) We offer education to patients regarding trauma’s effects and connects patients to resources to support healing.

Sometimes we can feel powerless in the face of trauma, yet we play a critical role in empowerment through education. Explaining the ways in which trauma dysregulates the body’s biology and, through cascading effects, exacerbates a multitude of health problems can be eye-opening for patients. We can offer simple resources to strengthen coping skills, such as mindfulness exercises, while also referring patients to high-quality, trauma-focused therapies and other mental health resources as needed.

Awareness, attitude, approach, and advice – these are the ways we can begin to operationalize trauma-informed care, as well as working with intention, humility, and compassion.