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Trauma Informed Care: Part 1

Megan Gerber MD, MPH, Neda Frayha, MD, and Sadie Elisseou, MD
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Many of our patients have lived through trauma, and the Covid-19 pandemic is a form of collective trauma in itself. How can we, as primary care clinicians, provide sensitive, trauma-informed care to our patients? Neda sits down with national experts Drs. Sadie Ellisseou and Megan Gerber to discuss this important topic. 

Pearls:

  • Trauma is widespread amongst our staff, trainees, patients and ourselves. COVID-19 is a traumatic experience that has affected all of us to some degree.

  • Trauma-informed care is one good framework for providing safe, healing and sensitive care that intentionally avoids retraumatizing people.

  • We can offer healing centered engagement where we try to partner with that person to find strength and move forward.

 

  • What is trauma-informed care?

    • Framework for providing quality, clinical care to survivors of various forms of trauma that involves understanding, recognizing and responding to the various effects that trauma can have on us as individuals and as a society

    • Emphasizes safety

    • Notion that healing happens through safe and collaborative relationships

    • Shift from “What is wrong with this person?” to “What happened to this person?”

  • Definition of trauma and importance:

    • SAMHSA (Substance Abuse and Mental Health Services Administration) defines with the 3 E’s:

      •  Specific Event Experienced as harmful with lasting adverse Effects

      • Six guiding principles:

        • Safety

        • Trustworthiness and transparency

        • Collaboration and mutuality

        • Peer support

        • Empowerment voice and choice

        • Cultural, historical, and gender issues

    • One study estimated at least 89.7% of US adult population will experience at least one traumatic event in their lifetime

    • 65% of adults in substance use treatment programs report history of childhood abuse

    • Adverse childhood events (ACE’s) are associated with physical and mental health conditions, substance abuse, depression, ischemic heart disease and an increase in mortality. People with 6 or more ACEs died nearly 20 years earlier than those without them

  • COVID pandemic and trauma:

    • Loss of social supports has had many downstream effects:

      • Reports of increased child and elder abuse

      • Straining relationships

      • Increased depression, anxiety, suicidality

    • Data from SARS pandemic showed an increase in substance use disorder, PTSD and worsened pre-existing mental health

  • Re-traumatization:

    • Medicine has the potential to open up old wounds and re-traumatize

    • Important to develop habits that don’t inadvertently re-traumatize patients

  • Trauma informed physical exam:

    • Three important guiding principles: safety, autonomy and trust

    • Nonverbal communication techniques:

      • Stand or sit at eye level

        • Consider anterior approach to the thyroid exam instead of from behind as it can simulate strangulation

      • Don’t make any sudden movements or sounds

    • Set an agenda that includes what you may be examining specifically

    • Consider a chaperone not just for female patients undergoing sensitive exams but also males and transgender individuals

    • During the exam:

      • Drape the patient appropriately

      • Ask permission before touching

      • Check-in with them periodically

      • Be efficient with the exam but also offer a break

    • Verbal communication:

      • Use simple clinical language

        • “Exam table” instead of “bed”

        • “I’m going to look at you or feel this” instead of “examine you and palpate this”

        • During the neuro exam, instead of "Put up your arms like you're going to fight and push me away" try "Bend at the elbows and push forward."

        • Omit “For me” (ie: “Take off your shirt for me”) to avoid enhancing the pre-existing power dynamic

    • After the exam:

      • Discuss results of the exam after they are dressed and comfortable in a seat of their choice

      • Ask, “What questions do you have?”

  • Telehealth and trauma-informed care:

    • SAMHSA six guiding principles:

      • Safety

        • Patients may choose their own environment that may not be their home (ie: car, park)

        • Headphones

      • Trustworthiness and transparency

        • Obtain permission before a physical exam and minimize removal of clothing

        • Open-ended questions like, “What is it you’d like to discuss today?”

        • Acknowledge noises that may come up in the background like trains or dogs barking

        • Dress professionally and far enough from the screen so they can see you as they would see you in clinic

      • Collaboration and mutuality

        • Thank patients for collaborating on the physical exam

        • Be careful about not cutting people off given the lag time on video visits. Trying counting to three in your head.

      • Peer support

        • Virtual groups

      • Empowerment voice and choice

        • Follow patient preferences regarding extent of the visit and that they can change the topic as needed

      • Cultural, historical, and gender issues

        • Communicate using affirming language

        • Consider social determinants of health

        • Lighting to make sure your face can be seen is very important

    • Resources:

      • Acesaware.org

      • Acesconnection.com

      • The National Council for Behavioral Health

      • The Trauma Informed Healthcare Education and Research Collaborative

 

References:

  1. Gerber M. Trauma-informed health care approaches: A guide for primary care. 1st ed. Springer; 2019.

  2. Gerber MR, et al. Trauma-Informed Telehealth in the COVID-19 Era and Beyond. Fed Pract. 2020;37(7):302-308. PMID: 32908333

  3. Azarang A, et al. Information Technologies: An Augmentation to Post-Traumatic Stress Disorder Treatment Among Trauma Survivors. Telemed J E Health. 2019;25(4):263-271. PMID: 30004318

  4. Bloom SL. The sanctuary model: developing generic inpatient programs for the treatment of  psychological trauma. In: Williams M, Sommer JF, eds. Handbook of post-traumatic therapy, a practical  guide to intervention, treatment, and research. New York: Greenwood Publishing; 1994: 474–49. 

  5. Blosnich JR, et al. Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry. 2014;71(9):1041-1048. PMID: 25054690

  6. Bremner JD. “Traumatic stress: effects on the brain”. Dialogues Clin Neurosci. 2006 Dec; 8(4): 445-461.

  7. Long D, et al. Building Trauma-Informed Connections via Telehealth during COVID-19. Webinar presented at: https://www.acesaware.org/events/2020-april-29-webinar/ 

  8. Casagrande, D., A Guide to Providing Telehealth During the COVID-19 Crisis. Webinar presented at:  https://www.acesconnection.com/blog/a-guide-to-providing-telehealth-during-the-covid-19-crisis 

  9. Elisseou S, et al. A novel, trauma-informed physical examination curriculum. Med Educ. 2018;52(5):555-556. PMID: 29572928

  10. Facts everyone should know about intimate partner violence, sexual violence & stalking: by understanding these types of violence, we can take action to stop them before they start in our communities. stacks.cdc.gov. Published September 8, 2014. Link

  11. Felitti VJ, 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. Am J Prev Med. 1998;14(4):245-258. PMID: 9635069

  12. Finkelhor D, et al. Children’s Exposure to Violence: A Comprehensive National Survey | Office of Juvenile Justice and Delinquency Prevention. Office of Juvenile Justice and Delinquency Prevention. Published October 2009. Accessed November 9, 2019. Link 

  13. Galea S, et al. The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. JAMA Intern Med. 2020;180(6):817-818. PMID: 32275292

  14. Gilmore AK, et al. "Do you expect me to receive PTSD care in a setting where most of the other patients remind me of the perpetrator?": Home-based telemedicine to address barriers to care unique to military sexual trauma and veterans affairs hospitals. Contemp Clin Trials. 2016;48:59-64. PMID: 26992740

  15. Hull HF. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis. 2005;11(2):354-355. PMID: 15759346

  16. Henry, BW, et al (2018). "Experienced practitioners'’ views on interpersonal skills in telehealth delivery." The Internet Journal of Allied Health Sciences and Practice. 16(2). Link

  17. Kilpatrick DG, et al. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013 Oct;26(5):537-47. PMID: 24151000

  18. Matchinger E, Lieberman A, Trauma and Resiliency-Informed Telehealth Care, Webinar presented at:  https://www.youtube.com/watch?v=6z7gwla__9M 

  19. McConnico N, et al. “A Framework for Trauma-Sensitive Schools: Infusing  Trauma-Informed Practices into Early Childhood Education Systems”. Zero to Three; 36(5): 36-44 May 2016. Link

  20. McFarlane AC. The long-term costs of traumatic stress: intertwined physical and psychological consequences. World Psychiatry. 2010;9(1):3-10. PMID: 20148146

  21. Morland LA, et al. Home-based clinical video teleconferencing care: Clinical considerations and future directions. Int Rev Psychiatry. 2015;27(6):504-512. PMID: 26619273

  22. PTSD: National Center for PTSD Home. Va.gov. Published January 8, 2021. Link

  23. Ramchand R, et al. Veterans and COVID-19: Projecting the Economic, Social, and Mental Health Needs of America’s Veterans – Bob Woodruff Foundation. Bob Woodruff Foundation. Published March 2020. Link

  24. Ravi A, Little V. Providing Trauma-Informed Care. Am Fam Physician. 2017;95(10):655-657. PMID: 28671409

  25. Robohm JS, Buttenheim M. The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation. Women Health. 1996;24(3):59-75. PMID: 9046553

  26. Scott E. Analysis | 4 reasons coronavirus is hitting black communities so hard. Washington Post. Published April 10, 2020. Link 

  27. APM Research Lab Staff. COVID-19 deaths analyzed by race and ethnicity, 04-24-2020. APM Research Lab. Published August 18, 2020. Link 

  28. Trauma and Violence | SAMHSA - Substance Abuse and Mental Health Services Administration. SAMHSA.gov. Published August 2, 2019. Link 

  29. Trauma Informed Care. Traumainformedcareproject.org. Published 2019. Link 

  30. Turgoose D, et al Systematic review of lessons learned from delivering tele-therapy to veterans with post-traumatic stress disorder. J Telemed Telecare. 2018;24(9):575-585. PMID: 28958211

  31. van Gelder N, et al. COVID-19: Reducing the risk of infection might increase the risk of intimate partner violence. EClinicalMedicine. 2020;21:100348. Published 2020 Apr 11. PMID: 32292900

  32. van Gurp J, et al. How outpatient palliative care teleconsultation facilitates empathic patient-professional relationships: a qualitative study. PLoS One. 2015;10(4):e0124387. Published 2015 Apr 22. PMID: 25902263

  33. Women Centered Health Podcast Trauma-informed Telehealth. http://womancenteredhealth.com/telehealth/

  1. ACEs Aware. https://www.acesaware.org  

  2. ACEs Connection. https://www.acesconnection.com 

  3. National Council for Behavioral Health. https://www.thenationalcouncil.org 

  4. National Collaborative on Trauma-Informed Health Care Education and Research. https://www.trauma-informedcare.com

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