Breaking the cycle of patient trauma

In recent years, clinicians and staff at the Women's HIV Program at the University of California, San Francisco (UCSF), began to realize that HIV wasn't the primary problem hurting and killing their patients. Rather, it was unaddressed trauma, manifested by substance use, depression, suicide, and violence, said Edward Machtinger, MD, director of the program.

“We for so long had focused on the virus and a biomedical treatment model and had been very successful achieving virologic control with our patients,” he said. “But a murder of a patient awakened us to the fact that we actually weren't doing a very good job.”

Even though most of the clinic's patients had their HIV controlled, many were dying of preventable illnesses related not to HIV but to unaddressed trauma and post-traumatic stress disorder (PTSD), Dr. Machtinger said. About 40% were using illicit drugs, 50% were prescribed opioids for chronic pain, more than half were depressed, 80% weren't working, and most weren't “out” about their HIV status, he said. To more effectively address these problems and provide optimal care for patients, “We dedicated ourselves to completely transforming our practice to one that is trauma-informed.”

A trauma-informed approach in health care involves recognition of the widespread impact of trauma and its signs and symptoms in patients and clinicians, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). To become fully trauma-informed, health care systems should then integrate knowledge about trauma into their policies, procedures, and practices.

Experts explained how this approach can more effectively help patients heal from past trauma and current illnesses related to it, as well as offered tips on how internists can break the cycle of trauma for patients and families.

Why it matters

In September 2018, the trauma of sexual assault was top of mind for many as Supreme Court Justice Brett Kavanaugh responded to allegations during an intense confirmation hearing. In the following weeks, Eve Rittenberg, MD, noticed that many of her patients were struggling, as the news brought back memories of experiences with abuse and trauma inflicted by people with power. She reflected on their stories and the importance of trauma-informed care in a perspective piece published in November 2018 by the New England Journal of Medicine.

“The health consequences of trauma are what we treat every day in our practices. It's really important to understand the role that trauma has had in those health outcomes so that we can actually respond appropriately and effectively,” said Dr. Rittenberg, a primary care internist at the Brigham and Women's Hospital Fish Center for Women's Health in Chestnut Hill, Mass.

Trauma-informed care has long been a focus of research and practice in mental and behavioral health and pediatric medicine. Now, across medicine more broadly, there is a growing awareness that adverse childhood experiences (ACEs), such as childhood physical and sexual abuse or the mental illness or substance use of a parent, may be the most important social determinant of adult health and well-being, said Dr. Machtinger, who is also a professor of medicine at UCSF.

The evidence on the impact of ACEs on health outcomes goes back more than 20 years. For example, the CDC-Kaiser Permanente ACE Study, published in the May 1998 American Journal of Preventive Medicine, found that exposure to ACEs and household dysfunction during childhood was associated with later risky behaviors (e.g., alcohol and drug abuse) and conditions such as heart disease, cancer, and severe obesity.

But while a trauma-informed approach has been applied in other health fields for many years, adult medicine is only beginning to adopt it, according to Dr. Rittenberg. “Across the country, pediatrics is way ahead of internal medicine in terms of thinking about both assessment and screening for trauma, and then implementation of response to the trauma,” she said.

Dr. Machtinger agreed, adding that internists who adopt a trauma-informed approach will be helping not only their adult patients but traumatized children as well. “I think internists have the most powerful role in the health care system to reduce childhood trauma by helping adult parents and caregivers heal from the impacts of their own trauma, like substance use and mental illness, and, in that way, interrupt generational cycles of trauma,” he said.

But too few clinicians have learned that it's possible to interrupt the link between trauma and health within health care settings or have the resources to do so, Dr. Machtinger noted. “As a result, despite really wanting to address social determinants of health and well-being, most internists are not familiar with how to provide trauma-informed care.”

Changing practice

A trauma-informed approach traditionally involves six key principles, according to SAMHSA: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues.

Dr. Machtinger noted that the model of trauma-informed care is aspirational, as few clinics and clinicians have the services in place to be fully trauma-informed. “But in the meantime, there's so much people can do to move towards trauma-informed approaches that can be more effective for patients and much more satisfying for clinicians.”

To help clinicians take these first steps in adult health care settings, Dr. Machtinger and a team of national trauma experts developed a framework for inquiring about and responding to past trauma. The paper, which was published with open access in the January 2019 Women's Health Issues, offers four options for asking about past trauma and notes the importance of a calm, safe, and empowering environment.

Internists who want to create such an environment can think about what they can do to help patients feel safe, Dr. Rittenberg said. For example, if people feel like their PTSD is triggered by being in a small enclosed room for a long time, then let them sit with the door open, she suggested.

Also, asking patients for permission before physically examining them gives them more control and the ability to guide their care in a way that's most comfortable, said Dr. Rittenberg, who is also an assistant professor at Harvard Medical School in Boston.

In addition, when documenting patient histories that are sensitive, “Letting people see what you're writing can be really helpful, particularly in cases of abuse or trauma, because what you write is going to be with the patient forever,” she added.

While many clinicians might be hesitant to change practice due to concern that it could be time-consuming, a trauma-informed approach is more of a philosophy than another burden, Dr. Machtinger said. “Most of us went into medicine to be healers and not just treaters, and we've seen our field be reduced to 15-minute-long visits and an emphasis that is strongly on biomedical interventions and checkboxes. … Trauma-informed care isn't another checkbox.”

Dr. Rittenberg agreed. “I think it's really a shift in how we provide care that we're already providing,” she said, recalling an example of a patient with typically well-controlled hypertension who came to clinic one day with out-of-control blood pressure.

A traditional approach might have been to ask the patient if she wasn't taking her medications or exercising, or to consider adding another antihypertensive medication. However, Dr. Rittenberg's approach was to ask the patient what she thought was making her blood pressure higher that day. She uncovered a story of the patient's father having cardiac arrest at the dinner table and being rushed to the hospital before recovering in the ICU and returning home.

“She said, ‘I walked in this room, and it was like the hospital all over again and I just freaked out. I can't be here,’” Dr. Rittenberg said. “That conversation with her led to a completely different set of interventions than it would have if I had not asked in that way.”

Teaching the next generation

Practicing internists aren't the only newcomers to trauma-informed care. Since internal medicine training does not traditionally cover ACEs, many trainees are also unaware of the health impacts of trauma, said Martina Jelley, MD, MSPH, FACP, professor and vice chair for research for the department of internal medicine at the University of Oklahoma School of Community Medicine in Tulsa.

About five years ago, she worked with other faculty members to begin to change that. “This was a whole new world. … We weren't really able to find a curriculum that somebody had already put together, so we decided to start doing some simulation training,” said Dr. Jelley.

In addition to didactic sessions, the curriculum uses standardized patient actors to teach primary care residents communication skills about ACEs. To create the communication curriculum, which has evolved over the years, faculty members wrote cases based on real patients they had seen in their internal medicine and family medicine clinics, Dr. Jelley said.

In the simulation training, the residents each see a standardized continuity patient and are asked to broach the subject of ACEs when clinically appropriate. “They have to bring up the topic of, ‘You know, when we see patients that have a lot of symptoms we're not able to explain, sometimes we think about something else that might have happened to them in the past,’ and go on in that direction,” said Dr. Jelley.

Then comes the end of the visit: What's next? “It might be something like, ‘Let's talk about it next time,’ or ‘Why don't you look up some stuff about this on your own to learn more about it and see if this might apply to you?’ or ‘Can I set you up with a counseling session with one of our counselors?’” she said. A faculty member and another resident watch from outside the room and after the encounter provide immediate feedback in a five-minute debrief.

The program, which has evolved over the years, also teaches several metaphors that can help explain concepts to patients, Dr. Jelley said. For example, one metaphor likens childhood trauma to putting bricks in a backpack and carrying it throughout one's life. “You don't really see it all the time. Sometimes you're not even sure that it's there, but it's weighing you down and it's not allowing you to move forward,” she said. “Maybe we won't be able to take the backpack off completely, but maybe we can unload some of the bricks from the backpack.”

So far, more than 700 trainees have completed simulations, which have all been videotaped, Dr. Jelley said. Primary care residents learn the curriculum for all three years, and training has now expanded to include third-year medical students, nursing students, social work students, and physical and occupational therapy students, she said.

From awareness to action

A physician who wants to adopt a more trauma-informed way of practicing does not need to use a formal approach, said Dr. Jelley, whose own clinic is not fully trauma-informed. “If your health care system is not really trauma-informed, that doesn't mean that you as an individual clinician can't bring up the topic, talk about it with your patients, and try to work on some interventions,” she said.

While there is debate about screening for ACEs (see sidebar) in adult populations, Dr. Jelley said she is an advocate for case finding, or screening patients who have chronic or unexplained health issues or other red flags. “That's going to keep us very busy for a long time, and then we can figure out whether we should be screening everybody or not in the future,” she said, adding that, for whatever reason, some people with high ACE scores are very resilient, have few problems, and may not benefit from being labeled.

For health care systems interested in adopting a trauma-informed approach, change can be implemented on a continuum. The Missouri Model, developed in 2014 by a multidisciplinary group of Missouri organizations representing health care, mental health, and youth services, defines four levels of the process for organizations: 1) trauma aware, or learning about the prevalence of trauma and considering the potential impact on patients and staff, 2) trauma sensitive, or exploring the principles, building consensus around them, and preparing for change, 3) trauma responsive, where staff begin rethinking the routines and infrastructure of the organization, and 4) trauma informed, where the full model is accepted and thoroughly embedded in culture and practice.

“Understanding where you are on that continuum allows you to harness the resources that are already in place and understand where additional resources can be targeted,” said Dr. Machtinger, the Women's HIV Program director at UCSF.

In 2016, a few years after the program began to focus on trauma-informed approaches, the Robert Wood Johnson Foundation funded a national demonstration of trauma-informed care at six sites, including the UCSF program. When this initiative got started, Dr. Machtinger thought it would be a good idea to partner with another agency in the city that was experienced with trauma.

However, when he announced the new partnership to staff members, he didn't get a warm response. “What I encountered was a staff that was deeply offended because many of them were already practicing with an awareness of trauma and using trauma-informed techniques,” said Dr. Machtinger. The clinic already had many of the necessary resources, such as a social worker, but he did not know where it fit on the trauma-informed care continuum and how to organize and add to existing resources.

To work toward becoming a trauma-informed organization, the clinic offered nine hours of training (three sessions of three hours each) to all staff, including clinicians, receptionists, and administrators. Even social workers and case managers with experience in trauma found the training to be helpful because it offered an underlying philosophy to organize their system of care for complex patients, Dr. Machtinger said. Now, his group is doing a prospective study to refine the model of trauma-informed primary care in hopes of providing the evidence necessary to support the model as standard of care.

At Partners HealthCare in Boston, Dr. Rittenberg and colleagues are developing education and training modules in trauma-informed care. She has also been giving workshops, training, and presentations to Harvard Medical School students. Training doesn't focus only on patients but on support for clinicians and staff as well, Dr. Rittenberg said.

“The stories of patients with trauma histories are often very difficult to hear. I think health care providers can have effects of vicarious trauma from the work that we do,” she said. “Peer support for each other as we engage in this work and our own self-care is really an important component.”