Trauma Informed Care – What You Can Do In Your Practice

PHC has had intensive care management programs in many of our FQHCs since 2012.  These care management programs will be evolving into our health homes programs in 2017.  Health Homes is an evolution of the patient centered medical home with an increased focus on substance abuse, integration of mental and behavioral health with medical care and a more intense effort to work with homeless members.

One of the new components in patient assessments will be a look at how trauma has affected the lives of our patients.  How serious is this problem?  Here are a few statistics:

  • Over half of women (55 to 99%) in substance abuse treatment report trauma
  • Nearly all women in the public mental health system (85 to 95%) have had trauma
  • Nearly all homeless veterans suffer PTSD
  • Trauma exposed youth have arrest rates 8 times that of same age peers
  • The economic costs of untreated trauma-related alcohol and drug abuse are estimated to have been $161 billion in 2000.

The Substance Abuse and Mental Health Services Administration (SAMHSA) concept of the trauma informed approach defines a trauma informed system of care:

  • Realize the widespread impact of trauma and understand paths to recovery
  • Recognize the signs and symptoms of trauma
  • Respond by integrating policies and procedures in your practices
  • Resist re-traumatizing patients

The goal is recognizing the effects of trauma on our patients is to provide an emotionally and physically safe environment for our patients.

How can you know if trauma is playing in a role in your patient’s behavior or choices?  You might start by asking about his or her childhood or how things are going at home.  Once you get a feel for whether trauma has affected your patient you may be able to be more direct in your questioning. The Life Events Checklist has 17 specific traumatic events, but you can consider a shorter list that we will be implementing into our PHC health risk assessments.

Have you been involved in or exposed to:

  • A natural disaster such as a flood, fire or earthquake?
  • Combat or a warzone?
  • Physical or emotional abuse?
  • Sexual abuse or assault?
  • Sudden violent death or unexpected death in someone close to you?
  • Any serious harm, injury or death caused by you?

Trauma is treatable. There are many evidence-based models and practices to help heal our patients and improve the behavioral manifestations of trauma.  A history of trauma is often hidden or denied and we don’t often ask about trauma in our patients with problematic behaviors.

How will this play out in your practices?  The next time someone acts out in your practice, consider asking “Can you tell me what happened to you?” instead of “What’s wrong with you?” You may be surprised at the answer.

And Now for Something Completely Different….

While most people associate “magic mushrooms” and “X” with illicit drug use some recent research indicates these substances may have a role with some of the most difficult-to-treat psychiatric patients.

Two studies published in the December edition of the Journal of Psychopharmacology used psilocybin and similar study designs to treat cancer patient’s depression and anxiety. Previous studies have (unsurprisingly) shown high rates of both conditions in cancer patients with life-threatening diagnoses along with difficulty in adequately treating these same conditions leading to a variety of poor outcomes. (e.g. decreased survival rates, increase in suicides, decreased function, among others)

Utilizing a crossover study and high or moderate dose of psilocybin versus placebo or very low dose psilocybin both studies found not only a marked improvement in both depression and anxiety scores but also improving measureable factors such as spiritual wellbeing, general life satisfaction, and quality of life, life meaning, and optimism, while decreasing cancer-related demoralization and hopelessness, and death anxiety. Even more remarkable the effect on depression and anxiety (with reduction rates as high as 80%) persisted for 6-8 months with only a single dose of psilocybin!!  Both studies even used a Mystical Experience Questionnaire (MEQ30) which “is a self-report questionnaire that evaluates discrete mystical experiences induced by serotoninergic psychedelics and is sensitive to detecting psilocybin-induced mystical experiences.” As an additional benefit, no subjects in either study suffered from any serious side effects.

 

Along this same vein the FDA announced this week that based on the success of small drug trials it is allowing large-scale Phase 3 clinical trials to study the use of MDMA, or Ecstasy, for patients with severe PTSD. The Multidisciplinary Association for Psychedelic Studies (MAPS), a non-profit group that advocates for the medical use of banned drugs, sponsored six Phase 2 studies that led to the FDA’s decision.

In 2 of the trials they studied combat veterans, sexual assault victims, firefighters and police officers that suffered from PTSD and had not responded to previous treatments. The average duration of symptoms was 17 years! Subjects were given 3 doses of MDMA a few weeks apart under supervision of a psychiatrist along with psychotherapy. This was also a crossover study.

One study showed a 56% decline in severity and by the study conclusion 2/3 no longer met the criteria for PTSD. In addition improvements persisted for over a year. The researchers have applied for “breakthrough therapy status” with the FDA which could allow approval by 2021. Other researchers urge caution, using the opioid crisis as an example of how the drug could be abused.

As a historical aside, MDMA was first patented in 1914 but in 1978 it was resynthesized by chemist Dr. Alexander Shulgin. (Dr. Shulgin was my toxicology professor during my MPH studies at UC Berkeley – an interesting man to say the least!) He gave it to friends in the psychiatric field to use for augmenting psychotherapy but when it spread to more general recreational use the FDA classified it a Schedule 1 drug and initial research was halted.

The results so far are promising but likely a long way off for routine clinical use.

BETTER DESIGNS FOR CARE – THE CASE OF PALLIATIVE CARE

Recently, Collabria Care hosted an annual symposium on palliative care that drew over 80 physicians, nurses, social workers and others to American Canyon to consider the advances in palliative care. This annual event is jointly sponsored by Partnership HealthPlan of California.

Each speaker over the two day symposium offered challenges for daily practice in palliative and end of life care. None was more challenging, dare I say, ground-breaking than the last presentation of the symposium by BJ Miller titled “Not Whether, But How: Exploring the Potential of Palliative Care”. Dr. Miller is a palliative care specialist at UCSF, and an internationally-renown thinker and speaker (see his TED talk at https://www.youtube.com/watch?v=apbSsILLh28 ) who brings design thinking to the reformation of palliative care.

His hour-long talk was part philosophy, part design, and wholly focused on the care that we give our patients who have serious illness and are moving towards the end of life. His prime challenge to us was how to move from a disease centered to a human centered approach to care. He reproached current medical systems who are locked into the increasing complexity and technologies of diagnosis and therapy, and miss the opportunity to address what really matters to patients that he identified as:

  • Not being a burden, esp financially to family and loved ones
  • Spiritual peace
  • Community and communion of loved ones
  • Respect for culture and traditions

He challenged us to move beyond the dualities that our health system has set up, and which impede human centered care. These include:

  • Acute vs chronic. Where is continuity and continuum of care in our system?
  • Intervening vs. supporting. Our system is geared towards doing, often because we can rather than because it is best for the patient. How does our health system support the needs of patients which are different than the needs of the providers?
  • Curing vs. healing. Does our health system truly understand what is meant by healing which is more than the elimination or control of disease?
  • Quality of health vs. quality of life. The focus of health systems is to restore physical health rather than achieve the patient-desired quality of life.
  • Less horrid vs. more wonderful. I love this paradigm where a health system moves beyond alleviating suffering (particularly physical) to a system that strives to bring delight and meaning to the people it serves. In other words, a system that brings wonder and creates an environment and state that is more wonderful. Contributing to the “horrid” mindset is our health systems proclivity to define illness, suffering, disability, aging, and dying as “abnormal” which need to be normalized.
  • Self vs other. Our health systems are constructed on the model of we, the care providers, doing to they, the patients in need, who are often categorized and compartmentalized by their disease state (we have pediatric floors, medical floors, surgical floors etc). How could we envision a system where we the dying are caring for others who are also dying. I am reminded of Gayle Stephens (one of the fathers of family medicine) who advocated person centered care defined as care of a person by a person.

Dr. Miller emphasized two other design keys. First is “proportionality”. We have a health system that can’t help itself, is so taken by the awesomeness of its capabilities that it “bestows” on patients often more than is desired, more than is needed, leading to more suffering rather than less.  Related to the first is the tyranny of choice. Too often “what can be done (choices) takes precedent over what is best for the patient (as negotiated in communion with the patient)”.

As with many other sectors of society, healthcare is enamored of words which are latinzied and too often not understand by the user or recipient. Dr. Miller challenged us to think beyond words, to the realm of experience and how health systems can design and use experience to care for patients.

Finally, and perhaps most radically, Dr. Miller challenged us to move beyond the healthcare paradigm that is wrapped into a time continuum of past into future. Palliative care buys into this paradigm through disease and outcome prognostication. His final (or at least what he left us to ponder) challenge was how to create a system where patient-provider and all their individual and amalgamated meanings converge in the real time of the present.

I walked away exhilarated and inspired that these design principles not only apply to the domain of palliative care but all of health care. There is hope that in the redesign of palliative care will be a blueprint for the rest of healthcare.

Scott Endsley MD, Associate Medical Director for Quality