The Substance Abuse and Mental Health Services Administration (SAMHSA^{1 )}defines the concept of a Trauma-Informed Approach as one that:

• Realizesthe widespread impact of trauma and understands potential paths for recovery;
• Recognizesthe signs and symptoms of trauma in clients, families, staff, and others involved with the system;
• Respondsby fully integrating knowledge about trauma into policies, procedures, and practices; and
• Seeks to actively resist re-traumatization.”

In my therapy practice, I found it more useful to assume that nearly every patient had a trauma history. The statistics bear this out². More than 1 in 3 women and more than 1 in 4 men in the United States have experienced rape, physical violence and/or stalking by an intimate partner. The majority of clients served by public mental health and substance abuse service systems are survivors of trauma.

Trauma also affects physical health. The CDC Adverse Childhood Experiences (ACEs)³ study (with 17,000 participants) revealed that 67% of the population has at least one ACE, and one in eight have four or more ACEs, a rate which correlates with worsened health outcomes: 2.5 times the risk of COPD or hepatitis, 4.5 times the risk of depression, 12 times the risk of suicidality. A person with 7 or more ACEs has triple the risk of lung cancer and 3.5 times the risk of ischemic heart disease.

It seems reasonable, therefore, for all health care providers to assume that their patients have experienced trauma and treat them accordingly, starting with understanding why medical offices can be so distressing for victims of trauma³.

1. Invasive procedures:

Problem: Much abuse involves sudden and unavoidable penetration (sexual or breaking of the skin). All ob-gyn procedures followed closely by shots and blood draws are guaranteed to be re-traumatizing.

Principle of a Trauma Informed Practice: Taking time. Allow the patient to control the timing (even as to whether a procedure is done during the current visit or the next visit). Provide a running verbal explanation of exactly what is happening, inquiring how the patient is tolerating the procedure, and maintain a total willingness to pause or stop based on the patient’s tolerance.

2. Removal of clothing and lack or loss of privacy:

Problem: The shame that accompanies forced nakedness in children or adults is often the most distressful part of the trauma. We tend to think that leaving a patient alone to disrobe and then knocking politely will do the trick. This can make the experience worse for victims who were forced to disrobe while their perpetrator lurked in the shadows.

Principles of a Trauma Informed Practice: Demonstrating awareness and knowledge of trauma and respecting boundaries. Remain client-centered by asking what would make them comfortable plus provide better gowns and coverings, especially blankets that provide heavier protection and warmth.

3. Physical touch and vulnerable physical positions:

Problem: One of the prime symptoms of chronic PTSD due to trauma is an exaggerated startle response when touched on most any part of one’s body. Unannounced and sudden touching is the worst.

Principle of a Trauma Informed Practice: Sharing information and control. Give patients the choice of having a trustworthy supportive person in the room with them. Signal every move and continually ask if it is hurtful or distressing. If possible, help the patient find a less vulnerable position.

4. Power dynamics of the relationship, gender of the health care provider, and personal questions that may be embarrassing or distressing:

Problem: Remember that trauma occurs when the child or adult is either physically or emotionally restrained by a more powerful person who uses their physical and mental power to overwhelm the victim and keep her/him silent.

Principal of a Trauma Informed Practice: Developing rapport and respect. The patient is THE expert on herself/himself. Your expertise is in the area of medical knowledge. Ask if the patient would be more comfortable with a person of another gender present in the room or doing the procedure. Never insist that any patient reveal the details of their trauma, but do provide a referral to counseling if desired.

References:

1. SAMHSA site: http://www.samhsa.gov/nctic/trauma-interventions
2. Shelly Virva, LMSW, Center for Integrative Medicine/Network 180, Trauma Informed Care Presentation, Integrated Clinics for High Utilizers Conference hosted by the California HealthCare Foundation, September 28, 2015 Documents Downloads available at http://www.chcf.org/events/2015/clinics-high-utilizers
3. Centers for Disease Control and Prevention (CDC). Adverse Childhood Experiences (ACE) Study. Available at http://www.cdc.gov/ace/

By: Karen Stephen, Ph.D., Mental Health Clinical Director