Providing Trauma-Informed Care
Am Fam Physician. 2017 May 15;95(10):655-657.
A 52-year-old woman who is a patient at our group practice made a walk-in visit to our clinic for treatment of bothersome vaginal discharge. She was accompanied by her five-year-old grandchild. I was covering for her primary care physician, and this was my first time meeting this patient. I offered to perform a speculum examination to address her vaginal discharge and to complete a Papanicolaou (Pap) smear because cervical cancer screening was not documented in her chart. However, she declined a speculum examination, stating, “I don’t really do those.” She was otherwise engaged in conversation, and remarked that the demands of her job as an administrator have caused her to miss many appointments. My colleague later informed me that the patient had experienced significant sexual trauma in her past and does not feel comfortable with speculum-based examinations. How could I have sensitively addressed this patient’s health care needs?
Family physicians commonly care for survivors of trauma, but they may not always realize it. Trauma, which can affect any patient regardless of age or sex, is broadly defined as the experience of violence or victimization, including sexual abuse, physical abuse, psychological abuse, neglect, loss, domestic violence or the witnessing of violence, and terrorism or disasters.1 Survivors of trauma experience poorer health outcomes, including onset of chronic medical and mental health conditions, at a higher rate than those who have not experienced trauma.2 Furthermore, shame and stigma may prevent survivors from disclosing their trauma histories during clinical encounters.3 For these reasons, it is important to incorporate trauma-informed care into practice as a universal precaution to optimally address patients’ health care needs while decreasing the risk of retraumatization.4 The core principles of this care include the four R’s: (1) realizing the widespread impact of trauma; (2) recognizing signs and symptoms of trauma, including in patients and their families and in staff and clinical team members; (3) responding by fully integrating knowledge about trauma into policies, procedures, and practices; and (4) seeking to actively resist retraumatization.5
SIGNS AND SYMPTOMS
Clinicians may find it challenging to identify patients who have experienced trauma. Signs and symptoms can vary depending on the type, frequency, or duration of trauma and the time elapsed since trauma was experienced. Clinical presentations may include vague, generalized symptoms, such as abdominal or pelvic discomfort, sexual dysfunction, headaches, or chronic pain, and mental health symptoms that suggest depression, anxiety, or posttraumatic stress disorder.3,6 Certain behaviors can also serve as coping mechanisms for these trauma-related symptoms, including smoking, alcohol and drug use, disordered eating, and high-risk sexual behaviors.4 Some persons may have a higher likelihood of experiencing trauma, including those who are entangled with the legal system and persons with a disability, as well as refugees, veterans, or those who identify as lesbian, gay, bisexual, transgender, or queer.6–9 More broadly, inconsistent patterns of clinical care, such as multiple missed appointments or missed health maintenance examinations or interventions, may also be associated with trauma-related behaviors. Fear of retraumatization can limit survivors’ use of health care services to emergency and acute care visits and lead to avoidance of routine primary care.6
APPROACH TO CARE
When trauma is suspected, multiple techniques can be useful for approaching the topic with a patient.10 First, it is important to create an environment where patients can feel comfortable disclosing trauma. For example, in scenarios such as this one, it may be helpful to ask support staff if they are available to assist with child care during a portion of the caregiver’s visit. Emphasizing confidentiality and using prompts that are normalizing or provide rationale for inquiry into past trauma may also be helpful. The clinician could begin this discussion by saying, “Because abuse and violence are common and can affect a person’s health, I make a point to ask patients if they have ever had these experiences.” It is important that clinicians be prepared to effectively respond to potential disclosure. This includes providing empathetic responses during the encounter and adequate care afterwards (e.g., by identifying resources or scheduling a follow-up appointment, if the patient desires). Survivors have expressed a range of preferences in how they wish to be asked about trauma, including being asked directly or indirectly about these experiences. Resources on trauma-informed approaches, including how to discuss the topic of trauma with patients, are listed in Table 1.
REFERENCESshow all references
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2. 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.
3. Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698–709.
4. Raja S, et al. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health. 2015;38(3):216–226.
5. Substance Abuse and Mental Health Services Administration. Trauma-informed approach and trauma-specific interventions. http://www.samhsa.gov/nctic/trauma-interventions. Accessed March 25, 2016.
6. Street A. Trauma-informed care for women veterans: lessons learned from research and clinical care. Talk presented at: Society for General Internal Medicine Annual Meeting; April 24, 2014; San Diego, Calif. http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/900-notes.pdf. Accessed March 6, 2017.
7. Dierkhising CB, et al. Trauma histories among justice-involved youth: findings from the National Child Traumatic Stress Network. Eur J Psychotraumatol. 2013;4
8. Shannon PJ. Refugees’ advice to physicians: how to ask about mental health. Fam Pract. 2014;31(4):462–466.
9. Emerson E, et al. The developmental health of children of parents with intellectual disabilities: cross sectional study. Res Dev Disabil. 2014;35(4):917–921.
10. Schachter CL, et al. Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Abuse. http://www.integration.samhsa.gov/clinical-practice/handbook-sensitivve-practices4healthcare.pdf. Accessed March 28, 2017.
11. Reproductive Health Access Project. Trauma-informed pelvic exams. http://www.reproductiveaccess.org/resource/trauma-informed-pelvic-exams/. Accessed March 6, 2017.
12. Clardie S. Post-traumatic stress disorder within a primary care setting: effectively and sensitively responding to sexual trauma survivors. WMJ. 2004;103(6):73–77.
13. Hemmings S, et al. Responding to the health needs of survivors of human trafficking: a systematic review. BMC Health Serv Res. 2016;16320.
14. Kelly JF, et al. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010;21(3):202–207.
15. Kelly JF, et al. Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. J Drug Issues. 2010;40(4):805–818.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
Please send scenarios to Caroline Wellbery, MD, at firstname.lastname@example.org. Materials are edited to retain confidentiality.
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