I decided to write a piece in response to the CFHA listserv discussion on detecting and addressing trauma in primary care.
As I watched the messages from my colleagues trickle in about how to address medical providers’ unease discussing trauma with their patients I paused and knew my contribution would be forthcoming. I have done a significant amount of work in my clinics to promote, train, and implement Trauma Informed Care (TIC) across our clinical system. The questions that were being asked on the listserv were real. They are the questions that my colleagues and I grapple with. How do we to address trauma in primary care? How do we prepare and support medical providers to do this work?
Why are we so uncomfortable with topics like trauma, with intimate partner violence, with suicidal ideation? The answer is complex and simple at the same time, these are not easy topics to talk about. Partially because they are sensitive, partially because they carry stigma, and partially because they are so prevalent that those having the conversations may be personally affected by them. Regardless of these factors, there is growing evidence for trauma informed care in medical settings. This work has been supported by agencies like SAMHSA, HRSA, and National Council for Behavioral Health.
I recently was asked to teach TIC to 3rd year medical students. In fact, one of our learning objectives was, “develop comfort in addressing a trauma disclosure with a patient.”
The first question I get in the class is should we be screening for trauma or PTSD. The listserv discussion included thoughts on universal screening for ACEs and PTSD in primary care patients. Although I think that screening is appropriate for some sub-populations served in a primary care setting, I have not yet seen robust evidence that this type of screening in a general primary care population leads to improved outcomes. As mentioned in the listserv discussion the USPSTF has not yet issued a guideline for screening for trauma or PTSD.
In the listserv discussion, there was a call for medical providers to provide validation, empathy, and sensitivity to patients with a history of trauma as an intervention that seems feasible and realistic for primary care providers to implement. It was pointed out that these should not just be applied to patients with a history of trauma or PTSD, but to all patients. I endorse this idea and will take it a step farther by suggesting that validation, empathy, and sensitivity should be applied in the context of trauma informed care and a universal precaution approach.
These three qualities (validation, empathy, and sensitivity) fit perfectly into the formal conception of trauma-informed care: fostering safety, autonomy, and trust in the patient-healthcare provider relationship. When operating with the universal precaution approach, direct screening is not necessary. We approach all patient care, every interaction, with the principles of trauma informed care including safety, trustworthiness & transparency, peer support, collaboration & mutuality, empowerment, voice, choice, and cultural, historical, and gender issues.
Being trauma-informed means that one can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization. It is important to remember that trauma-informed is different than trauma specific or trauma sensitive.
So, what did I teach my 3rd year med students? We discussed how to ask about trauma and how to respond to a trauma disclosure. I introduced the five points below. I hope these can help you in your practice. You may even want to share them with a colleague.
Use a Trauma Education Statement. It is important that we explain why you are asking about trauma in the context of their medical care and that we acknowledge the impact of trauma.
“We’ve learned a lot about how abuse, neglect, and chronic stress can lead to health issues like chronic pain...
“What we know about trauma is that people who have been exposed to abuse or have had bad things happen to them are more likely to have certain health problems like chronic pain…”
Inquire about the patient’s experience. I suggest to my students that the first time we bring trauma up we are simply planting a seed. I encourage them to lead with curiosity and compassion. I emphasize that it is important that we let our patients know it is not necessary to gather details for them to be able to help.
“I wonder if you have had some experiences like this in your past…”
“I don’t need to know the details of anything that may have happened to you. I wonder if you have experienced emotional, physical or sexual abuse in your past…”
Create safety. Once someone has shared about their experiences it is crucial that we validate their emotions and experiences. We also must act as a container and prevent activation and emotional dysregulation.
“You don’t have to share details with me. I want you to know that you can talk with me about these experiences and how they may be affecting you now.”
“I want to acknowledge that these are really hard things to talk about for most people because talking about them can bring up emotions or you might feel like you are reliving what happened to you.”
Addressing a disclosure. This is where my students felt the most unprepared. I encourage them to thank their patient for sharing their story. And I encourage them to connect how knowing the patient’s history can help them provide better care.
“Thank you for sharing your story with me because it really helps me understand the whole picture of your health and how you live your day to day.”
“Thank you for telling me this. Given what we know about certain health conditions and trauma, this will help your healthcare team provide better care.”
Preventing and reducing activation. If you begin to notice that your patient is fidgeting, playing with something in their hands, rocking in their chair, avoiding eye contact or seems “checked out” they may be activated or dissociated from retelling their experiences. I teach that in these moments it is ok to interrupt their story. Validate their experiences and emotions and explain that reliving emotions and telling the details of an experience is not necessary for you to help.
“I’m actually going to interrupt you because I can see that this is really distressing and hard to talk about and I don’t want you to have to feel the emotions that go with those experiences.”
“This sounds like this was a really significant event in your life. I want you to know that you don’t have to tell that story because you don’t have to relive the emotions that you experienced.”
If you have questions or if you wish to have further conversation about this topic, feel free to contact me at email@example.com.
Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.