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Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e
Chapter 36:Trauma and Trauma-Informed Care
Leigh Kimberg
OBJECTIVES
Define trauma.
Describe the risk and protective factors for trauma.
Review the eects of trauma on health.
Review how childhood trauma results in adulthood disease and poor outcomes.
Describe ways of addressing trauma in health care.
INTRODUCTION
Marta is a 23-year-old woman who brings her healthy 3-year-old child in for a check-up with her new family
practice provider. She presented to her prior provider’s oice with severe headaches many times and has
had an extensive workup. Today, she appears depressed and overwhelmed and says she cannot concentrate
due to the headaches. When her new provider asks compassionately why Marta thinks she has headaches,
Marta wonders if it could be that her father used to slam her head against the table if she did not know the
answers to questions. Upon further questioning, Marta’s provider learns that Marta’s mother died when she
was a baby. She was the youngest of six children in a poor family in Mexico. Her father was particularly
abusive to her. When she was 16 she was taken to an older man’s house and told that she was now married to
him. She fled across the Mexico–US border. She does not want to talk about the journey across the border.
Marta reveals to her new provider that she is worried that she does not know how to be a good mother.
Trauma is a leading cause of morbidity and mortality worldwide. Traumatic experiences refer to everything
from being in a car accident to witnessing terrible events, being abused, or living through a natural disaster
or a war. Traumatic events are more disruptive and likely to overwhelm a person’s ability to adapt than the
normal stresses and vicissitudes of life. Trauma’s risks also multiply: being exposed to one traumatic event
increases both individual and community risks for future traumatic events. The impacts of trauma are
dependent on individual and community vulnerabilities, resources, and protective factors. Trauma,
especially in childhood, causes health disparities. It is a root cause of adult disease and high-risk behaviors.
Trauma also disproportionately aects the most vulnerable people and populations. Trauma prevention and
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treatment are evolving and improving. Addressing trauma in the health-care setting holds the potential to
more eectively improve health, decrease suering, and promote the achievement of health equity.
DEFINITION OF TRAUMA AND TYPES OF TRAUMATIC EVENTS
Defining trauma is challenging. The term “trauma” is oen used interchangeably and inconsistently to refer
to events and to the outcomes of the events. Defining an event as traumatic depends on the totality of
circumstances. Each person may respond to a similar event dierently based upon the circumstances
surrounding the event and the interplay between genetic, epigenetic, biological, psychological,
environmental, family, community, societal, historical, and other factors. Thus, most experts now understand
that trauma is a
process
that involves the interaction between an event or series of events and the individual
and community’s vulnerability, protective and resiliency factors. If an event or series of events overwhelms
the person or community’s capacity to adapt in a positive manner and instead lead them to suer adverse
consequences, then the event is considered traumatic.
In discussing trauma the terms individual trauma and complex trauma are oen used. The Substance Abuse
and Mental Health Services Administration (SAMHSA) defines individual trauma
(http://www.samhsa.gov/nctic/about):
Individual trauma: “
Individual trauma results from an event, series of events, or set of circumstances that is
experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse
eects on the individual’s functioning and physical, social, emotional, or spiritual well-being
.”
Complex trauma or complex psychological trauma, on the other hand, is defined as
“resulting from exposure
to severe stressors that (1) are repetitive or prolonged, (2) involve harm or abandonment by caregivers or
other ostensibly responsible adults, and (3) occur at developmentally vulnerable times in the victims’ life,
such as early childhood: …
”1 but, can also occur later in life.
Trauma may happen to individuals and to entire communities or cultural groups. A traumatic event may be a
one-time occurrence. Much more oen, it is a series of traumatic events or prolonged exposure to traumatic
circumstances. Events or experiences that are traumatic for human beings include catastrophic
environmental events (both natural and human influenced); various types of accidents; large-scale violence
(e.g., war, genocide, torture, human traicking, terrorism, and forced migration); “structural violence” that
involves systematic oppression or discrimination (e.g., racism, homophobia, and transphobia); interpersonal
violence, family violence, childhood or adult sexual assault, abuse and neglect (see Chapter 35); and life
events that reduce trust or a sense of safety and security such as the death of loved ones, divorce of one’s
parents, major illness, or other life upheavals. This chapter focuses mainly on traumatic events that involve
some type of individual interpersonal violence, abuse, or neglect. Nevertheless, to understand, treat, and
prevent interpersonal violence, consideration of the broader societal context is necessary.
PREVALENCE OF TRAUMA
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Exposure to some form of trauma is exceedingly common. Traumatic deaths represent a small fraction of the
total burden of trauma. Globally, more than 5 million people die annually of injuries. These traumatic deaths
represent 9% of all deaths worldwide and exceed the deaths from HIV/AIDS, malaria, and tuberculosis
combined.2 In 2011 in the United States, injuries, including all causes of unintentional and violence-related
injuries combined, accounted for 51.3% of all deaths among persons 1–44 years of age (more deaths than
noncommunicable diseases and infectious diseases combined).3 In 2012, homicide was the third leading
cause of death for 15- to 34-year-olds and the fourth leading cause of death for 1- to 14-year-olds in the
United States.4 Almost 90% of a national random sample of US residents (who had Internet access) has
experienced exposure to a very serious traumatic event (meeting DSM-5 criterion A).5 Exposure to physical or
sexual assault over the lifespan for adults in this sample was 53.1% (see Chapter 35).
In one of the largest, most comprehensive studies of the eects of childhood trauma on adulthood disease,
the “Adverse Childhood Experiences” (or “ACE Study”), the high prevalence of trauma occurring during
childhood has been highlighted.6 In this study, 17,337 adults enrolled in care in Kaiser Permanente’s Health
Appraisal Clinic in San Diego completed questionnaires about 10 categories of traumatic events (called
“adverse childhood events” or “ACE’s”), including childhood emotional, sexual, and physical abuse; neglect;
and familial dysfunction (i.e., witnessing of parental domestic violence, separation, or divorce; or mental
illness, substance use or incarceration in a household member). Each category of adverse events is scored as
either present or absent and given one point. In this predominantly white, middle-class population, 63.9% of
the participants had experienced at least one ACE category and 12.5% had experienced four or more ACE
categories. Having one ACE markedly increases the risk of having more than one ACE. Twenty-five percent of
the women and 16% of the men reported childhood sexual abuse, a traumatic event rarely identified in the
health-care setting.
While adverse childhood experiences are quite common in all communities and the overall ACE score does
not vary widely by race/ethnicity, they are more common in communities plagued with adversity such as
poverty, low educational attainment, and low employment.7,8 The ACE study also does not measure
adversity that exists outside of the family and household, such as community violence or structural violence.
The burden of overall trauma in urban underserved communities is thought to approach that of conflict-
ridden developing countries.9 The Institute for Safe Families in Philadelphia has developed an “Urban ACE
score” that includes measures of witnessed community violence, adverse neighborhood experiences,
bullying, and discrimination.10 The World Health Organization has developed and is validating an “ACE
International Questionnaire” that includes additional questions related to forced marriage, peer violence,
exposure to community violence, and war and collective violence (link:
http://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/en/)
The prevalence of trauma in certain disease states is startling high. Increasingly, these diseases are seen as
symptoms of the larger epidemic of trauma. For example, among women living with HIV, the rate of intimate
partner violence (IPV) is 55%, which is even higher than the rates among national samples of women (36%).
The rates of childhood sexual abuse and physical abuse are 39% and 42%, respectively, more than twice the
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national rates of 16.2% and 22.9%. Lifetime sexual abuse among women living with HIV is 61%, more than
five times the national rate (12%).11
RISK FACTORS FOR TRAUMA
David lives with his mother in a neighborhood plagued by community violence, drug dealing, and chronic
neglect by city government. David’s father was arrested for domestic violence against his mother when he
was 5 years old. As a young child, an uncle who lived with his family sexually abused him. David never told
anyone. He attends an overcrowded, under-resourced, and underperforming school where he is frequently
bullied and does very poorly in school. His mother, who works multiple jobs, spends hours commuting to
work. She is never able to be home to care for David until very late in the evening. At the age of 16, David
drops out of school, joins a gang for protection, and is shot in the leg in gang-related violence.
INTERPERSONAL VIOLENCE
Abuse and violence have been characterized as occurring within the context of an ecological model that
takes into account individual, family, community, societal, and macrosocial factors (see Figure 35-1).12 In this
model, all forms of interpersonal violence are interrelated and there are common risk and protective factors
that create conditions in which violence takes root or is prevented.13 Any characteristic that is associated
with diminished real or perceived power and status in society may be a risk factor for increased exposure to
many traumatic events and experiences (Box 36-1).
Box 36-1.Risk Factors for Trauma
Lack of safe, stable, nurturing relationships
Young age
Female sex for IPV/sexual violence
Male sex for community violence
Minority status (race, ethnicity, religion, sexual orientation, gender identity, other)
Psychiatric illness
Substance use
Disability (physical and mental)
Family history of violence
Homelessness
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Poverty
Childhood is a particularly vulnerable time for trauma exposure. The youngest children (ages 0–5) are at the
highest risk for exposure to trauma and this trauma may be repetitive and chronic.14 Growing up without the
care of a safe, responsive, nurturing caregiver dramatically alters healthy childhood development and sets a
child up for a lifetime of future adversity. Parents are at increased risk of abusing or neglecting their children
if they do not understand children’s development or needs; have low levels of education and/or poor
parenting skills; are unable to be attentive due to substance addiction or severe mental health problems; or
have a history of being abused themselves during childhood.14 Exposure to IPV markedly increases the risk
of childhood maltreatment. In more than 50% of families with IPV, children are also abused.15 Trauma begets
more traumas in an intergenerational cycle. Mothers who were abused as children are more likely to abuse
their children, and children who grew up observing IPV are more likely to be in a violent relationship as
adults,16 and thus, also have children who are exposed to IPV.17
SOCIAL ISOLATION
Social isolation of families and communities puts children at higher risk of being maltreated. In communities
that have low “social capital” and are plagued by violence, poverty, housing instability, high density of
alcohol sales, and poor social cohesion, the likelihood that children will be abused or neglected is increased
(see http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html).
GENDER
Gender is highly correlated with the types of trauma that people experience. Violence against women and
girls is a worldwide epidemic that includes childhood abuse and sexual exploitation and assault, IPV, rape by
nonintimate partner perpetrators and as an instrument of war, “honor killings,” and female genital
mutilation. Men (and boys) perpetrate the vast majority of violence against women and girls; their risk of
perpetrating violence against women and girls is increased if they have been abused as children themselves.
Most oen violence against women and girls is perpetrated by intimate partners, family members, and close
contacts rather than strangers12 (see Chapter 35). Natural disasters and warfare increase the risk of sexual
violence via nonintimate partners/strangers for women worldwide.18
Boys are also at risk of childhood abuse and childhood sexual exploitation.19 Although among young
children boys are at risk of violence within the family or by close contacts, adolescent and adult males are
predominantly at risk of community and war violence that is perpetrated by other men. Worldwide, three
quarters of all homicide victims are boys and men, especially those 15–29 years old. Community violence is a
more common cause of homicide than war.2 Yet, homicide represents a very small fraction of the devastating
eects of abuse and violence. It is estimated that for every young person killed, there are many more young
people who have injuries caused by violence.2
PHYSICAL AND MENTAL DISABILITIES
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Physical and mental disabilities are both caused by trauma and markedly increase one’s risk of violent
victimization and trauma. The risk of child abuse, IPV, sexual violence, elder abuse, and community violence
are all increased in people who are vulnerable due to disabilities. Discrimination on the basis of disabilities
also leads to a multitude of disadvantages like poverty, homelessness, and lack of access to social and
medical services that increase the likelihood of victimization (see Chapter 42).
MINORITY STATUS
Because various forms of discrimination and structural violence against minority-identified groups and
individuals are tolerated and perpetuated in most communities worldwide, minority status in society is a risk
factor for being exposed to trauma and multiplicative forms of trauma. For example, LGBTQ individuals are at
increased risk of being bullied and are likely at increased risk of sexual assault.20 People who identify as
bisexual or lesbian or gay have a 58–66% increased risk of exposure to “ACEs” as compared with heterosexual
people.21 Transgender people experience extraordinarily high rates of violent victimization by strangers as
well as intimate partners.22
People of minority race/ethnicity are targeted by discrimination resulting in trauma, oen by the systems
meant to serve them. When measured by household survey, race and ethnicity are not associated with any
dierence in the rate of child maltreatment.23 Yet, African-American children are reported to child protective
service authorities for child maltreatment at a 78% higher prevalence rate than that of white children.24
Racial minorities, targeted by both historical and structural violence, are at dramatically increased risk of
community violence. In the United States, between 2007 and 2009, the relative rate dierence of homicide for
non-Hispanic blacks was at least 650% higher than the rate reported for non-Hispanic whites. Hispanic and
American-Indian/Alaskan native people in the United States also had higher homicide rates than non-
Hispanic whites.25
The killing of young minority men in the United States by the police is a stark reminder of the traumatic
eects of institutionalized racism. Oicial data are woefully inadequate in reporting exactly how much more
oen minorities are likely to be killed by police than whites in the United States and estimates vary widely. An
analysis of federally collected data by Propublica shows that young black males in recent years were 21 times
more likely to be killed by police than their white counterparts (http://www.propublica.org/article/deadly-
force-in-black-and-white). The Centers for Disease Control and Prevention (CDC) data likewise reveal racial
disparities in rates for both death and injury at the hands of police. According to the CDC, between 1968 and
2011, black people were between two to eight times more likely to die at the hands of law enforcement than
whites. (National Violent Death Reporting System: http://wisqars.cdc.gov:8080/nvdrs/nvdrsDisplay.jsp and
as reported in Mother Jones, 2014: http://www.motherjones.com/politics/2014/08/police-shootings-
ferguson-race-data.) These data reveal a pattern of policing that produces racial disparity and inflicts
extensive trauma in minority communities. Black and Latino men are also far more likely to be imprisoned
than white men. Generations of minority children suer the trauma that results from growing up with an
incarcerated parent.26
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POVERTY AND SOCIETAL NORMS
Poverty and societal norms regarding violence also influence the prevalence of violence and trauma in
communities. Globally, high rates of income inequality and a society tolerant of violence are associated with
high rates of youth violence.27 Living in poverty and, more specifically, in a neighborhood with multiple
forms of disadvantage increases one’s risk of exposure to many traumatic experiences including abuse and
neglect, hunger, inconsistent housing, family and community violence, parental substance use, severe
maternal depression, discrimination, disease, loss of loved ones to premature mortality, and more.13
Trauma and homelessness are inextricably intertwined. Trauma may directly result in homelessness and
homelessness increases the risk for subsequent trauma. Family violence and IPV are immediate causes of
homelessness when children and adult victims must flee their homes. In a prospective, population-based
longitudinal study, both childhood exposure to family adversity and experiences of violent victimization were
found to be associated with increased risk of future homelessness.28 In turn, homelessness in both adults
and adolescents markedly increases the risk of future violent victimization.29,30
SUBSTANCE USE
Substance use is also highly correlated with the risk of violence and trauma. Worldwide, alcohol use has been
found to increase risk for violent victimization and perpetration through multiple mechanisms including
acute and chronic physical and cognitive impairment, increased aggression, the use of alcohol as an excuse
to perpetrate violence, and more. Alcohol use increases the risk for violence and is increased by the
experience of violence and abuse.31
PROTECTIVE FACTORS AGAINST TRAUMA
David’s best childhood friend, Richard, lives with his mother and grandparents. His father is in jail. His
mother works two jobs in order to make enough money to send Richard to a parochial school. When Richard
was young, she treasured the 15 minutes she spent reading to Richard before bed. His grandparents picked
him up from school and stressed the importance of doing his homework. Richard does well in school and his
teachers help him apply to college and for financial aid. Richard dreams of becoming a lawyer to help people
like his father, who he thinks was falsely accused of a crime he denies committing.
Protective factors that decrease the likelihood of trauma have not been studied as much as risk factors that
increase the likelihood of trauma (Box 36-2). These protective factors also may be examined within the
context of an ecological model that takes into account individual, family, community, societal, and
macrosocial factors (see Figure 35-1).12 Individual and family factors that protect against childhood
maltreatment and violence include individual genetic expression, child IQ, nurturing parenting, parent–child
relationship quality, and stable family relationships.32,33 Additional protective factors include parental
employment, housing stability, care by other supportive adults, and access to health and social services.
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Communities that are able to support parents and focus on preventing abuse and violence also protect
children from maltreatment.34
Box 36-2.Factors Protective Against Trauma
Supportive family relationships
Secure communities
Financial security
Employment
Stable housing
Higher educational status
IQ
Community engagement
Good health
The single most significant protective factor in preventing both childhood trauma and its adverse outcomes
is the presence of a safe, stable, nurturing adult caregiver consistently present in a child’s life.35 In fact, in
families in which the mother, who had experienced her own childhood maltreatment, grew up to have safe,
stable, nurturing relationships with her intimate partner and her children, the risk of child maltreatment was
equivalent to families in which the mother had not been maltreated as a child. Safe, stable, and nurturing
relationships can eectively break the intergenerational transmission of abuse.36
Despite trauma and adversity, some children and adults are resilient and able to thrive. Resilience is the
capability to surmount adversity. It refers to a “positive, adaptive response despite significant adversity.” The
close and responsive attention of a nurturing adult alters childhood development to promote resiliency not
only due to the close relationship but also the skills-building and positive experiences that develop through
this relationship.35 Some researchers have proposed that resilience be reconsidered as a social-ecological
construct in which the community rather than an individual is the source of resilience.37
CONDITIONS RELATED TO TRAUMA
David has chronic pain in his leg from his gunshot wound. He drinks three 48-ounce beers daily and smokes
marijuana to “calm down.” He contracts hepatitis C from a tattoo done by a friend and develops diabetes and
hypertension by the age of 30. He is unemployed, intermittently homeless, and has just been arrested for
physically and sexually assaulting his girlfriend aer she got an abortion he didn’t want her to have.
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Trauma can be devastating (Box 36-3). Physical injuries from traumatic violence are oen life altering. Both
children and adults may suer severe traumatic brain injuries due to violence. Children’s brains are
particularly vulnerable to physical violence. Babies may suer blindness, cerebral palsy, severe cognitive
impairment, and even death from “shaken baby syndrome.”38 Less visible are the emotional disturbances,
psychological scars, and injury to the ability to form and sustain good relationships that result from trauma.
Trauma, whether caused by a one-time catastrophic events or chronic, ongoing traumatic events, can shatter
one’s sense of safety. Trauma that involves interpersonal abuse and violence especially from a family
member or partner represents profound human betrayal and has been found to be particularly devastating.
Box 36-3.Conditions Related to Trauma
Physical injury and homicide
Psychiatric illnesses (anxiety, depression, posttraumatic stress disorder [PTSD], complex PTSD [cPTSD],
suicidality)
Chronic illnesses (heart, lung, liver, and other diseases)
Sexually transmitted infections including HIV
Sleep disorders
Unwanted pregnancy and pregnancy at early age
Childhood learning and behavior problems
Substance use
Homelessness
Premature death (due to poor health, homicide, suicide)
Future victimization or perpetration of violence
Although all people who experience trauma are altered by it, children are particularly vulnerable to serious
lifelong adverse eects of trauma. In order to develop optimally healthy brains, bodies, and relationships,
children need stable, nurturing, consistent, and highly attuned relationships with caregivers. Secure and
attuned attachments with caregivers allow children to internalize abilities to self-soothe, develop a positive
self-image, learn to relate to others with care and love, and to play and explore in ways that promote healthy
brain development. Conversely, the developmental life course of children who have been abused and
neglected, oen by someone who was supposed to be a trustworthy or caregiving figure, is profoundly
disturbed.
TOXIC STRESS
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Trauma disrupts our optimal health and normal development. The mechanisms through which trauma
aects our health are beginning to be elucidated. There is a dynamic, continuous, and interplay between
“nature” (our biology) and “nurture” (our environment). Our biology is altered by our experiences,
relationships, and other responses to our environment. Positive stress that briefly increases stress hormones
but then remits, as when a toddler falls and gets back up or when an adolescent takes a test, is necessary for
normal development. Prolonged stress or trauma that overwhelms one’s capacity to weather these
experiences and is not relieved by a healthy, caring relationship or one’s capability to self-soothe is called
“toxic stress” or “traumatic stress.”
Toxic stress adversely aects our health through autonomic, neuroendocrine, inflammatory, genetic,
epigenetic, and behavioral pathways. Cumulative exposure to extreme stress can result in an imbalance in
our biological steady state. Persistent activation of stress hormones and other bodily stress-reactive
processes can result in pathological biological changes. For example, toxic stress activates the
hypothalamic–pituitary–adrenocortical axis and the sympathetic-adrenomedullary system and causes the
release of inflammatory mediators.
When toxic stress occurs during the extraordinarily active periods of brain development in childhood and
adolescence, it can cause remodeling of the brain’s architecture and body’s biology in ways that have lasting
ill eects throughout the lifespan.39,40,41 This brain remodeling results in adverse changes that aect one’s
ability to learn and make constructive decisions; one’s behavior and way of relating; and one’s physical and
mental health. Prolonged exposure to childhood adversity remodels the areas in the brain that control
executive function, addiction, and craving.41
Research has focused on epigenetic changes (i.e., changes in the way genes are expressed) in response to
toxic stress as one pathway through which trauma can impact health and behavior. Telomeres, the DNA-
based caps and protein structures at the chromosome tips, are associated with accelerated aging and later
disease.42 Telomere shortening in response to childhood maltreatment has been studied prospectively:
children exposed to multiple forms of abuse at age 5 (exposure to maternal domestic violence, frequent
bullying, or physical maltreatment by an adult) were found to have shorter telomeres at age 10 than children
who were not maltreated.43
Children who have suered from maltreatment demonstrate many sequelae of trauma or toxic stress that is
not ascribed to their root cause. Childhood trauma manifests dierently at dierent developmental stages.
Infants may suer from failure to thrive; school age children may present with attention and learning
diiculties; and adolescents may engage in early and risky sexual activity or substance use. Prolonged or
repetitive trauma in childhood puts children at risk for life-long psychological and relationship problems.
Children and adults who experience traumatic events may suer from fear, mistrust, a sense of vulnerability,
feelings of isolation, and multiple adverse psychological sequelae including insomnia and other sleep
disturbances, anxiety disorders, PTSD, substance abuse disorders, and mood disorders. Trauma markedly
increases the risk of suicidality in both adolescents and adults.44
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POSTTRAUMATIC STRESS DISORDER
PTSD is a trauma- and stress-related condition that can occur aer exposure to an extremely traumatic event.
The lifetime prevalence of PTSD is 7.8% in the United States45 and varies from .3% to 6.1% in other
countries.46 Certain vulnerable populations who have suered extraordinarily high burdens of trauma,
women living with HIV and incarcerated people, for example, also have extremely high rates of PTSD.11,47
The risk of development of PTSD aer a traumatic event varies markedly depending upon the type of trauma.
Aer a natural disaster, for example, only approximately 5% of men developed PTSD. Aer rape, however,
65% of men and 49.7% of women develop PTSD. Other types of trauma with a high risk of PTSD include
combat, childhood neglect, and childhood physical and sexual abuse.48 Overall, for all traumatic events
combined, women seem to develop PTSD at twice the rate that men do, even aer accounting for the
prevalence and type of trauma exposure.49 It is now understood that adults, adolescents, children, and even
infants can develop PTSD. Although it is not possible to predict exactly who will develop PTSD aer a
traumatic event, risk factors for developing PTSD include having a prior trauma histories, a family psychiatric
history, a perceived life threat from the trauma, poor social support, and peritraumatic emotional
responses.50
PTSD rarely occurs as the single sequela of trauma and oen presents with a “co-occurring” mood disorder
or substance use disorder.48 People who have been exposed to complex and prolonged psychological
trauma may develop complete post-traumatic stress disorder (cPTSD), a disorder characterized by adverse
changes in the mind, emotions, body, and relationships.1 People suering from cPTSD have all of the
characteristics of PTSD and also have additional profound disturbances of emotion regulation, a negative
self-concept, and interpersonal problems. People with cPTSD are oen misdiagnosed as having a personality
disorder, especially borderline personality disorder.51
IMPACT OF CHILDHOOD TRAUMA AND ADVERSITY
Childhood trauma and adversity are now understood to be the most significant root causes of adulthood
disease, oen occurring decades later. Adaptive but unhealthy behaviors such as overeating, sexual risk
taking, smoking, and alcohol and other substance use are more likely in adults who experienced adversity or
toxic stress during childhood. These behaviors contribute greatly to the development of chronic illnesses.
Yet, the correlation between childhood adversity and adulthood disease exceeds that explained by the
impact of high-risk behaviors, thus supporting the research findings of biological impacts of trauma.39 In the
“ACE study,” the ACE scores correlate with both adulthood health risk factors and disease in remarkably
consistent and strong, dose–response relationships. Increasing ACE scores are associated with increased risk
of adulthood IPV, smoking and the early initiation of smoking, alcoholism and alcohol abuse, increased
number of sexual partners and early initiation of sexual activity, adolescent pregnancy, unintended
pregnancy, abortion, sexually transmitted diseases, fetal death, depression, suicide attempts, health-related
quality of life, ischemic heart disease, chronic obstructive pulmonary disease (COPD), and liver disease.
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When compared with adults without any ACEs, adults who had four or more ACEs had 12 times the risk of
attempting suicide and double the risk of liver disease and COPD.52
In England, a prospective, longitudinal study of “ACEs” (defined dierently from the Kaiser study)
demonstrated a relationship between adverse childhood events and an increased risk of premature
mortality.53 Women with one ACE had a 66% increased risk of premature death and those with two or more
ACEs had an 80% increased risk of death as compared with women with no ACEs. Kaiser Permanente and the
CDC have developed a model that explains how ACEs lead to early mortality (Figure 36-1).
Figure 36-1.
Mechanisms by which adverse childhood experiences influence health and well-being throughout the
lifespan. (From https://captus.samhsa.gov/prevention-practice/targeted-prevention/adverse-childhood-
experiences/1.)
TRAUMA AND WOMEN LIVING WITH HIV
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The impact of trauma on women living with HIV has been particularly well studied. Recent and/or past abuse
has been associated with poor health outcomes at each stage of the HIV Care Continuum, including between
two and four times the odds of antiretroviral medication failure, faster disease progression, and more
hospitalizations.54 More importantly, HIV/AIDS is rarely the cause of death in women living with HIV who die.
Now, deaths among women living with HIV are mostly related to trauma, directly through murders and
indirectly through suicide, overdose, and other trauma-related medical conditions.55
POSTTRAUMATIC GROWTH
Not all sequelae of trauma are thought to be negative. Posttraumatic growth is defined as “the subjective
experience of positive psychological change reported by an individual as result of the struggle with trauma.
Examples of positive psychological change are an increased appreciation of life, setting of new life priorities,
a sense of increased personal strength, identification of new possibilities, improved closeness of intimate
relationships, or positive spiritual change.” Interestingly, it is very unclear whether posttraumatic growth has
any modulating eect on the negative psychological sequela of trauma. Studies of the relationship between
posttraumatic growth and PTSD, depression, and other adjustment problems have conflicting results.56
HEALTH-CARE ENVIRONMENTS ARE CHALLENGING FOR TRAUMA
SURVIVORS
Kim is a 40-year-old survivor of childhood sexual abuse perpetrated by her father. Kim has suered from
untreated bouts of severe anxiety and depression ever since she was abused. When she was a 22-year-old,
she went to a clinic for a Pap smear. The nurse told her to undress and lie on the exam table with her legs in
the stirrups before she met the physician who would do her Pap smear. The physician entered the room,
asked her a few quick questions, and then proceeded to do the Pap smear without explaining anything. Kim
felt sudden, overwhelming terror, chest tightness, and palpitations. She says, “I felt like I le my body” and
doesn’t remember what happened during the visit or how she got home. She never returned for Pap
screening. Recently, aer many years of very heavy vaginal bleeding, Kim fainted, was brought to the
hospital, and diagnosed with advanced cervical cancer.
In health-care settings serving disadvantaged and underserved clients, the proportion of patients who have
histories of trauma is extraordinarily high. Survivors of trauma, even in the absence of PTSD, may be
consciously and unconsciously “triggered” by sights, smells, sounds, and situations that occur in the health-
care setting. Excessive waiting times, invasive physical procedures, the need to undress, the inherent
imbalance in power between the patient and the providers, the use of physical restraints, and more may
result in retraumatization. Oen, patients entering a health-care or treatment setting do not fully
comprehend the connection between their heightened emotional state and their history of past trauma. This
“triggering” of traumatic memories or sensations may make a treatment setting intolerable to a patient.57
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A patient who has suered trauma may act belligerently resulting in being discharged from care, or may
experience dissociation from the present moment and not be able to recall important events in his or her
medical history and may have problems retaining important health-care instructions. Survivors of childhood
or other abuse may react in an overly aggressive or overly submissive manner to authoritarian health-care
providers. And many patients with a history of trauma who find the health-care setting intolerable may
simply give up altogether and not follow up with appropriate care. Eective treatment for trauma survivors
depends upon the health-care setting becoming “trauma informed.”
TRAUMA-INFORMED CARE
The principles of trauma-informed care are consistent with patient-centered care approaches. Trauma-
informed care has been defined as “a strengths-based service delivery approach that is grounded in an
understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and
emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a
sense of control and empowerment”
(http://beta.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/key_terms.html).
Trauma-specific care refers to the methods used to treat the physical, emotional, relational, and other
sequelae of trauma. Multiple trauma-specific interventions have been evaluated and found to improve
various patient outcomes.58 Models of comprehensive trauma-informed care in the health-care setting,
though, have not yet been tested to determine whether they improve patient outcomes or provider and sta
well-being. Pediatric practices, responding to powerful evidence about how toxic stress harms children, have
led eorts to create trauma-informed clinics.59,60 The American Academy of Pediatrics has developed a
“trauma tool kit” available at www.aap.org/traumaguide.
CONCEPTUAL MODEL OF TRAUMA-INFORMED CARE
Experts recently developed a conceptual model of trauma-informed care for adults.61 Ideally, trauma-
informed care creates healing and empowerment for the patient, the patient’s family, and the health-care
providers and sta, and rests firmly upon a foundation of trauma-informed principles and competencies
(Figure 36-2).62
The San Francisco Department of Public Health has developed foundational trauma-informed principles and
competencies including: trauma understanding, cultural humility and responsiveness, safety and stability,
compassion and dependability, collaboration and empowerment, and resilience and recovery
(http://www.leapsf.org/pdf/Trauma-Informed-Systems-Initative-2014.pdf).
Figure 36-2.
A framework for trauma-informed primary care. (From Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg
LS. From Treatment to Healing: The Promise of Trauma-Informed Primary Care.
Womens Health Issues
2015;25:193-197.)
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Trauma Understanding
A trauma-informed clinic or hospital is one in which all providers and sta have been trained to understand
trauma and its eects on all of us. All providers and sta understand that almost every single person entering
the health-care facility (including each of their coworkers) has experienced some form of hidden trauma.
They respect each patient and coworker for her/his strength and resilience in facing adversity. They
understand that people’s unhealthy ways of relating to others and unhealthy behaviors are oen adaptations
to traumatic experiences. They understand that our many identities (culture, race/ethnicity, religion, sexual
orientation, gender identity, and more) aect our risk of experiencing trauma, our responses to trauma, and
the types of support we are able to access when experiencing trauma. Historical and structural trauma that
has harmed entire communities and community resiliencies are acknowledged and inform responses to
trauma.
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Safety and Compassion
Providers and sta work together to create and sustain an atmosphere that is clean, safe, calm, and suused
with compassion. Educational materials about various forms of trauma and programs that assist trauma
survivors are prominently displayed in public and private settings like waiting rooms, exam rooms, and
bathrooms.
Providers and sta treat patients with respect and a nonjudgmental perspective, emphasize patient
strengths and resilience, educate patients and families about trauma, and strive to provide patients with as
much control and choice regarding their care as is possible. The health-care team partners with peer
advocates who have survived traumatic experiences and are well trained in trauma-informed care. Peer
advocates provide examples of resiliency, mentorship about paths to healing, and navigation through
treatment options.
Because traumatized patients may be fearful about accessing care, the health-care system does community
outreach and case management that extends beyond the clinic and hospital walls. The management of the
health-care clinic or hospital involves providers and sta in collaborative processes of decision making and
treats employees with respect because they understand that highly hierarchical and abusive management
practices perpetuate the dynamics of trauma.
Collaboration and Empowerment
In trauma-informed care, trauma is considered an important “root cause” of many emotional, behavioral,
physical, and psychological illnesses. When behaviors that are usually stigmatizing, such as depression or
substance use, are framed as adaptations to traumatic experience, the patient is oered an opportunity to
see herself or himself in a dierent, more positive light. The health-care team and peer advocates can
emphasize the remarkable courage and strength it takes to survive traumatic experiences.
Universal Education About the Eects of Trauma
In trauma-informed care, patients are given universal education about the eects of trauma on health as a
safe way to introduce trauma. With proper training and implementation of safeguards, direct and indirect
inquiry about trauma and the social determinants leading to trauma are incorporated into team-based care.
Patients are oered opportunities to disclose traumatic events and the eects of those experiences on the
patient’s practical, spiritual, psychological, relational, and physical life course if they choose to do so.
The health-care team incorporates evidence-based screening for various forms of trauma (including
interpersonal violence and abuse) in order to enhance patient safety, address the “root causes” of unhealthy
behaviors, improve health outcomes, and refer patients to helpful treatment and support options. Even
when patients choose not to disclose trauma, they can access treatment options on-site and in the
community via facilitated self-referral.
Trauma Treatment Programs
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In trauma-informed care, patients and families are introduced to evidence-based trauma treatment
programs on-site, through home visits and in the community. Patients who have experienced trauma are
oered a wide array of healing experiences and treatments that are developmentally appropriate, evidence
based, and culturally attuned. Evidence-based trauma-specific interventions including parent–child therapy
and trauma-informed substance use, depression, anxiety, PTSD, and cPTSD treatment are promptly
available. Resources that promote increased resiliency are easily accessible, such as vocational training and
housing and educational support.
Vicarious Traumatization
In trauma-informed care, particular attention is paid to the personal traumatic experiences of providers and
sta and the phenomenon of “vicarious traumatization” or “VT,” defined as “the negative transformation in
the helper that results from empathic engagement with trauma survivors and their trauma material,
combined with a commitment or responsibility to help them.”63 Providers and sta explore how their own
traumatic experiences and cultural perspectives have shaped their outlook on relationships and their work.
Providers and sta learn how to care for themselves in the moment, so that when they are listening
empathically to a patient describe experiences of human cruelty and betrayal and other traumas they may
stay as calm as possible. Providers learn to balance maintaining compassion and empathy while not over-
identifying with and re-living the patient’s experience. Providers and sta also learn how to care for
themselves over the long term in order to maintain hope, meaning, and faith in humanity. A safe, calm, well-
organized clinical environment that emphasizes respectful, nonhierarchical teamwork and supportive
policies and practices supports provider and sta well-being.
ROUTINE SCREENING FOR ABUSE AND TRAUMA
In the United States, screening all women for IPV is required by the Joint Commission on Accreditation of
Healthcare (JCAHO) and the Aordable Care Act (ACA) and screening is recommended by the US Preventive
Services Task Force (USPSTF). The American Congress of Obstetricians and Gynecologists issued an opinion
that all women should be screened for childhood sexual abuse (in addition to the required IPV screening)
and have provided guidance on how to do this (see Chapter 35).64 Direct and routine screening of all adults
for earlier child abuse and for other types of traumatic experiences in the context of primary care and
specialty care (other than psychiatry) has not been adequately studied.
There are no well-validated and reliable tools for screening of asymptomatic children and their caregivers for
the abuse and neglect of children. In 2004, the USPSTF found insuicient evidence to recommend for or
against the routine screening of parents or caregivers for the abuse and neglect of children; they did find
evidence that primary child abuse prevention programs oered in the health-care setting are eective.65
Despite a lack of research, clinics and providers are rapidly adopting these practices and are incorporating
some form of ACEs screening for all patients.59,60 Others advise a universal education approach (rather than
routine screening) as a safer option due to concerns over the potential adverse eects of screening for
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lifetime trauma including stigmatizing patients and focusing on pathology rather than resilience.66 Some
practices are also piloting “resilience questionnaires” (see http://acestoohigh.com/2014/07/29/to-prevent-
childhood-trauma-pediatricians-screen-children-and-their-parentsand-sometimes-just-parents/#more-
3327).
Lorraine’s mother abused methamphetamines and dated a series of highly abusive men, one of whom raped
Lorraine repeatedly when she was 12. As a teenager, she began drinking alcohol and binge eating to numb
her emotional pain. Lorraine presents to primary care, smelling of alcohol. She is morbidly obese. Her blood
pressure is 190/98. She wants her provider to prescribe something “to help me fall asleep”.
INQUIRY ABOUT ABUSE AND TRAUMA BASED ON “INDICATOR” CONDITIONS
In patients with relationship diiculties, behavioral problems, emotional distress, mental health disorders
including depression, anxiety, PTSD, cPTSD, suicidality, sleep disorders, substance use disorders, chronic
pain, a current or past injury, sexually transmitted infections, or the early onset and high burden of chronic
diseases, a history of past traumatic experiences is highly ranked in the dierential diagnosis. In safety-net
clinics and hospitals, these indicator conditions are present in most patients.
There is inadequate study and guidance on how best to inquire about past traumatic experiences in both
children and adults who have conditions that may be sequelae of trauma. Standardized tools for trauma
screening exist, yet are cumbersome to use. Trauma exposure checklists for adults
(http://www.ptsd.va.gov/professional/assessment/te-measures/chart-trauma-exposure.asp) and children
(http://www.ptsd.va.gov/professional/assessment/child/child-measures.asp) are used in some settings.
There is evidence that many patients prefer to be screened for sensitive topics such as IPV through “audio
computer-assisted self-interview” (ACASI) which can be done with audio assistance in various languages in
order to provide screening and, even, individualized to low literacy patients (see Chapter 35).
SCREENING FOR THE PSYCHOLOGICAL SEQUELAE OF TRAUMA
Because trauma results in an increased prevalence of substance use, depression, anxiety, and PTSD,
screening for these conditions is warranted in patients who have experienced trauma or are at very high risk
of trauma. Many patients with PTSD go unrecognized and experience delays in receiving treatment. In a
nationally representative survey of US adults, only 7.1% of patients with PTSD talked to a physician or other
professional about their symptoms within the first year of experiencing them, and the median time between
onset of PTSD symptoms and receipt of mental health treatment was 12.1 years.67 Screening for PTSD in
primary care may prevent delays in diagnosis and mental health treatment and should certainly be done
when trauma is discovered or when the patient complains of symptoms typical of PTSD. Several brief
questionnaires have been validated in primary care settings. A study comparing four PTSD screening
questionnaires in a family medicine clinic population found the primary care PTSD (PC-PTSD) screen had the
best test characteristics68
(http://www.ptsd.va.gov/professional/assessment/DSM_5_Validated_Measures.asp).
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TRAUMA-SPECIFIC INTERVENTIONS
Lorraine’s primary care physician makes several empathic statements in their first visits. (See Core
Competency). During her third primary care visit, Lorraine reveals that she was sexually assaulted as a child.
She shares that she has felt horribly ashamed for decades about this experience and her drinking. Lorraine’s
provider responds: “No wonder you started drinking when you were 11. It was so important for you to find a
way to cope with an impossible and painful situation. We all deserve to be treated well. I am so sorry you
were hurt as a child.” Aer discussing coping techniques, Lorraine accepts a referral to a trauma-informed
program that helps women suering from trauma, mental health problems, and substance addiction heal.
Explaining that substance use, overeating, self-harm, or other injurious behaviors are common coping
techniques in response to trauma can be a healing experience for patients. Emphasizing the extraordinary
strength that a patient has demonstrated in coping with trauma can be empowering. Practicing calming
breathing exercises with a patient when discussing trauma and limiting trauma history appropriately to
provide a patient with an environment that prioritizes emotional safety is helpful. Focusing on coping
techniques, resiliency, and positive support rather than delving deeply into traumatic details in the primary
care setting allows patients to feel more in control.
The Women with Co-Occurring Disorders Study (WCDS) demonstrated that trauma-informed care in mental
health and substance use settings was more beneficial to patients than usual care.
SAMHSA maintains a National Registry of Evidence-based Programs and Practices (NREPP) that is continually
updated and currently describes 37 trauma-related evidence-based interventions.69 These treatment
programs are eective in treating various poor health and relationship outcomes related to trauma.
Certainly, the mental health sequelae of trauma, including PTSD, are treatable. A systematic review found
that psychological therapies such as exposure therapy, cognitive processing therapy, cognitive behavioral
therapy–mixed therapies, eye movement desensitization and reprocessing, and narrative exposure therapy
were eective for improving PTSD symptoms and/or achieving loss of diagnosis. The eect sizes for these
treatments were quite large. Medications (including fluoxetine, paroxetine, sertraline, topiramate, and
venlafaxine) have also been found to be eective in reducing PTSD symptoms (although the eect sizes are
smaller).70
Helping patients suering from complex traumatic stress disorders is naturally more challenging than
treating PTSD. Survivors of complex trauma who have cPTSD not only have symptoms related to PTSD but
also have had their development utterly disrupted resulting in problems regulating their emotions, a
negative self-image, and impaired relationships with others. Thus, it is essential for the health-care provider
to maintain a calm, compassionate demeanor and model a healthy relationship with appropriate
relationship boundaries when caring for a patient with cPTSD. Especially in the context of brief primary care
visits, helping a patient heal from complex trauma can be daunting. Fortunately, promising treatments for
cPTSD are being developed.71 Mindfulness meditation, yoga, and other somatic and creative therapies for
the psychological sequelae of trauma also provide hope for healing.72,73
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The evidence for the treatment of PTSD notwithstanding, there is generally a lack of research on
interventions to address the physical, mental health, and practical sequelae of trauma in highly
disadvantaged urban communities. Urban underserved victims of violent crime may need urgent help with
finding safe housing, food, medical service, and financial assistance. Stigma about mental health treatment,
poverty, and lack of access to trauma treatment services influence outcomes for low income and minority
victims of crime. Pioneering models of care to address the full panoply of issues confronting trauma victims
from underserved communities emphasize assertive outreach, engagement in treatment, and practical
assistance in order to increase access, adherence, and eicacy of treatment. In a mental health trauma
center, this model resulted in patients receiving trauma treatment services six times more oen than usual
community services.9 Trauma centers in urban environments in the United States also have been pioneering
new models of care for victims of community violence. These models of care are based on trauma-informed
principles and have been proven to be both eective in reducing violence recidivism as well as cost-
eective.74
PREVENTION—REDUCING TRAUMA TO ACHIEVE HEALTH EQUITY
Since the biological and psychological sequelae of interpersonal violence are a root cause of most of the
leading causes of morbidity and mortality worldwide, eliminating preventable forms of trauma such as
abuse and neglect holds great promise in achieving health equity.75 Treating the sequelae of lifelong abuse
(such as substance addiction and mental illness) in parents and caregivers prevents exposure to adversity
and trauma for the next generation. Because IPV is so highly associated with child abuse and witnessing IPV
is so harmful to children, preventing and reducing IPV is a primary prevention strategy for reducing
childhood trauma, abuse, and neglect.
Primary prevention evidence-based programs to eliminate childhood abuse and neglect include specific
evidence-based home visitation programs (based on the Nurse–Family Partnership model) for first time
expectant mothers in families at greater risk of having child abuse and neglect76; the Positive Parenting
Program (Triple P); Safe Environment for Every Kid (SEEK); and the Strengthening Families initiatives.65,77
Prevention programs designed to eliminate the many intersecting and interrelated forms of violence show
great promise.13,75
CONCLUSION
Worldwide, trauma is a leading cause of morbidity and mortality. Traumatic experiences are disruptive and
overwhelm a person’s ability to adapt to the stresses and vicissitudes of life. The impacts of trauma are
dependent on individual and community vulnerabilities, resources, and protective factors. Trauma,
especially in childhood, is a root cause of adult disease and high-risk behaviors. Trauma disproportionately
aects the most vulnerable people and populations. Addressing trauma in the health-care setting has the
potential to improve health, decrease suering, and promote the achievement of health equity. Health-care
providers have a uniquely influential role to play in implementing trauma-informed care and in
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recommending evidence-based health care community and societal trauma prevention programs and
policies. Violence prevention, poverty elimination, education promotion, hunger prevention, homelessness
prevention, and other strategies that eliminate social disparities all contribute to the prevention of life-
altering trauma and the achievement of health equity.
KEY CONCEPTS
Trauma is a nearly universal human experience and is more common in vulnerable populations.
Childhood trauma results in later adulthood high-risk behaviors, and disease.
Individual, family, community, and societal risk and protective factors as well as resiliency aect the
prevalence and experience of all types of violence and trauma.
Trauma-informed care holds promise for improving health outcomes and helping to break the cycle of
intergenerational transmission of trauma.
CORE COMPETENCY
Skills in Trauma-Informed Care: Caring for Survivors of Lifetime Abuse
Four C’s:
Favorite Table | Download (.pdf) | Print
Calm Pay attention to how you are feeling while caring for the patient. Breathe and calm yourself to help
model and promote calmness for the patient and care for yourself.
Contain Ask the level of detail of trauma history that will allow patient to maintain emotional and physical
safety, respect the time frame of your interaction, and will allow you to oer patients further
treatment.
Care Remember to emphasize, for patient and yourself, good self-care and compassion.
Cope Remember to emphasize, for patient and yourself, coping skills to build upon strength, resiliency,
and hope.
Calm
Keep questions simple and nonjudgmental.
Many patients may be more comfortable revealing details of trauma on questionnaire/computer touch
screen than in face-to-face interview.
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Screen for depression, PTSD, substance use, risk-taking behaviors (use the PHQ-9, PC-PTSD).
Learn and practice breathing and “grounding” techniques during the visit for yourself and for the patient who
is anxious or distressed.
Remember
—all of us have histories of traumatic events in our lives. Trauma that you have experienced
yourself can sometimes make hearing about trauma harder or can sometimes help you understand trauma,
strength, and resiliency in a more personal way.
Contain: Limit trauma history detail to maintain safety:
The goal of taking a trauma history or providing education about trauma is to improve safety, well-being,
health, and relationships. Thus, for example, pushing a patient who feels that her/his life will be endangered
by revelation of abuse or trauma would be unethical and dangerous.
Most situations involving taking a trauma history in the context of primary care are more nuanced than this
and involve patient and provider decisions about the level of trauma history detail appropriate to share in a
particular situation.
Most patients with a trauma history will not reveal their history without your inquiring. Yet, once you do
inquire, it can be challenging for the patient and provider to judge what level of detail is optimal to reveal. It
is quite possible that a patient (especially one with a history of complex childhood trauma) may go into a
level detail that could lead to destabilization during or aer the visit.
Methods to contain “trauma history telling” with patients:
First, remember that one of the most important thing you are doing is modeling a healthy, safe relationship—
and that it is healthy to know if someone is trustworthy prior to revealing a great deal of vulnerability (even
with health-care providers who may be “assumed” to be trustworthy).
“It is important that you explore this with a therapist who understands how to help people who have
experienced trauma, so that you only go into as much detail as you can handle without feeling too exposed
or too out of control.”
If patient hints at a childhood trauma history in a visit …. ” I hear that something diicult might have
happened when you were a child. In the future, when we know each other better, I am open to talking to you
about this in order to help you get help.”
“We have just met and don’t know each other well yet. So, it is important that we get to know each other over
time and figure out together how to help you while also keeping you safe emotionally.”
For early in clinician–patient relationship or with distressed patient: “In my experience, when a patient tells
me that he began drinking at age 12, it is oen because he was experiencing very diicult things during
childhood. We are just meeting each other for the first time today, so we don’t need to go into those details
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right now. I do want you to know that I am open to discussing those things in the future or referring you to a
counselor who specializes in trauma treatment if you think that would be helpful.”
“I am going to ask you to pause and check in with yourself. It is important that you only discuss the level of
detail about your traumatic experience that will allow you to feel safe, even aer this visit is over.”
Practice breathing and “grounding” exercises at the beginning of visit and at the end of visit with the patient
to help the patient focus on developing skills to self-soothe (Calm).
“Let’s slow down and do some deep breathing together. Let’s sink into our chairs and feel how solid the earth
is beneath us.
Care: Demonstrate compassion and caring for patient, while caring for self:
Share messages of support:
“I am so sorry this happened to you.” “We all deserve to be treated well.” “I am sorry you were hurt as a
child.” “It can be very hard to learn to take good care of yourself when you were hurt as a child.”
De-stigmatize adverse coping behaviors:
“No wonder you started drinking when you were 10. It was so important for you to find a way to cope with an
impossible and painful situation.”
Cope: Emphasize resiliency, coping skills, positive relationships, and patient’s wisdom.
Listen carefully for patient’s own words of wisdom and good self-advice and repeat those back to patient.
Counter patient’s negative self-messages respectfully.
Positive relationships with people or pets demonstrate to patient that she/he is worthy of love. Remind the
patient of any caring relationships.
Model healthy, caring, and reliable relationship in patient–provider relationship.
Messages:
“Look at how strong you are to survive such diicult circumstances.”
“I am so glad you had the strength to reach out for help today. That was brave of you.”
“I hear how loved you felt by your favorite aunt. It sounds like she was very important in your life.”
Practical techniques:
The “aer visit” written summary for patient
: Include patient’s own words of advice to herself/himself and
read them aloud to patient. “You told yourself: “I think if I take a walk around the block when I feel nervous I
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might not need to drink as much.”
“Solutions list”
: in medical records, rather than making only a “Problem list,” add a solutions list to the
record that includes all the patient’s positive coping techniques so that each member of the health-care team
can emphasize and reinforce patient’s preferred coping techniques.
If patient is distressed during visit, practice grounding and calming techniques and, also, ask patient
: “When
you feel this badly, what do you usually do to cope?” This is important in order to help the patient pull
herself/himself back together before leaving. Otherwise, the patient is le with associating coming to see you
with a feeling of lack of control. So, help the patient remember her/his strengths.
Self-care tips:
In the moment
: breathing (SLOW it down), relax tensed muscles, “grounding”—(feel your weight sink into the
chair, floor, and earth). What else works for you?
Between each patient
: Send the patient you just saw a compassionate blessing or wish as you take a deep
breath (“I wish you peace”), really pay attention when you wash your hands and feel yourself “let go” before
you move on to the next patient—again with deep breathing and grounding.
Aer you are done seeing patients
: Practice resting, escaping, playing, creating hope, and meaning with
healthy practices that foster connection to self, others, nature, or whatever else feels healing for you. Monitor
yourself and learn more about vicarious traumatization.
For students
: It is fine if you need to (calmly) excuse yourself and tell patient. “I would like to get my teacher
to help us discuss this as safely as possible.” (And for more experienced providers who work in settings with
psychological providers on-site, it may be possible to do this when needed as well.)
DISCUSSION QUESTIONS
1. Discuss how minority status (race/ethnicity, religion, sexual orientation, gender identity, and other
factors) aects individual or community risk for violence and trauma.
2. Discuss ways in which you could introduce the topic of trauma and its eects with adult patients and with
children and parents in pediatric practice.
3. Discuss ways in which you could approach both trauma and vicarious traumatization from a “resiliency or
strength-based” framework. How would this framework change the ways you care for patients and
yourself?
RESOURCES
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Harvard Center for the Developing Child has videos to explain core concepts in development and their
disruption by trauma: http://developingchild.harvard.edu/index.php/resources/multimedia/#videos.
TED talk by Nadine Burke Harris on childhood trauma and its eects on health across the lifespan:
http://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_aects_health_across_a_lifetime?
language=en.
ACES too high Web site has links to many videos about ACES and trauma: http://acestoohigh.com/resources/.
National Center for PTSD has many videos about PTSD, and treatment for PTSD:
http://www.ptsd.va.gov/professional/materials/videos/index.asp.
Centers for Disease Control online course on violence prevention:
http://vetoviolence.cdc.gov/apps/pop/prevention-main.html.
Useful Web sites:
The Centers for Disease Control has extensive information, resources, and numerous violence prevention
projects described at: http://www.cdc.gov/ViolencePrevention/index.html.
ACES too high is a website devoted to sharing national and international information about ACES, trauma,
and innovative community solutions to preventing and ameliorating ACES: www.acestoohigh.com.
SAMHSA (Substance Abuse and Mental Health Services Administration) describes foundational principles of
trauma-informed systems and care at: http://www.samhsa.gov/nctic/trauma-interventions.
National Center for PTSD site has numerous helpful resources on understanding and treating PTSD (see “For
Professionals” section: http://www.ptsd.va.gov/.
National Child Traumatic Stress Network has extensive information and resources on trauma and children
and families: http://nctsn.org/.
Useful Books:
Trauma and Recovery: The Aermath of Violence—From Domestic Abuse to Political Terror by Judith
Herman.
The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook—What
Traumatized Children Can Teach Us About Loss, Love, and Healing by Bruce Perry and Maia Szalavitz.
The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel Van der Kolk.
Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others by Laura Van Dernoot
Lipsky with Connie Burk.
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
ACKNOWLEDGMENTS
With special thanks to Margaret Wheeler, MD, for invaluable editorial advice; to Edward Machtinger, MD, for
invaluable guidance, partnership, editorial assistance, and contributions to the discussion of women living
with HIV; and to Beth Cohen, MD, for contributions to the discussion of PTSD.
Dedicated to Patricia Van Horn, PhD, JD
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