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Promoting Health Equity Through Trauma-Informed Care

Critical Role for Physicians in Policy and Program Development

Levy-Carrick, Nomi C., MD, MPhil; Lewis-O'Connor, Annie, PhD, MPH, NP-BC; Rittenberg, Eve, MD, MA; Manosalvas, Kiara, MA; Stoklosa, Hanni M., MD, MPH; Silbersweig, David A., MD

doi: 10.1097/FCH.0000000000000214
Original Articles
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Trauma-informed care has emerged as an important model to address the pervasiveness of traumatic experiences across the life cycle and their association with significant adverse medical and psychiatric consequences. To achieve health equity, in which all people have the opportunity for health, it is crucial for physicians to become comfortable with a neurobiopsychosocial understanding of trauma and how to provide optimal trauma-informed care. Given the pervasiveness of trauma exposure, and its impact on individual and community health, this paradigm shift in adult health care delivery systems requires physician engagement at every stage of development and implementation.

Division of Medical Psychiatry (Dr Levy-Carrick), Department of Psychiatry (Dr Silbersweig); Division of Women's Health (Dr Lewis-O'Connor and Ms Manosalvas), Department of Medicine (Dr Rittenberg); and Department of Emergency Medicine (Dr Stoklosa), Brigham and Women's Hospital, Boston, Massachusetts; Departments of Psychiatry (Drs Levy-Carrick and Silbersweig) and Medicine (Drs Lewis-O'Connor and Stoklosa), Harvard Medical School, Boston, Massachusetts; and Mary Horrigan Connors Center for Women's Health & Gender Biology, Boston, Massachusetts (Dr Stoklosa).

Correspondence: Nomi C. Levy-Carrick, MD, MPhil, Brigham and Women's Hospital, Department of Psychiatry, 75 Francis Street, Boston, MA 02115 (nlevy-carrick@bwh.harvard.edu).

No conflicts of interest were reported by the authors of this article.

TRAUMA EXPERIENCES are pervasive across the life cycle and are associated with significant adverse consequences for medical and psychiatric well-being. Potential pathology can be magnified or mitigated by policies and programs supporting health equity, defined by the US Department of Health and Human Services and Healthy People 2020 as “the attainment of the highest level of health for all people.”1 There is growing recognition that trauma exposure often occurs within contexts of socioeconomic disparity, historical injustice, and cultural complexity; equitable opportunities for optimal health require deliberate attention to these dimensions of an individual's lived experience.2 There is little consensus, however, about how best to screen for trauma in medical settings or how to integrate knowledge of the physiological impact of traumatic exposures in ways that improve both the clinical experience and medical outcomes.3 The trauma-informed care (TIC) approach has emerged as an important model to address these challenges. TIC is designated by the Substance Abuse and Mental Health Services Administration (SAMHSA) as an organizational framework that realizes, recognizes, and responds in meaningful ways to individuals who have experienced trauma. This represents a call to action far beyond traditional behavioral health settings and typically focuses on nonphysician roles and perspectives.4 The health care environment is evolving and changing, and the landscape is ripe for physician input and leadership in this crucial area.

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PERVASIVENESS AND HEALTH CONSEQUENCES OF TRAUMA

Although incidence and prevalence of trauma exposures in the population vary widely, a recent global general population survey revealed traumatic exposure proportions exceeding 70%, with 30.5% reporting exposure to 4 or more such events.5 In one large self-administered survey of US adults, an estimated 90% reported having experienced a serious adverse event in their lifetime, 30% experienced 6 or more events, and 53% reported exposure to either physical or sexual interpersonal violence over their lifetime.6 Trauma and adversity are among the critical social determinants of health that affect not just individuals but also families, communities, and society.7,8

Biological sciences have expanded our understanding of traumatic exposures as precipitants of neurologic, immune, endocrine, autonomic, inflammatory, and metabolic processes.9–12 The stress response triggers a cascade of neurotransmitters, hormones, and inflammatory cytokines that can serve as short-term protective mechanisms. With sustained release, however, these stress responses can negatively influence lifelong neurodevelopment, physiology, and behavior. In turn, these factors contribute to an increased burden of disease and mortality.

The landmark Adverse Child Experience (ACE) study in the United States demonstrated that violence in childhood results in a dose-response association with chronic medical and mental health conditions in adulthood.13 A total of 10 adverse events were identified in 3 categories: abuse (physical, emotional, sexual); neglect (emotional, physical); and household challenges (separation/divorce, mother treated violently, substance abuse or mental illness, member of family incarcerated). The relationship was striking: people who had 6 or more ACEs died 20 years earlier than those with no ACEs.14 Individuals with 4 or more ACE exposures were 2.2 times as likely to be smokers, 7.4 times more likely to have alcohol use disorders, 10.3 times more likely to have ever injected drugs, and 12.2 times more likely to have attempted suicide. These individuals also had a remarkable increase in medical illness: they were 3.9 times more likely to develop chronic bronchitis/emphysema, 2.4 times more likely to suffer a stroke, 2.2 times as likely to have ischemic heart disease, 1.9 times more likely to suffer from cancer, and 1.6 times more likely to have diabetes.13 Trauma exposure later in life also negatively impacts medical outcomes.15,16

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BRIDGING THE GAP TO PROMOTE HEALTH EQUITY

A trauma-informed framework assumes that trauma is pervasive and that medical evaluation and treatment themselves are potentially traumatizing.17 Access to health care and engagement with physicians can enhance the services patients receive in ways that are meaningful and impactful.18 There remains a gap in the current response to trauma in medical settings, and TIC approaches may bridge this chasm. One salient example: 92% of women abused by their partner do not discuss it with their physician, and only a small percentage (32%) of sexual assault survivors are seen and treated.19 In another example, trauma-related symptoms negatively impact medication adherence,20 a critical determinant of treatment efficacy for chronic disease management.21 Because of the prevalence of trauma, an approach that recognizes the innate potential for trauma and triggering within the health care setting warrants a “universal trauma precautions” approach that decreases barriers to access to care and creates a safe space for patients to participate optimally in treatment. With increasing recognition of the impacts of trauma on health, the health care landscape is ripe for physician input and leadership in developing systems to mitigate those adverse effects. Physicians can utilize the principles of TIC to fundamentally change the experience that trauma survivors have when they seek medical care. By resisting retraumatization, physicians can decrease the barriers that survivors face to engaging in care. The patient-doctor relationship is a unique and powerful one, and physicians can benefit from an understanding and sensitivity to the effects of trauma as much as other providers in fields such as nursing and social work, who earlier in health care delivery adopted this framework. This paradigm shift in adult health care delivery systems will only succeed if physicians are fully engaged in the process at every stage of development and application.

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OPERATIONALIZING A TIC APPROACH

Education and practice

For a medical system to become less traumatizing and retriggering, physicians must be sensitive to patients' individual and collective trauma experiences and recognize the impact of that history on their health care experience. There are many dimensions of humanistic and meaningful engagement that appear self-evident yet seem lacking in routine encounters: for example, asking for permission before starting an examination, allowing a patient to decline parts of the examination, and collaborating with patients in developing their treatment plan. During a busy clinical day, these basic routines will be preserved only if they have become internalized and instinctive—the result of consistent practice and modeling, as well as positive feedback from patients.

A trauma-informed work environment is valuable for physicians as well as patients. Physician burnout is an increasingly recognized phenomenon; some element of this is related to vicarious trauma and a sense of helplessness when interacting with patients who are suffering and in distress or who are nonadherent to our medical advice. TIC interventions can provide support to mitigate the vicarious trauma, to improve patients' ability to engage in their own health care, and to intervene more effectively for our patients.17 Preserving a sense of meaning and purpose in clinical work requires proactive skills and consensus building to counteract the physician burnout epidemic.22,23

Given the pervasiveness of trauma exposure, and its impact on individual and community health, a trauma-informed perspective should be introduced during the first year of medical school and reinforced throughout the physician's professional life. Best evidence information about the multidimensional aspects of acute and chronic stress physiology on long-term physical and mental health should be explicitly taught. Sources of resilience and preventive strategies should be explored at every level of the health care delivery. Learning modalities can include didactics, mentorship, and peer support, as well as innovative techniques such as simulation technology.

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Biomedical and systems-based research

Physicians are central to establishment of research agendas and implementation of research protocols. Exploration of the effects of trauma, as well as trauma-informed interventions on biological measures of stress, executive functioning, and other markers, will help inform the field in promoting effective evidence-based programs.

Evidence-based programs demonstrating efficacy of curriculum development and implementation, as well as clinical screening tools and interventions, will require resources, institutional commitment, and engagement with all stakeholders.

Specifically, systems-based research that tracks medical outcome and cost will have a major impact on policy and clinical procedures. Meaningful measurements regarding return on investment—from decreased no-show rates and emergency department visits to improved engagement and medical outcomes—are essential to optimize trauma-informed approaches and the value of implementation at the organizational level. Utilization of developing technologies such as simulation training and smartphone applications, as well as virtual appointments and artificial intelligence modalities, has strong potential in promoting health equity but requires further investigation, including stakeholder input and outcomes research. Establishment of evidenced-based strategies for shared decision-making will improve the chances of those with trauma exposures to successfully connect with the health care system, participate in medical decision-making, and successfully adhere to treatment. Ultimately, this could help bend the arc of health care outcomes toward improved health and decreased disease burden.

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Screening

Physicians play an integral role in providing a safe environment for patients to share as little or as much of their trauma histories as they choose. There is much need to explore effective strategies for accomplishing this, and formal stakeholder input has been sparse.24 Screening questionnaires completed by self-report prior to the clinical encounter, or during triage by a clinician who will not take part in ongoing care of the patient, have significant limitations. An ideal screening would involve minimizing the need for a person to repeat his or her story and include ongoing care by the screener, a warm handoff to the treating clinician, and documentation of the unique care needs of the patient.

Applying principles of Psychological First Aid (PFA)25 may provide a valuable foundation on which to build a proactive trauma-informed approach to patients at all points of contact across the health care system, including critical care settings. Although PFA's role is recognized in the aftermath of an acute crisis, individual trauma, or community-wide disaster, its application in the setting of potentially traumatic encounters including medical history taking, invasive procedures, and monitoring examinations should be further investigated.

As physicians, moreover, this framework can be expanded to one of Psychiatric First Aid, ensuring physicians of all specialties feel capable of proactively addressing physiological and pharmacological contributors to, and mitigators of, the stress response. It is crucial that every physician recognizes the impact he or she can make in a patient encounter and feel capable of navigating these personal interactions in ways that both minimize the potential for causing or magnifying trauma and maximize the opportunity for reinforcing resiliency and positive coping strategies.

Not everyone who screens positive for trauma experiences and symptoms may have a need for, or interest in, referral for trauma-focused treatment. There is much to learn about how to provide preventive and mitigating treatments through development of novel interventions that build or restore a sense of competence and self-efficacy before symptoms progress to pathology. Strengths-based interventions beyond trauma-focused mental health treatment can improve levels of patient functioning that may have been compromised by trauma exposures.

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Interviews

Physicians play a central role in diagnostic evaluation, and lack of physician sensitivity to trauma history can be retraumatizing. History taking must be adaptive, varying in level of detail based on both clinical context and physician role. Notably, an expanding understanding of epigenetics and delayed or transgenerational impacts of trauma has implications for the potential utility of screening for a “family traumatic exposures history” when addressing risk stratification or understanding the nature of an individual's vulnerabilities, challenges, and resources in managing their health.

It can be very triggering to be asked repeatedly about a trauma history at every clinical encounter. The goal is to put the locus of control with the patients to determine whether and how much they wish to share their trauma history and to have an experience in which disclosure is received without perception of judgment. The goal of inquiry is not detailed disclosure, rather providing the space for patients to share as much or as little of their history as they choose. More research is required to understand what scope of information and level of detail is required for accurate diagnostic evaluations in both medical and behavioral health settings.

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Continuity of care

Trauma exposure can add a psychological barrier to the many logistic and administrative challenges of accessing care and treatment within a complex health care system. Therefore, communication is crucial across transitions of care such as emergency department or hospital admissions and discharges as well as outpatient referrals. Clinical discussion between members of a health care team in advance of a referral visit may improve patient follow-up in many ways, not least by limiting the possibility of being triggered, or retraumatized, by being asked a full history that includes trauma exposures. Warm handovers provide the clinician with an opportunity to share pertinent patient history with a colleague in a way that can add critical meaning in care management. Crucial issues about whether, how, when, and where trauma histories are obtained and documented in the electronic health record need thoughtful consideration and policy development. For physicians to feel comfortable expanding scope of engagement in trauma-informed inquiry, guidelines for documentation should be clear and consistent throughout the continuum of care.

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CONCLUSION

People who have experienced high burdens of trauma face markedly higher risks of medical illness, psychiatric disease, and early mortality. To achieve health equity, in which all people have the opportunity for health, it is crucial for physicians to become comfortable with a neurobiopsychosocial understanding of trauma and how to provide optimal TIC. Adaptation of the TIC approach in the health care setting for adult populations will require a significant investment in education, clinical, research, and public health policy domains. Physicians play a central role within the multidisciplinary world of health care delivery, ranging from team leadership to frontline research; from clinical screening, evaluation, and treatment planning to broader curriculum development and administrative and advocacy efforts. Greater engagement and integration of physicians in development of trauma-informed medical programs will increase the opportunity for expanded research agendas and, above all, for patients to benefit from the advances in pertinent translational research. Moreover, physicians themselves have an opportunity for fulfillment that derives from improved patient engagement and outcomes, recognizing and mitigating the potential for vicarious traumatization and burnout. Even the best-intentioned clinician may unintentionally traumatize or retrigger patients, and physicians are as vulnerable as any discipline to vicarious and secondary trauma. Helping our patients and ourselves will require a critical shift in perspective that needs to be introduced at the start of training, reinforced throughout, modeled by its most senior practitioners, and promoted by its upcoming generations.

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Keywords:

health equity; medical education; trauma-informed care; universal trauma precautions

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