Show and Tell by Adia Scrubb, MD, MPP
Adverse Childhood Experiences (ACEs) and trauma-informed care (TIC) are on our minds these days. It’s in the news, it’s shaping healthcare policy, and it’s even more relevant during this devastating global pandemic while our patients suffer such dramatic impacts to their lives. What’s more, the usual social supports that help mitigate trauma’s impact have been unraveled by the need to socially distance. As we start to recover from the pandemic, new and secondary issues will emerge. In this post, I’m recommending a podcast episode that gives new insight into trauma-informed approaches to healthcare.
The California Surgeon General’s office advocates for universal ACEs screening however, many physicians and healthcare systems express hesitation. However, I want to share with my colleagues, the foundation of any plan to screen patients for past trauma is to adopt a trauma-informed approach to your practice. That is, to assume your patients are more likely than not to have a history of trauma and acknowledge the role that trauma might play in a person’s life and choices. There couldn’t be a better time to have a listen to this very insightful podcast. I think it will address many of the concerns out there about universal ACEs screenings and asking about trauma histories.
Dr. Megan Gerber, Associate Professor of Medicine at Boston University School of Medicine, (Twitter: @meggerber) is a nationally recognized expert on trauma-informed care (TIC) in primary practice. Curbsiders (a podcast team who “curbside” experts to deconstruct various topics in the world of medicine) interviewed Dr. Gerber in June of 2020.
The hour-long interview gets down to the key points at roughly minute 16:00, when Dr. Gerber provides a definition of trauma and its prevalence in our society. She lays the table for the conversation by clarifying that people enter traumatic experiences with different backgrounds, skillsets, and families of origin; therefore, even though trauma is incredibly common, not everyone responds to traumatic events in the same way.
She goes on to explain that trauma-informed care is, at its foundation, about practicing universal trauma precautions; fostering a trusting healthcare relationship based on collaboration and mutuality. Since we all regularly work with patients who’ve experienced traumatic life events, embracing a trauma-informed approach can help us understand patients who might appear to be non-compliant, intractable, impatient, or even rude.
I completely agree with Dr. Gerber when she explains that it’s not the asking that’s the problem, it’s the pressure to recount the details. You can practice a trauma-informed approach without eliciting every single detail of your patients’ past traumatic events. The evidence shows that most trauma-survivors want to be sensitively asked about their histories. For our purposes, in family medicine, the exact details don’t matter as much as the fact that something terrifying or horrible happened to our patient. Many of our adult patients have been “carrying” these burdens for years and can be relieved to share it. For this reason, Gerber urges us to be a little less afraid of the inquiry and, in the podcast, she shares specific ideas for useful, broad opening questions.
The first thing to do, Dr. Gerber explains, is to provide a validating, empathic response, something along the lines of, “I’m so sorry that this happened to you, that sounds really difficult.” Rather than jump to thinking about interventions or therapeutics right away, ask a next question: “How much difficulty is this causing you in your current life?” If the traumatic experience is preventing your patient from enjoying a happy, stable life, then interventions should be considered. You’ll want to have local resources queued up and at the ready for these situations (for example, social work referrals, hotline numbers, palm cards, pamphlets, websites, and behavioral health sources). But keep in mind that a patient might disclose their past trauma to you and that might be it. They may not be open to seeing a therapist or a social worker right now; they might just want to talk with you.
Dr. Gerber points out that if you get in the habit of working with a trauma-informed lens, it will become a natural part of your workflow. She also makes the point that adopting a TIC-approach will, ultimately, save time. Yes, the initial investment might require some additional time, but over the long run, when your patient feels heard and you gain insight into the long-term patterns impacting their health, their care (and your effectiveness) will improve.