How to make your integrative practice trauma-informed

By Julie Luzarraga

It is hard to listen to the news today without hearing about some type of traumatic event. From sexual harassment, mass shootings, child abuse, and natural disasters, these stories span age, class, and ethnicity.  

According to the 2017 National Intimate Partner and Sexual Violence Survey, more than one in three women and about one in six men have experienced some form of sexual violence in their lifetime.   The Center for Disease Control and Prevention reports that one in four adult women and approximately one in seven adult men report having experienced physical abuse from an intimate partner in their lifetime.  According to the National Children’s Alliance, approximately 700,000 children in the United States are abused each year. The data highlights the disturbing reality that regardless of who they are or where they come from, many of our patients will experience or already have experienced some form of trauma in their lifetimes. 

The research on post-traumatic stress disorder began with professionals looking for ways to treat the aftermath of the traumatic experiences of combat.  As awareness of intimate partner violence, child abuse, and sexual abuse grew, the scope of trauma and post-traumatic disorders expanded to include more than combat.

War and violence are not the only experiences which create a traumatic response.  In the Encyclopedia of Social Work, Chase Wilson and colleagues describe trauma as, “a combination of a terrible event or series of events that involve real or perceived threats of death or serious injury, or threat to the physical integrity of the person or others, and from which that person experiences overwhelming fear, hopelessness, helplessness, or horror.” 

For some, grief, neglect, living through natural disasters, or life-threatening accidents can create a traumatic response. Medical trauma, such as heart attacks, strokes, childbirth trauma, and stays in intensive care units can also lead to symptoms of post-traumatic stress disorder. 

Trauma effects body, mind, and spirit. According to A Treatment Improvement Protocol from the Substance Abuse and Mental Health Services Administration (SAMHSA) survivors of trauma may experience difficulty regulating emotions; cognitive distortions; and biological and neurological dysregulation, in addition to physical symptoms and sequelae of trauma exposure. The Adverse Childhood Experiences (ACEs) study conducted by the Center for Disease Control and Prevention show a graded relationship between adverse childhood experiences and chronic health conditions such as obesity, diabetes, heart disease, cancer, stroke, and more. 

Considering the high prevalence of exposure to trauma, all healthcare should be trauma-informed care.  Our integrative principles of putting the patient at the center of the treatment relationship and treating the whole person create a solid foundation for providing trauma-informed care, but we are called to do more.    

The first step in ensuring your integrative practice is trauma-informed is to appreciate the prevalence and pervasiveness of trauma across all populations. Trauma is extremely complex; the goal is not to understand all aspects of trauma but to recognize the likelihood that many of your patients will have some experience of trauma. Looking through a trauma lens, we learn to be curious instead of making judgments. Instead of labeling a person “crazy” or “hyper,” we can query “I wonder what happened to make him so jumpy?” 

As in integrative approaches, trauma-informed providers look to know the whole person and their unique life experiences. It is important to know that trauma-informed care is not asking detailed questions about past trauma. Using screening tools such as the ACEs and asking if there is a history of trauma with clear and respectful language is encouraged. But, asking details about past trauma is not therapeutic because it can be triggering and exhausting. Fortunately, providers do not need to know the details to provide trauma-informed care. Trauma-informed care does not mean treating the symptoms, unless that is what the patient is coming for and the provider is appropriately trained. When trauma symptoms are creating health or emotional problems, the best approach is to refer to a licensed mental health provider who has experience working with trauma. 

Trauma-informed providers can identify and remove barriers to create more access and meaningful care for survivors. According to SAMHSA, trauma-informed organizations should understand the potential options for recovery; recognize the signs and symptoms of trauma; respond by integrating knowledge of trauma into policies, procedures and practices; and intentionally work to prevent re-traumatization.  Re-traumatization occurs when a survivor feels as if the trauma is re-occurring or experiences intense emotions similar to those experienced during past situations that were unsafe. Part of what makes trauma so complex is how memories are stored and the varied stages of recovery of trauma, which are unique for each person. Triggers can be subtle and re-traumatization is usually unintentional. However, there are steps providers can take to minimize potential triggers and create a sense of trust and safety.  A trauma-informed practice intentionally uses the following five core values identified in the 2009 publication, Creating cultures of trauma-informed care: A self-assessment and planning protocol:

• Safety
• Trustworthiness
• Collaboration
• Choice
• Empowerment

Patients need to feel both physically and emotionally safe. Ensuring that parking lots are well-lit; making support staff visible; and creating a soothing environment are all ways of creating a safe space. Emotional and social safety can be achieved through using inclusive and welcoming language; sharing information about the facilities; and communicating clearly. One way to practice clear communication is to describe and ask permission. For example, instead of talking about the weather while placing the stethoscope on a patient’s chest, a provider can say, “I’d like to listen to your lungs with the stethoscope. Would that be okay?”  Being clear about treatment plans and giving opportunity for questions also creates safety.

 A trauma-informed relationship between provider and patient is similar to that in the integrative healthcare setting. The patient-provider relationship is a collaborative partnership built on trust. This is particularly important for trauma survivors who likely have been in situations in which they learned to not trust others. Trustworthiness takes time and repetition. Patients who are in active recovery from trauma may not be consistent in the beginning of a treatment relationship. They may fear being judged or rejected. Seeing this as part of trauma and continuing to welcome them back shows trustworthiness and creates safety.

Choice is paramount in providing trauma-informed care. When someone experiences trauma they feel a loss of control over their safety and wellbeing. Whether this stems from a car accident, being the victim of a crime, or a natural disaster the feeling of being unsafe is terrifying and has long-lasting impacts on a person. Giving patients choice can be as simple as asking when they would like to schedule a procedure versus assigning a day and time. Choice can also mean exploring different options of care and different ways of delivery care. For example, when working with a sexual abuse survivor a provider may ask if the patient would like to remain dressed or have a trusted friend in the room during an exam. There are many ways we can give our patients choice which empowers patients, a key component to trauma recovery.

There are many ways we as integrative healthcare providers can expand upon our model to create more safety and ease of access for survivors of all trauma. To start, increase your knowledge about the pervasiveness of trauma and its deep effects on so many. Then let that inform how you can further enhance safety, trustworthiness, collaboration, choice, and empowerment in your practice. Incorporating trauma-informed principles takes the integrative healthcare model a step further, better meeting the needs of more people. We say that we look toward a day when there will not be a need for the term “integrative healthcare” because healthcare will simply be integrative. We can say the same thing about trauma-informed care; let’s hope someday we will not need the term “trauma-informed” because it will just be good care.