Trauma-informed care

Trauma awareness and acknowledgment

Step 1. Bear witness to the patient’s experience of trauma: This is a fundamental step and can be therapeutic on its own. In some ways, it is the easiest step, and in some ways, it is the one that most deeply threatens to undermine the physician’s worldview. This step involves bearing witness to the patient’s experience of trauma, not in all its terrible detail but in its general outlines, while acknowledging the persistent and ongoing effect of this trauma on all facets of the person’s life. It involves identifying for the patient that the violence and abuse they had experienced led to coping strategies that might have once been necessary for survival, but that are often maladaptive once these threats no longer exist. Bearing witness offers an opportunity for clinicians to ensure that patients do not feel responsible for their neglect or abuse. Adverse childhood experiences are not their fault. The guilt and shame that often accompany these experiences need to be acknowledged and, most important, validated as relevant to current health and coping strategies. Understanding the connection between these past experiences and current functioning can be life changing.

Safety and trustworthiness

Step 2. Help patients feel they are in a safe space and recognize their need for physical and emotional safety: This step has 2 components, and although the step appears straightforward it is often hard to achieve. The first component is fundamental to the structure and delivery of care. Consistency and predictability in the procedure of care is essential. Consider that anxiety might easily be triggered in a patient living with ACEs. Perhaps appointments could be scheduled for this patient at times when the waiting room is not full, which would minimize time spent in the waiting room and accommodate last-minute cancellations. A survivor of ACEs is supremely sensitive to nonverbal communication. A rushed, harried, or patronizing physician can undo a great deal of progress toward regaining a sense of safety. A safe and predictable relationship with a health care provider can be a critical component of this step.

The second component involves recognizing the need for the physical and emotional safety of a person with a history of ACEs. There are many factors that can affect one’s sense of safety, such as financial instability, involvement with child protection agencies, and insecure housing issues. These circumstances all diminish one’s ability to feel calm, secure, and safe. For example, if a patient living with anxiety had a father who was an abusive alcoholic, that patient’s anxiety might be triggered by a drunk partner even if he or she is never abusive; living with this current partner is not a safe space for this patient and will undermine treatment of anxiety.

Choice, control, and collaboration

Step 3. Include patients in the healing process: Here we are seeking to actively involve patients in their own healing process using informed choice. By presenting both positive and negative choices (including the option to not engage in care), we can begin to override the passivity or deferral to authority that is typically used as a means of self-preservation by survivors of trauma. Physicians should seek to develop truly collaborative relationships with such patients, despite the initial added time required to do so. This will encourage the patient to move toward more active engagement in health care, rather than passivity or dependence. This step helps overcome the “no-show” problem (ie, the patient who habitually misses specialist appointments; the one who has no intention of going but does not dare to disagree with the proposed referral) or, similarly, the “failure-to-change” dilemma (ie, the patient who does not modify behaviour despite his or her apparent repeated commitments to do so). Active involvement helps patients avoid feeling they have failed yet again. A more collaborative approach might also elicit the reasons behind their reticence, resulting in better and more effective care.

Strengths-based and skills-building care

Step 4. Believe in the patient’s strength and resilience: Here the physician is called upon to shift from seeing the patient as a victim with symptoms and pathology, to a person with tremendous strength and resilience who has survived serious ACEs. Supporting a patient’s evolution from passive victim to active, motivated participant is one the most rewarding aspects of a health care provider’s work. This might be the first time someone has highlighted these strengths to a patient. One of the fundamental experiences of abuse is disempowerment, and even the most benevolent paternalism (often inherent in the medical system) recreates a cycle of helplessness from which a person must emerge. If a physician truly believes in a patient’s strength and resilience, then this belief can be conveyed, and the patient will be encouraged to move on, albeit slowly and with setbacks at times.

Cultural, historical, and gender issues

Step 5. Incorporate processes that are sensitive to a patient’s culture, ethnicity, and personal and social identity: Understandably, in addition to the issues of ACEs, there are groups who have experienced and continue to experience more systemic abuse based on their race, culture, gender identity, biological sex, or sexual orientation. This sometimes leads to intergenerational transmission of both trauma and shame that must be recognized. Demonstrating a sensitivity to group marginalization will augment the effectiveness of a trauma-informed care approach.