What doctors wish patients knew about trauma-informed care

Trauma experienced from surviving or witnessing car accidents, natural disasters, mass-casualty events, racism, global pandemics, violence or any distressing experience can shake up a person’s life. It can also challenge a person’s core beliefs and views of the world. But sometimes patients may not realize they have experienced trauma in their life, which could account for their behavior or physical symptoms. That is where trauma-informed care can help.

In 2021, the AMA adopted policy recognizing trauma-informed care as a practice that acknowledges the widespread impact of trauma on patients, identifies the signs and symptoms of trauma, and treats patients by fully integrating knowledge about trauma into procedures to avoid retraumatization.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two physicians took time to discuss what patients need to know about trauma-informed care. These AMA members are:

• Anita Ravi, MD, MPH, MSHP, a family physician and co-founder and CEO of the PurpLE (Purpose: Listen and Engage) Health Foundation, a nonprofit organization that is ending the cycle of gender-based violence against women by providing physical, mental and financial services for survivors.
• Kanani Titchen, MD, an adolescent medicine physician and pediatrician at the University of California, San Diego School of Medicine and Rady Children's Hospital. 

“When we think about training physicians to understand trauma-informed care, it’s equally important to train physicians in what not to do as it is to train physicians how to respond to trauma,” said Dr. Titchen. “Some of the things that we don’t want to do are not to force disclosure.

“We don’t want to attempt to rescue the patient and we don’t want to make promises that we can’t keep,” she added. “In light of that, we don’t want to leave it up to the patient or the person to identify themselves as a victim or survivor of trauma.”

“Instead, what we want to do is apply trauma-informed principles or trauma-sensitive principles universally to all of our patients and ideally to everybody that we work with,” Dr. Titchen said.

Trauma-informed care is “an approach to health care delivery that is respectful of the impact of trauma,” said Dr. Ravi, who spoke about breaking the cycle of gender-based violence against women during an appearance on “AMA Update.”

“That includes supporting individuals who recognize and share their trauma histories and caring for people who may not know they’ve experienced trauma or may not choose to discuss it.

“In a clinical setting, indicators that trauma has impacted patients can be observed in medical symptoms and diagnoses, verbal and nonverbal communication, and beyond,” she added, noting “trauma can also vicariously impact the health care team and affect the way we deliver the care.”

“It’s key for physicians to recognize that trauma reverberates through so many aspects of health and health care delivery and to actively design care that acknowledges that fact,” Dr. Ravi said. “It’s actually effective when we’re doing it.”

“Part of the training involves dispelling myths about what trauma looks like in trauma response,” said Dr. Titchen. “A second arm of trauma-informed care is emphasizing safety—both physical as well as psychological or emotional safety for all participants.”

“In recognition of the emphasis on safety, really helping patients or coworkers to have a sense of autonomy and restoring a sense of control to that person and giving them choice and options,” she said. “The third part of trauma-informed care involves just applying these things universally throughout a system, throughout an organization, providing universal education so that people don't need to ask for trauma-informed care.

“But instead, every person coming into contact with an organization, be it a hospital or a clinic or even an operating room, is assumed to have experienced some form of trauma in their life and therefore is assumed to be in need of trauma-informed care,” Dr. Titchen said.

“In the patient population that I work with, specifically victims and survivors of human trafficking, many times the individual will not identify as a victim,” said Dr. Titchen, adding that “many individuals who've experienced trauma don't fully understand their trauma until they are well on their way to recovery.”

“Many of the teenagers and young adults who I see may think that abusive tactics and relationship dating violence, emotional violence, manipulation, or control by their significant other or even family members is normal,” she said. “They might not have a context for understanding that they are being victimized or that they are victims of trauma.”

“There is a perception that experiencing trauma implies experiencing physical trauma—like a bruised cheek or broken bone,” said Dr. Ravi. “However, trauma can also result from other types of violence, such as verbal abuse and emotional neglect. 

“These forms can be particularly insidious as they can be normalized in families and leave individuals believing they are just overly sensitive or weak for feeling the impact of those experiences,” she added.

“Recognition of one’s own trauma is really the first step in the road to recovery,” said Dr. Titchen. “And the road may be long and full of twists and turns.”

“Uncovering trauma and its impact is a journey. The downstream effect of traumatic experiences can unexpectedly show up in all aspects of someone’s life, including their health,” Dr. Ravi said. “For example, a patient diagnosed with obesity may know that they frequently binge eat but may not realize that the behavior is connected to a trauma history where they frequently overate as a child because an abusive parent would unpredictably withhold food, causing them to never know when their next meal would be.”

“Our brains are wired for survival, and trauma can train the brain to be stuck in an over-protective survival-mode, even when abuse is no longer present,” she said. “Recognizing that the world isn’t as scary as our post-trauma brain prepares us for makes the recovery process of feeling safe in the world a journey.”

Additionally, “when we talk about the human trafficking population, people may return to their abuser or their exploiter because there are real trauma bonds there,” Dr. Titchen said. “The more complex the trauma, the longer the recovery and the more steps or interventions might be needed to help a person recover.”

“Trauma is highly individualized and therefore the response is highly individualized. One of the mistakes we don't want to make is assuming that we can define somebody else's trauma,” said Dr. Titchen. “We need to acknowledge that each person’s experience of their own trauma is what's important.”

“Recognizing trauma means unlearning stereotypes. When we talk about what trauma looks like in clinic, it can often assume expressions of sadness or negativity, causing us to limit our ability to identify the presence or impact of trauma,” Dr. Ravi said. “For example, physicians may not recognize that a patient has experienced trauma because the patient frequently smiles or laughs throughout the interaction.”

“But being trauma-informed means recognizing that individuals have varying coping mechanisms and humor can be quite effective for some,” she explained. “Laughing and joking might be a way for someone to cope with the reality of their world and the trauma they have experienced.”

That is why it is important for physicians to recognize “our own stereotypes of what trauma looks like and how people express their emotional experience through their behavior and interactions,” Dr. Ravi said.

“The other thing patients share is frustration in being told by doctors that symptoms of pain are in their head,” said Dr. Ravi. “These experiences can be retraumatizing because their reality has been undermined and invalidated.”

“When a patient comes to be with symptoms but no clear diagnosis, it can be helpful to approach the issue with openness and curiosity to increase your ability to get the right diagnosis,” she said. “This includes being aware that trauma can result in an unexpected constellation of symptoms and diagnoses, and recognizing that if something doesn’t make sense, changing the conversation from ‘it’s in your head’ to ‘this is different, and I may need more time and information to help’ can be useful.”

Patients should identify “fears they have walking into a clinical setting,” said Dr. Ravi. For example, “patients with certain trauma histories may experience anxiety over routine parts of a doctor’s visit, such as being weighed, or having a Pap smear.

“To address this, collaboration between patients and the health care team is key,” she added, noting that “patients might say, ‘Can we skip this?’ when it comes to being weighed or delaying a needed Pap smear.”

“A trauma-informed approach allows the physician to observe what’s actually being communicated, such as feelings of shame, fear or avoidance, and recognizing there may be unknown factors motivating these actions—such as a history of trauma—and integrating this information into how care is discussed and delivered,” Dr. Ravi explained.  

“If there are things that are not comfortable in that experience, a helpful approach can be talking to your doctor about the discomfort,” she said. For example, say, “I know I keep missing the Pap smear. Honestly, I’m terrified of it. Is there a way we can do this differently?”

“Having the opportunity to discuss and collaborate is helpful and can help reduce the risk of retraumatizing the patient,” Dr. Ravi said.

While patients can look online for survivor groups, they also “can advocate for themselves, and parents can advocate for their kids by letting their doctors, hospitals or clinics know that they are interested in a trauma-informed approach,” said Dr. Titchen, noting it is also important for patients to “speak up when they feel that they have been mistreated or misunderstood."

“It’s not just a matter of complaining to higher-ups in hospitals, but actually coming forward and sharing ideas for how care might be improved,” she added. “It’s always good if you’re going to come forward with a complaint about something to also offer a suggestion for how that gap or that deficit could be addressed.”

“Both patients and health care professionals need to maintain an open mind and understand that psychological and physical trauma—even those that have been experienced in the past—can carry forward,” said Dr. Titchen. “There’s good evidence for that in the effect of a patient’s current physical state, psychological state or even their diagnosis.