From Treatment to Healing: The Promise of Trauma-Informed Primary Care
2015; Elsevier BV; Volume: 25; Issue: 3 Linguagem: Inglês
10.1016/j.whi.2015.03.008
ISSN1878-4321
AutoresEdward L. Machtinger, Yvette P. Cuca, Naina Khanna, Carol Dawson Rose, Leigh Kimberg,
Tópico(s)Child and Adolescent Health
ResumoIn August 2013, a national strategy group convened in Washington, DC to clarify a framework for trauma-informed primary care (TIPC) for women. The group was motivated by an increasing body of research and experience revealing that people from all races, ethnicities, and socioeconomic backgrounds come to primary care with common conditions (e.g., heart, lung, and liver diseases, obesity, diabetes, depression, substance use, and sexually transmitted infections) that can be traced to recent and past trauma. These conditions are often stubbornly refractory to treatment, in part because we are not addressing the trauma and posttraumatic stress disorder (PTSD) that underlie and perpetuate them. The purpose of the strategy group was to review the evidence linking trauma to health and provide practical guidance to clinicians, researchers, and policymakers about the core components of an effective response to recent and past trauma in the setting of primary care. We describe the results of this work and advocate for the adoption of TIPC as a practical and ethical imperative for women's health and well-being. Janice 1Janice represents a composite of cases seen in our clinics.1Janice represents a composite of cases seen in our clinics. is a 45-year-old woman with poorly controlled diabetes, obesity, and alcoholism. She feels ashamed about her alcohol use and about her body. She fears that her clinician will be angry with her for not checking her blood sugar, not losing weight, and for missing multiple gynecology appointments. Janice's clinician has worked with her for over a year and is frustrated by their inability to make progress together on her health issues. Janice has never revealed to any of her clinicians that she was sexually abused during childhood nor that she is currently experiencing severe emotional abuse by her husband. For many people like Janice and her provider, understanding the connection between traumatic experiences and health can be transformative and healing. When patients understand that childhood and adult trauma underlie many illnesses and unhealthy behaviors, they often stop blaming themselves, feel more self-acceptance, and make progress toward health and well-being. Providers who understand this connection are able to create clinical environments that are less triggering for both patients and staff, identify referrals to appropriate trauma-specific services, and develop more effective therapeutic alliances and treatment plans with their patients. Our strategy group worked to clarify a practical framework for TIPC, a patient-centered approach that acknowledges and addresses the broad impact of both recent and lifetime trauma on health behaviors and outcomes. The goal of TIPC is to improve the efficacy and experience of primary care for both patients and providers by integrating an evidence-based response to this key social determinant of health. The Substance Abuse and Mental Health Services Administration defines trauma as "an event, series of events, or set of circumstances [e.g., childhood and adult physical, sexual, and emotional abuse; neglect; loss; community violence; structural violence] that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects" (Substance Abuse and Mental Health Services Administration, 2014bSubstance Abuse and Mental Health Services AdministrationSAMHSA's concept of trauma and guidance for a trauma-informed approach. SAMHSA, Rockville, MD2014http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdfGoogle Scholar). Childhood and adult trauma have been shown to be major risk factors for the most common causes of adult illness, death, and disability in the United States. The seminal Adverse Childhood Experiences (ACE) study found remarkably high rates of childhood physical and sexual abuse, neglect, and household dysfunction among 17,000 predominately white, middle-class adults (Centers for Disease Control and Prevention Division of Violence Prevention, 2014aCenters for Disease Control and Prevention Division of Violence Prevention (2014a). Adverse Childhood Experiences Study. Available: http://www.cdc.gov/violenceprevention/acestudy. Accessed January 28, 2015.Google Scholar, ACE Study–Health Presentations (2014)ACE Study–Health Presentations (2014). Adverse Childhood Experiences Study. Available: http://acestudy.org. Accessed January 28, 2015.Google Scholar). The study calculated an ACE Score (0–10) based on how many categories of childhood abuse individuals had experienced: 64% reported at least one ACE category, and one in six reported four or more. Women were 50% more likely than men to have experienced six or more categories of ACEs. Notably, 25% of women and 16% of men reported having experienced childhood sexual abuse. The study also revealed a strong dose–response relationship between childhood trauma and adult heart, lung, and liver disease, obesity, diabetes, depression, substance abuse, sexually transmitted infection risk, and intimate partner violence (IPV). For example, individuals who reported four or more ACE categories had twice the rates of lung and liver disease, 3 times the rate of depression, at least 3 times the rate of alcoholism, 11 times the rate of intravenous drug use, and 14 times the rate of attempting suicide than those who reported ACE scores of 0. Similarly, trauma in adulthood is common, linked with poor health, and often undiagnosed. More than one-third of U.S. women experience stalking, physical violence, and/or rape from an intimate partner during their lifetime (Black et al., 2011Black M.C. Basile K.C. Breiding M.J. Smith S.G. Walters M.L. Merrick M.T. Chen J. Stevens M.R. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Atlanta2011Google Scholar). Work over the course of many years has demonstrated that both IPV and PTSD are correlated strongly with most of the same illnesses and unhealthy coping strategies as childhood trauma (Centers for Disease Control and Prevention Division of Violence Prevention, 2014bCenters for Disease Control and Prevention Division of Violence Prevention. (2014b). Intimate partner violence. Available: http://www.cdc.gov/violenceprevention/intimatepartnerviolence/. 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More recently, the U.S. Preventive Services Task Force found that screening for IPV increases its identification, is not harmful, and that effective interventions exist to reduce repeat victimization. They now call for clinicians to screen women for IPV and "provide or refer women who screen positive to intervention services" (Nelson et al., 2012Nelson H.D. Bougatsos C. Blazina I. Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force recommendation.Annals of Internal Medicine. 2012; 156 (W-279, W-280, W-281, W-282): 796-808Crossref PubMed Scopus (234) Google Scholar). The Institute of Medicine and the Agency for Healthcare Research and Quality have also called for the integration and evaluation of a response to trauma in primary care (Carey et al., 2010Carey T.S. Crotty K.A. Morrissey J.P. Jonas D.E. Viswanathan M. Thaker S. Ellis A.R. Woodell C. Wines C. Future research needs for the integration of mental health/substance abuse and primary care: Identification of future research needs from evidence. Report/technology assessment No. 173 Future Research Needs Papers. Agency for Healthcare Research and Quality, Rockville, MD2010http://www.ncbi.nlm.nih.gov/books/NBK51247/Google Scholar, Institute of Medicine Committee on Preventive Services for Women, 2011Institute of Medicine Committee on Preventive Services for WomenClinical preventive services for women: Closing the gaps. The National Academies Press, Washington, DC2011http://www.nap.edu/openbook.php?record_id=13181Google Scholar). Recent calls for trauma-informed services have been particularly eloquent from clinicians, researchers, and advocates working with women living with human immunodeficiency virus (HIV), among whom rates of IPV and PTSD are estimated to be 55% and 30%, respectively (Machtinger et al., 2012bMachtinger E.L. Wilson T.C. Haberer J.E. Weiss D.S. Psychological trauma and PTSD in HIV-positive women: A meta-analysis.AIDS and Behavior. 2012; 16: 2091-2100Crossref PubMed Scopus (230) Google Scholar). Participants in a 2010 forum sponsored by the U.S. Office on Women's Health and the Joint United Nations Programme on HIV/AIDS identified practical opportunities to integrate services for HIV and gender-based violence and described this integration as fundamental to achieving and building on the goals of the National HIV/AIDS Strategy (Forbes et al., 2011Forbes A. Bowers M. Langhorne A. Yakovchenko V. Taylor S. Bringing it back home: Making gender central in the domestic US AIDS response.Women's Health Issues. 2011; 21: S221-S226Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, Wyatt et al., 2011Wyatt G.E. Hamilton A.B. Myers H.F. Ullman J.B. Chin D. Sumner L.A. 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However, a practical approach to incorporating interventions for both IPV and the impacts of lifelong trauma into primary care is needed. Our efforts to respond to trauma in a more comprehensive way began after more fully clarifying the devastating impact of trauma on the lives of women living with HIV (Machtinger et al., 2012aMachtinger E.L. Haberer J.E. Wilson T.C. Weiss D.S. Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders.AIDS and Behavior. 2012; 16: 2160-2170Crossref PubMed Scopus (81) Google Scholar, Machtinger et al., 2012bMachtinger E.L. Wilson T.C. Haberer J.E. Weiss D.S. Psychological trauma and PTSD in HIV-positive women: A meta-analysis.AIDS and Behavior. 2012; 16: 2091-2100Crossref PubMed Scopus (230) Google Scholar). A review of patient deaths at the Women's HIV Program (WHP) at the University of California, San Francisco, revealed that most were not from HIV, but rather from trauma—directly through murders and indirectly through depression, suicide, and addiction. These deaths occurred in a clinic that already had integrated physical, mental health and social services. Positive Women's Network—USA (PWN-USA) had also noted the pervasive impact of trauma among its national network of women living with HIV. Together, we looked for ways to address trauma in a clinic setting and found that, despite national calls to action, there was a lack of guidance about the core components of a practical approach to addressing recent and past traumatic experiences within adult primary health care settings. 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Based on a review of the literature and input by experts from the national strategy group, we developed an approach to TIPC that defines trauma broadly, addresses both recent and lifelong trauma, and includes an essential focus on provider support and well-being (Figure 1). This approach has four core components: environment, screening, response, and a robust organizational foundation. A TIPC practice is designed to reduce trauma-related triggers and promote healing. All staff and providers receive training about the impact of trauma on health, available trauma-specific services, and trauma-informed practices for use with both patients and one another. The physical space provides opportunities for privacy, confidentiality, and community. Where possible, providers work as an interdisciplinary team to ensure that existing services are trauma-informed and well-coordinated. Outreach is offered to encourage access and connection to trauma-informed services. Power differentials among staff and between patients and providers are acknowledged and minimized. The environment also supports providers, many of whom may have experienced trauma themselves, and/or may experience vicarious trauma by working with affected patients. TIPC practices routinely and universally inquire about trauma, ideally as part of an ongoing relationship. Screening is normalized and patients are educated in a variety of ways about the links between trauma and health. In general, TIPC practices screen for 1) recent abuse, including IPV, 2) lifetime trauma, and 3) the emotional and physical consequences of trauma, including PTSD, depression, suicidality, substance use, and chronic pain. Trauma-related information and interventions can be offered to patients, regardless of whether they choose to disclose their trauma. A patient's disclosure of recent or past abuse is, in itself, potentially therapeutic. Provider responses to trauma disclosures are empathetic and supportive; validate individuals' experiences, choices, and autonomy; and build on patient strengths. Practices determine which responses will be provided through linkages with community partners and which will be available on site. Specific responses to recent trauma may include safety planning; danger assessments (Campbell et al., 2009Campbell J.C. Webster D.W. Glass N. The Danger Assessment: Validation of a lethality risk assessment instrument for intimate partner femicide.Journal of Interpersonal Violence. 2009; 24: 653-674Crossref PubMed Scopus (381) Google Scholar); referrals for safe housing, legal, police and other community resources; individual and/or group therapy; and peer support. Practices respond to lifelong trauma and its consequences by ensuring that existing services are trauma-informed, by building strong community partnerships, and by facilitating referrals to trauma-specific group and/or individual therapy and peer support. The effectiveness and sustainability of TIPC depend on an organizational foundation that includes a core set of trauma-informed values that inform the clinic's physical setting, activities, and relationships: safety, collaboration, trustworthiness, empowerment, and respect for patient choice (Harris and Fallot, 2001Using trauma theory to design service systems. Vol. 89. Jossey-Bass, San Francisco2001Google Scholar). The foundation also includes clinic champion(s); "buy-in" from clinic leadership; partnerships with trauma-informed community organizations and municipal agencies; support for providers and staff; and ongoing monitoring and evaluation. This approach to TIPC is aspirational; it is possible and likely beneficial to implement its elements incrementally. A first step is for every member of the practice (e.g., receptionists, medical assistants, administrators, and clinicians) to participate in one or more of the many existing trainings to learn about the impact of trauma on the health of patients and on the well-being of caregivers, and to develop trauma-informed skills to communicate more effectively with patients and each other. Over time, clinic champion(s) can be identified, partnerships can be made with local trauma and service organizations, and protocols for screening and response can be developed. The initial cost of introducing TIPC is relatively modest (e.g., a half-day training for all staff and providers). Its full implementation, however, requires genuine commitment, resources, and support from clinic/institutional leadership. This effort is facilitated by policy directives and mandated reimbursement for addressing interpersonal violence and abuse by the Affordable Care Act (Dawson and Kates, 2014Dawson L. Kates J. HIV, intimate partner violence, and women: New opportunities under the Affordable Care Act (ACA).in: The Henry J. Kaiser Family Foundation Issue Brief. 2014http://files.kff.org/attachment/hiv-intimate-partner-violence-and-women-new-opportunities-under-the-acaGoogle Scholar), Joint Commission on Accreditation of Healthcare Organizations, 2002Joint Commission on Accreditation of Healthcare OrganizationsHow to recognize abuse and neglect. Joint Commission Resources, Oak Brook, IL2002Google Scholar, and many state regulations, as well as emerging incentives in accountable care organizations. Exceptionally good quality practical resources and technical assistance are available to guide each element of TIPC (Bott, Guedes, Claremont, & Guezmes, 2004Bott S. Guedes A. Claramunt M.C. Guezmes A. 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Eventually, Janice accepts referrals to an outpatient alcohol treatment program and to group therapy, both of which are trauma-informed.
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