A Call to Action: Adoption of Trauma Informed Care in Complementary and Integrative Health Services
2021; Mary Ann Liebert, Inc.; Volume: 27; Issue: 2 Linguagem: Inglês
10.1089/acm.2021.0018
ISSN1557-7708
AutoresKathryn Hansen, Elizabeth G. Walsh, Cynthia Price,
Tópico(s)Musculoskeletal pain and rehabilitation
ResumoThe Journal of Alternative and Complementary MedicineVol. 27, No. 2 Osher Collaborative Forum: Outlooks, Opinions, and OpportunitiesFree AccessA Call to Action: Adoption of Trauma Informed Care in Complementary and Integrative Health ServicesKathryn A. Hansen, Elizabeth G. Walsh, and Cynthia PriceKathryn A. HansenAddress correspondence to: Kathryn A. Hansen, APRN, PhD(c), Department of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, 3401 West End Avenue, Suite 380, Nashville, TN 37203, USA E-mail Address: kathryn.a.hansen@vanderbilt.eduDepartment of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, Nashville, TN, USA.Vanderbilt University School of Nursing, Nashville, TN, USA.Osher Center for Integrative Medicine, Vanderbilt University, Nashville, TN, USA.Search for more papers by this author, Elizabeth G. WalshDepartment of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, Nashville, TN, USA.Osher Center for Integrative Medicine, Vanderbilt University, Nashville, TN, USA.Search for more papers by this author, and Cynthia PriceUniversity of Washington School of Nursing, Seattle, WA, USA.Osher Center for Integrative Medicine, University of Washington, Seattle, WA, USA.Search for more papers by this authorPublished Online:12 Feb 2021https://doi.org/10.1089/acm.2021.0018AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Kathryn A. Hansen, APRN, PhD(c)Elizabeth G. Walsh, PhDCynthia Price, PhD, MA, LMTEditor's Note: This is the seventh commentary through the JACM column partnership with the Osher Collaborative for Integrative Medicine. Our goal with these commentaries is to stimulate critical conversations in the field through perspectives from the leaders of the Collaborative's seven prominent academically-based integrative centers. This commentary elevates a theme that is tangled up in all kinds of human troubles: prior trauma. Trauma Informed Care (TIC) proposes that outing this powerfully determinant force is key to untangling and healing. The overlaps of this model with the integrative health model are significant. The authors represent two of the 7 Centers: Kathryn A. Hansen APRN, PhD(c) of the Vanderbilt University School of Nursing and Elizabeth Walsh PhD of the Department of Physical Medicine and Rehabilitation, Vanderbilt University School of Medicine, both with the Osher Center for Integrative Medicine, Vanderbilt University; and Cynthia Price PhD, MA, LMT, with the University of Washington School of Nursing and Osher Center for Integrative Medicine, University of Washington. They propose that direct engagement with emerging TIC practice will empower the integrative movement. Their commentary is rightfully a call to action. —John Weeks, Contributing Editor, Special Projects and Collaborations, JACMIntroductionComplementary and integrative health and medicine (CIH) includes a diverse collection of healing systems and clinicians not often represented in modern conventional medicine. While there are many differences among these CIH systems and clinicians, many have a shared value of relationship-centered care with an emphasis on nonpharmacological therapies. To address a history of trauma, patients would be best served if trauma-informed care was incorporated into all CIH practices. A structural shift in education and expectations is needed for this to occur.Over the past several decades, awareness of the widespread prevalence of traumatic experiences and the potential for related lifelong negative impacts on mental and physical health has increased dramatically. The interplay of mind, body, and spirit could not be more apparent in the myriad ways trauma impacts individuals, families, and communities. The mission of complementary and integrative health and medicine (CIH) is to emphasize care that is relationship centered, whole person, and interdisciplinary, to promote optimal health and healing.1,2 CIH is thus highly appropriate for individuals dealing with the sequela of trauma exposure.CIH includes a diverse collection of healing systems and clinicians not often represented in modern conventional medicine. While there are many differences among these CIH systems and clinicians, many have a shared value of relationship-centered care with an emphasis on nonpharmacologic therapies. To address a history of trauma, patients would be best served if trauma-informed care (TIC) was incorporated into all CIH practices. A structural shift in education and expectations is needed for this to occur.The Widespread Impact of TraumaTrauma is commonly defined as experiencing or witnessing a potentially life-threatening or emotionally overwhelming event such as childhood abuse, natural disaster, combat, sexual assault, or car accident.3 Experiencing systemic oppression, such as racism, is also a form of insidious trauma.4 Exposure to potentially traumatic experiences is very common: over 60% of the U.S. population report at least one adverse childhood experience (ACE), while 25% have three or more.5 Many, particularly traditionally under-resourced populations, have repeated exposure to trauma over their lifetime. Demographic and identity group factors, including race, gender, immigration status, and profession (e.g., soldier or first responder), correlate with a higher risk for trauma exposure. Membership in one or more “in risk” groups generally compounds trauma exposure and consequently increases risk for many chronic diseases.6,7Post-traumatic stress disorder (PTSD) is the most recognized, but by no means the only, sequela of trauma exposure. Trauma exposure results in increased risk of psychological distress and substance use misuse later in life.8 The more ACEs one has increases the risk of obesity, hypertension, suicide, teen pregnancy, and polypharmacy.9 Developing PTSD increases the risk for negative health outcomes: adults with PTSD are approximately three times more likely to develop a functional somatic syndrome.10 They also have more severe pain symptoms, poorer functioning, and health prognosis.11,12 Recent research has started to elucidate the mechanisms involved in this process, showing that PTSD is associated with accelerated cellular aging.8,13,14In this context, asking clinicians to care for patients without skills and systems to address underlying trauma is like asking a clinician to manage type 2 diabetes without the knowledge that dietary sugar contributes to the disease. According to the Centers for Disease Control and Prevention, 90% of health care expenditures are for chronic disease.15 Now that it is well established that exposure to potentially traumatic experiences is a major risk factor for chronic disease, it is undeniable that the health care system, including CIH, must reorient itself to directly and systemically address trauma and its sequela.What Is TIC?TIC involves understanding the impact of violence and victimization on a person's life and development, then offering care that promotes safety and healing and avoids retraumatization.16 The practice of TIC is based on five core values: safety, trustworthiness, choice, collaboration, and empowerment.16,17 These values are translated into practice through a set of organizational and clinical reforms. Organizational practices include training of both clinicians and nonclinical staff, active engagement of patients in the change process, and modifying the physical clinical environment. Clinical practices include sensitively screening for trauma exposure, engaging patients as active partners in their care, and building referral networks for specialized treatment18 (Table 1). It is important to note that TIC does not necessarily involve providing psychological treatment for trauma. It does involve recognizing when untreated trauma may be impeding a patient's progress and referring to evidence-based trauma treatment—such as Eye Movement Desensitization and Reprocessing (EMDR) or cognitive processing therapy—when appropriate.19Table 1. Application of TIC to CIHCIH valueTIC valueDefinitionCIH operational applicationRelationship-centered careSafetyEnsuring physical and emotional safety- Services are delivered in a calm environment- Training front desk staff in TIC so the entire clinical experience promotes safety- Speak in a calm voiceTrustworthinessEstablishing clarity and consistency in policies and modeling appropriate interpersonal boundaries- Providing materials on cost and appropriate expectations of recommended treatments- Clinicians and staff engage in practices that promote their own self-regulation- Create policies that are clear and consistent for staff and cliniciansChoicePatients have choices and control over decisions related to their health- Choices on available services and treatment are provided in a health-literate way- Support staff and clinician in generating solutions to clinic issuesCollaborationSharing power among clinicians, staff, and patients- Patients have an opportunity to provide feedback on the care they receive- Patients have a voice in developing and evaluating services, e.g., patient advisory council- Include staff and clinicians in discussions on policies and priorities that will impact themEmpowermentRecognizing and honoring strengths in others- Help patients to identify their idea of successful care- Craft treatment plan to meet that goal- Support education and development of all staff and cliniciansRelationship-centered careSafetyEnsuring physical and emotional safety- Services are delivered in a calm environment- Training front desk staff in TIC so the entire clinical experience promotes safety- Speak in a calm voiceTrustworthinessEstablishing clarity and consistency in policies and modeling appropriate interpersonal boundaries- Providing materials on cost and appropriate expectations of recommended treatments- Clinicians and staff engage in practices that promote their own self-regulation- Create policies that are clear and consistent for staff and cliniciansChoicePatients have choices and control over decisions related to their health- Choices on available services and treatment are provided in a health-literate way- Support staff and clinician in generating solutions to clinic issuesCollaborationSharing power among clinicians, staff, and patients- Patients have an opportunity to provide feedback on the care they receive- Patients have a voice in developing and evaluating services, e.g., patient advisory council- Include staff and clinicians in discussions on policies and priorities that will impact themEmpowermentRecognizing and honoring strengths in others- Help patients to identify their idea of successful care- Craft treatment plan to meet that goal- Support education and development of all staff and cliniciansCIH, complementary and integrative health and medicine; TIC, trauma-informed care.TIC acknowledges that both those receiving and delivering care may have a history of trauma. The TIC focus in health care is on creating a safe environment in the workplace and in the treatment room. TIC thus addresses the well-being of clinicians and staff who work in health care settings. Providing care to trauma survivors and experiencing the traumatic impact of grief and death (including palliative and hospice care, and in situations like our current pandemic) contribute to secondary trauma and burnout in our workforce. This is especially apparent among clinicians who are at greater risk for secondary trauma due to having their own trauma history.20 Due to the evidence of its effectiveness and appropriateness, TIC is now recognized as best practice in diverse systems including foster care, court rooms, schools, public health, and social services to address the ubiquity of trauma in our society.21,22Recommendations for Integrating TIC into CIHIntegrating TIC values and operationalizing TIC care in CIH are appropriate for providing the best care to patients, and the best support for clinicians. For CIH to be delivered in a trauma informed way, anyone practicing within CIH should be able to provide a safe environment for patients, recognize trauma symptoms, know how to therapeutically communicate about trauma, and know when to refer to trauma specialists. To accomplish this, TIC should be incorporated into interdisciplinary CIH curricula. This includes massage therapy, chiropractic, acupuncture/Chinese medicine, naturopathic, nursing, and medical training programs. If the national interdisciplinary organizations that represent CIH could define the incorporation of TIC into a call for CIH “best practices,” this could provide the guidance and framework necessary for the diversity of fields represented in CIH to incorporate these values and allow for different applications in different fields. For example, TIC training might have different areas of emphasis for massage therapists versus integrative nutritionists. This effort would include a call for a change in health systems, so that clinicians have adequate time with patients to foster therapeutic relationships, and are able to care for themselves and model healthy self-care.The Veterans Administration's (VA) “Whole Health” program provides an example of how TIC and CIH can be systematically integrated. The VA, which is the nation's largest health care system and serves a population with high post-traumatic stress symptom burden, has been implementing TIC and offering an array of CIH approaches for years. The Whole Health initiative involves both the expansion of CIH and wellness services, and a reorientation of the way care is directed and provided by engaging individuals in developing a “personal health plan”.23,24 In this way, the program illustrates how the central TIC tenets of choice and empowerment can enrich the delivery of CIH modalities. Program evaluation data underscore the importance of having strong leadership and a clear implementation plan when proposing to change system's culture and care delivery Models.25Furthermore, integrating TIC into CIH would provide important opportunities to enrich understanding of how individuals can truly recover from trauma—in mind, body, and spirit. Much of TIC application has focused on avoiding retraumatization within social services systems, and on increasing access to conventional psychological treatment for PTSD (i.e., Cognitive Behavioral Therapy, EMDR). CIH modalities, many of which focus on mind–body integration, increasing resilience and regulation, and healthy lifestyle, have great potential to expand opportunities to heal from the psychological, physiological, and relational sequela of trauma.26,27Barriers and ChallengesAs already noted, CIH is a diverse field incorporating many different healing professionals working in highly varied settings and governed by different licensing and credentialing bodies. Adopting TIC within the delivery of CIH will require systematic efforts to operationalize, including the education of TIC principles across the disciplines. It is for this reason that we urge the academic organizations promoting CIH (e.g., the Academic Consortium for Integrative Medicine and the Academy of Integrative Health and Medicine and its interprofessional Academic Collaborative for Integrative Health) to lead the charge on promoting TIC and disseminating information for how to integrate into CIH practice.Finally, it is important to consider that barriers and access issues for CIH echo those of mental health. In general, access to recovery for psychological trauma is very limited. The shortage of care for mental health in this country is an ongoing catastrophe, contributing to both individual and familial suffering. CIH has largely been utilized by wealthier, whiter, and more educated people in the United States.28 This is, in part, due to the lack of adequate insurance coverage for the evidence-informed care provided by CIH. It is also due to how CIH care tends to be delivered in the United States: clinics are often located in affluent settings, relying heavily on retail services, involving frequent visits that can be difficult for working people to transport themselves to and engage in. Thus optimal value from clinicians skilled with TIC will require removing such barriers to CIH.And yet, given the prevalence of trauma, it is inevitable that a large proportion of those currently receiving CIH have been impacted by trauma exposure and PTSD. Perhaps some of the popularity of CIH comes from its efficacy in reducing anxiety, depression, and trauma symptoms.29,30 Designing accessible services, with transparency regarding cost, and cocreating treatment plans that can be feasible to those with limited resources can promote safety and trustworthiness. Incorporating these principles into CIH will help better serve those already seeking CIH and cast a wider net to meet the needs of those who have not always felt seen, welcome, or had adequate access to such services in the health care system.Call to ActionGiven the pervasiveness of trauma exposure, it is imperative that all health care become trauma informed. CIH, with its emphasis on the whole-person (mind–body–spirit health), has a particular responsibility to implement TIC. Moreover, the integration of TIC into CIH presents unique opportunities to operationalize the shared values of relationship-centered care and integrative care (i.e., incorporation of complementary and traditional healing practices) to deeply support lasting healing from the sequela of trauma.For CIH to implement TIC requires an interdisciplinary effort. To implement TIC, leaders in CIH should prioritize training their clinicians and staff and reviewing administrative and clinical practices. There are many free resources available to guide this process.17,31–33 The case for better systems of CIH delivery could be strengthened by more explicitly adopting the approaches and rationale of TIC into CIH practice. Further, by incorporating TIC, we have the opportunity within the medical community to disseminate and model how health care can and should be delivered. Done collectively, this transformation can spark a cultural shift in health care.At a time when we are searching, as a nation, to dismantle systems of oppression, trauma-informed CIH has an opportunity to illuminate a path to restore safety and stability, to remember and grieve what has passed, and to restore relationships individually and collectively as we care for ourselves and our patients.Author Disclosure StatementNo competing financial interests exist.Funding InformationNo funding was received.References1. Tick H, Nielsen A. 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Google ScholarFiguresReferencesRelatedDetailsCited byPerceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension Henna Budhwani, Prabal De, and Ruoyan Sun19 April 2022 | Population Health Management, Vol. 25, No. 2 Volume 27Issue 2Feb 2021 InformationCopyright 2021, Mary Ann Liebert, Inc., publishersTo cite this article:Kathryn A. Hansen, Elizabeth G. Walsh, and Cynthia Price.A Call to Action: Adoption of Trauma Informed Care in Complementary and Integrative Health Services.The Journal of Alternative and Complementary Medicine.Feb 2021.103-107.http://doi.org/10.1089/acm.2021.0018Published in Volume: 27 Issue 2: February 12, 2021PDF download
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