The COVID-19 pandemic is being discussed more and more as a traumatic stressor. The damage that has been done differs from person to person, but many are left head in their hands, wondering how to cope. With the burnout rate increasing for health care workers, a new approach is needed. One option that has been identified as something that could ease burnout and compassion fatigue, while also benefiting patients, is trauma-informed care (TIC).
TIC originated after the Vietnam War era as awareness of the trauma that soldiers faced in battle grew. As more and more research illustrated the prevalence of trauma and the long-term impacts it can have, there was a growing need for trauma-informed policies and care. A groundbreaking 1998 study revealed that adults with high adverse childhood experience scores had a life expectancy 20 years shorter than those with fewer toxic exposures. In 2000, the National Child Traumatic Stress Network was established, boosting TIC in pediatrics and education. TIC then flourished again when Dr. Eve Rittenberg, assistant professor at Harvard Medical School and practicing physician at Gretchen S. and Edward A. Fish Center for Women's Health at Brigham and Women’s Hospital, reflected on the impact that the Kavanaugh hearing and the #MeToo movement had on patients who had experienced sexual violence.
“[TIC is] a framework to recognize the prevalence and impact of trauma, mitigate the harmful consequences of those traumatic exposures, and promote safety, resilience, and help,” said Dr. Rittenberg. Recognizing that every patient may have a history of trauma helps create a continuity of care and a compassionate atmosphere to benefit both patients and the clinicians supporting them. This approach empowers patients to be active in their health care, improving patient engagement and efficacy of treatment.
“When we think about folks who have experienced a lot of trauma, it can be very hard for them to engage with the medical system,” Dr. Rittenberg said. As an example, she cited the power differential in medicine, where “people have to come into a little small enclosed room and they often have to tell their story over and over and take off their clothes.”
Dr. Rittenberg noted that embedding the TIC approach into practice is not an extra task to fit into a 10-minute patient visit. Instead, it exemplifies a paradigm shift. Using TIC can help avoid re-triggering a patient and promote health equity.
Anthony Velasco, NP recently shared his tips via Twitter on using TIC during sensitive procedures such as pelvic exams. “Explain the importance of preventative care and the purpose of procedures like a pelvic exam. We must empower patients to be active participants in their care,” said Velasco. “Verbalize what you are seeing and what you are doing to keep them aware of what is going on and what you are about to perform.” This patient-centered approach promotes trust between the patient and clinician, where the patient is more aware and can choose how much to share.
Every patient population may struggle with different trauma. At the very start of the pandemic, Dr. Rittenberg noted that a “perfect storm” of economic stressors and isolation led to an increase in intimate partner violence. Recognizing this increase allowed her to be better prepared in creating a safe space for her patients. Organizations could work on refreshing resources for those struggling with intimate partner violence in this situation.
As the pandemic progressed, she saw her patient population carrying guilt about stress eating and drinking. Instead of the idea that something is inherently wrong with her patients, Dr. Rittenberg advised a new perspective: “Shifting their paradigm to, ‘What are the traumatic experiences going on now? How can I acknowledge that, understand how it's impacting me, and then find ways of coping with it, mitigating the effects of that trauma on my own well-being on my own body, in ways that are healthy?’”
This approach starts at the individual level, but it is important to note that this shift of mindset is also a team effort. Utilizing TIC in peer groups can help with student, staff, and clinician wellness. Peer support can look different in every hospital depending on needs. Dr. Rittenberg has found value from both physician groups and interdisciplinary teams: “You’re not alone. So don’t worry alone.” Together, health care teams can work to address the trauma they and their patients face. With greater organizational knowledge of the trauma their populations are facing, teams can grow their trauma-specific resources and be better equipped to help.
Success in TIC is difficult to measure, and research on TIC is in its early stages. Dr. Rittenberg described success in TIC as “people being able to come in and form a therapeutic relationship with their health care providers.” As TIC research continues to expand, she imagines this definition of success in TIC will grow to include “better health outcomes for patients and better well-being for staff and providers.”
The pandemic has revealed the widespread prevalence of trauma and the impact it can have. Studies have shown a dose-response relationship between the number of traumatic events and depression, stroke, PTSD, diabetes, and more. Trauma-informed care meets the root causes of trauma head on and is a strength-based approach to promote resilience.
What successful strategies have you used to promote healing from trauma in your patient population?
Illustration by April Brust