Trauma as a determinant of health

Dr. Vanessa Brcic (biography, no disclosures) and Dr. Devon Christie (biography and disclosures) Dr. Christie disclosures: MAPS Canada Advisory Board. MAPS is a non-profit organization funding research into novel treatments for PTSD. The content of the article reflects changes in medical practice that can better serve patients with a history of trauma, which is also the purpose of the research being done by MAPS, and is purely in the interest of patients, and is not for commercial profit. The content of the article does not in any way promote the work being done by MAPS. I do not have any affiliations with commercial organizations. Mitigating potential bias: Recommendations in this article are unrelated to products/services involved in disclosure statements.

What I did before

We provide compassionate care to marginalized and complex patients with multiple comorbidities, unexplained multi-system complaints, and those with chronic pain, addictions, and mental health issues. We believe that this is the bread and butter of family practice, yet we often see these patients falling through the cracks in the system and not getting the care they need. We also notice that the biomedical approach can amplify patient’s worries by dividing a person into multiple body systems with multiple pathologies and diagnoses, without providing a framework for understanding their complex suffering.

Like everyone, we struggle with time pressure when working with complex patients, yet we try to offer compassion, validation, and support. We avoid pathologizing, and we avoid perpetuating stigma¹, or stereotypes that complex patients are difficult². We are inspired by opportunities for longitudinal care in family medicine, and “the healing power of interactions” over time, as described by the CFPC³.

What changed my practice

We both pursued additional training in trauma therapy after discovering literature that opened our eyes to the extensive bio-psycho-social impact of trauma⁴, as well as the Adverse Childhood Experiences (ACE) Study and other related research indicating that most family practice patients have experienced trauma^5,6,7. Part of this learning included developing an understanding of how our own trauma has impacted our health and wellbeing, and the care we provide.

What changed our practice was a fundamental recognition of trauma as a determinant of health, and furthermore, that PTSD is only the tip of the iceberg when it comes to trauma. Much lies under the surface for our patients. The experience of trauma is subjective and stored in the “implicit memory”, often poorly understood and described through cognitive processes, with symptoms manifesting as emotional and sensorimotor responses^8,9, which we spend most of our time treating in family medicine. Enduring adverse circumstances of childhood, particularly neglect and psycho-emotional abuse, can impact a person’s health across their lifespan^10,11. Furthermore, ongoing stress, discrimination, powerlessness or oppression – also known as “structural violence” – can perpetuate the trauma response¹². However, any trauma can also evolve to post-traumatic growth and resilience^13,14 – a transition that as family physicians we would like to support.

These recognitions are especially important in the care of Indigenous peoples in Canada who are survivors of genocide and face ongoing impacts of colonization and persistent disparities in health access and outcome^15,16.

There are 4 key points that we have learned by acknowledging trauma as a determinant of health. These are key principles in mind-body therapies for trauma that we present in the context of family practice. These principles can and should inform every health care encounter that has potential to contribute to consistent, ongoing experiences of safety, to avoid ongoing triggers and re-traumatization, and to support healing.

First, helping a patient feel safe is the primary intervention.  

Simply put, trauma can be defined as a state of physiological overwhelm that involves a nervous system response, along with a profound sense of vulnerability and/or loss of control. Thus creating experiences of validation and safe, relationship-based connection are critical in trauma healing, and these should be of primary importance in the clinical visit. Most trauma arises interpersonally, and involves boundary violation; thus maintaining an awareness of one’s position of power in the physician-patient relationship, and helping patients to experience a sense of physical control (e.g. by asking permission before performing any physical examination) can also promote safety.

Second, expect and normalize strong emotions that are part of the survival response.

Compassionately meeting patients requires us to maintain a contextual view of how one’s traumatic past can show up in the present. Traumatized individuals are prone to experience the present with physical sensations and emotions associated with the past. Physiologic hypo- and hyper-arousal, and accompanying emotions of helplessness, shame/depression, fear/anxiety, or rage, typically arise via implicit memory activation^8,9 without ‘explicit’ recollection or rational understanding. Simultaneously, while in a survival response, there is decreased activation of brain areas involved in sensorimotor integration, modulation of physiologic arousal, communication of experience, planning and executive functions⁴. Thus trauma survivors are vulnerable to react with intense emotion and irrational or maladaptive behaviours, and should not be judged or blamed for this adaptive survival response.

Our patients are not trying to be difficult^17,18. Give them space to feel what they are feeling and show them you are there for them. Then, check in with yourself about how much capacity you have to do this; it isn’t easy. Physician self-care practices, including support for our own emotions that arise in providing care, are essential to support the resiliency that is necessary to compassionately meet this kind of suffering in our patients^19,20.

Third, expect that health care settings will feel threatening for many patients.

Being in a state of ill health means uncertainty, fear, the need for additional support, and the need to navigate a complex maze of services. Both the experience of illness and the stress of navigating health care services can perpetuate unresolved traumatic stress^21,22. Furthermore, health care in Canada has an institutional and colonial history that can perpetuate structural violence and discrimination^21–23. Thus, acknowledging trauma as a determinant of health means acknowledging that health care is not always a safe space for patients. People impacted by trauma feel a sense of ongoing threat and lack of safety – a normal response to trauma²⁴ – so we should expect this, and strive to create a sense of safety and support for our patients in navigating the health care system.

Fourth, inquire about social determinants of health (SDOH) and experiences of structural violence.

Trauma doesn’t exist as an isolated incident in a person’s life or at one point in time. Stressful and overwhelming experiences are cumulative, and it is impossible to separate the impact of past trauma from ongoing experiences of stress and overwhelm²⁵. Thus in treating trauma, we must address ongoing experiences of stress, oppression, discrimination or powerlessness, which can be defined as structural violence^12,26. Instead of pathologizing trauma, we can recognize that the problem of trauma arises from structural conditions and overwhelming experiences, not in the psyche of the individual²⁷. We can intervene by inquiring regularly about SDOH, and including specific supportive actions in patient action plans²⁸. This allows us to see patients with greater compassion and identify structural conditions that we can try to change.

What I do now

In summary: 1. Listen, 2. Validate, 3. Enhance support, 4. Address SDOH, 5. Advocate.

1. In a busy family practice, we can do little to resolve or heal past trauma, and we should be careful about triggering trauma experiences by probing too deeply in a short office visit. Talk therapy can also be triggering and re-traumatizing, especially if the patient hasn’t had sufficient felt experiences of safety. Thus we focus on creating validation and present moment safety in a relational context.
   Listening goes a long way. At the provincial ACEs summit held in Vancouver in November 2017, Dr. Vincent Felitti, the principal investigator of the original ACEs study, gave a compelling keynote address in which he emphasized that when screening for ACEs, the intervention was: “To listen. Period.” Appropriate referrals are important, yet if we are too quick to refer a patient to outside services, they may feel that their trauma is “too much” for us, and we may skip the essential step of creating an opportunity for felt safety in the relationship with us. A slow, unhurried pace is critical in working with trauma, as it provides a disconfirming experience when compared to the overwhelm of trauma. When slowing down is tough, tell the patient how much time you have up front, so that even for 10 or 15 minutes, you can slow down together.
2. Patient validation and education can also go a long way. We can compassionately acknowledge and explain to our patients that past trauma (including ACEs) is a significant determinant of health that has taken a real physiological toll on important regulatory systems of the body, thus impacting physical illness in a variety of ways. This helps our patients to have a framework of understanding for their complex suffering, rather than just attending to multiple system-based symptoms in a piecemeal fashion.A simple statement like, “You know, it sounds like there were many stresses that you faced, and your whole body is working hard to survive. Children are particularly sensitive and vulnerable. When those survival responses are activated a lot over time, it takes a toll on the body. It’s no wonder you’ve been struggling with so many health challenges for so long.” When we make compassionate statements like these, patients often report a sense of relief that someone finally understands and can help them to understand their suffering.
3. Remember that every encounter is an opportunity for safety in your therapeutic relationship with the patient. If a person needs additional support, there are several evidence-based mind-body therapies that you can refer a patient to, including trauma-informed yoga practices (supporting a person to feel safe in their body), somatic (body and sensory-based) therapies originally developed by Dr. Peter Levine, and EMDR therapy (Eye Movement Desensitization and Reprogramming) – these evidence-based interventions are reviewed in Bessel Van der Kolk’s compelling book, The Body Keeps the Score⁴. Combined with other trauma-informed interventions, Mindfulness-Based Stress Reduction (MBSR) and Cognitive Therapy (MBCT) may be helpful for symptoms of avoidance and dissociation, however these modalities may not be appropriate for patients with significant hyper-arousal or panic. Non-response to CBT for patients with PTSD is significant²⁹ thus we use this resource with caution. Community organizations (such as PainBC, Disability Alliance BC, etc.) can also provide additional support and social connections.
4. Work in the present time to address ongoing stressors and challenges in a patient’s life. We keep lists of SDOH needs, existing resources and supports patients have, and what more is needed. We can use this to routinely identify and follow up on action plans that support patients to meet basic socio-economic needs and reduce the burden of ongoing stress, and replace experiences of discrimination, powerlessness and exclusion with experiences of safety and connection.
5. In all organizations in which you are a member, advocate for movement towards trauma and violence-informed care^27,30. A process of delivering care that acknowledges trauma and structural violence as determinants of health in primary care has been outlined by Browne, Varcoe and colleagues, who have created a toolkit for health providers interested in doing this work^27,30. Trauma and violence-informed health care includes increased support from trauma-informed colleagues and office staff, policies that support trauma and violence-informed practices, support for providers to prevent and address experiences of vicarious trauma, and appropriate supports for patients with unique needs^27,30. More information about trauma and violence-informed care can be found here https://equiphealthcare.ca/toolkit/. Finally, we should advocate for trauma and violence-informed health care services, including trauma-informed mind-body therapies, to be publicly funded in hospital and community settings, as this will benefit the majority of patients seeking care.

References and Additional reading

The literature that impacted us most was Dr. Bessel Van der Kolk’s “The Body Keeps the Score”⁴, Peter Levine’s “Waking the Tiger” and “In an Unspoken Voice”⁸, and multiple studies describing the importance of Adverse Childhood Experiences (ACEs) in predicting health outcomes^31–33. The impact of ACEs is powerfully described in paediatrician Nadine Burke-Harris’ TED talk, “How Childhood Trauma Affects Health Across A Lifetime”³⁴, which you can listen to here (https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime). Trauma and violence-informed health care has been richly described by Browne and colleagues, and is an essential guide for any health provider or organization^27,30.  The citations below may also be of interest.

References

1. Dubin, R. E., Kaplan, A., Graves, L. & Ng, V. K. Acknowledging stigma: Its presence in patient care and medical education. Can. Fam. Physician 63, 906–908 (2017). (View)
2. Haas, L. J., Leiser, J. P., Magill, M. K. & Sanyer, O. N. Management of the difficult patient. Am Fam Physician 72, 2063–8 (2005). (View)
3. College of Family Physicians of Canada (CFPC). Four Principles of Family Medicine. May 2014. (View)
4. Van der Kolk, B. A. The body keeps the score: brain, mind, and body in the healing of trauma. (Viking, 2014). (Request from CPSBC)
5. Chartier MJ, Walker JR, Naimark B. Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization. Child Abuse $ Neglect. 2010:34:454-464 (View with CPSBC or UBC)
6. Felitti V, Anda R, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245-258. (View with CPSBC or UBC)
7. van Ameringen M, Mancini C, Patterson B, Boyle M. Post-Traumatic Stress Disorder in Canada. CNS Neurosci Ther. 2008;14:171-181. (Request with CPSBC or view with UBC)
8. Levine, Peter A. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, California: North Atlantic Books; 2010.
9. Ogden P, Minton K, Pain C. Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton; 2006.
10. Power C, Atherton K, Strachan D, et al. Life-course influences on health in British adults: effects of socio-economic position in childhood and adulthood. Int J Epidemiol. 2007;36:532-539. (Request with CPSBC or view with UBC)
11. Christian WM, Spittal PM. The Cedar Project: acknowledging the pain of our children. The Lancet. 2008;372:1132-1133. (View with CPSBC or UBC)
12. Browne A, Varcoe C, Lavoie J, et al. Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BCM Health Serv Res. 2016;16:544. (View)
13. Tousignant M, Sioui N. Resilience and Aboriginal Communities in Crisis; Theory and Interventions. J Aborig Health. 2009;5:43-61. (Request with CPSBC or view with UBC)
14. Stout MD, Kipling GD, Aboriginal Healing Foundation (Canada), desLibris – Documents. Aboriginal People, Resilience and the Residential School Legacy. Aboriginal Healing Foundation; 2003. (View with UBC)
15. Haskell L, Randall M. Disrupted Attachments: A Social Context Complex Trauma Framework and the Lives of Aboriginal Peoples in Canada. J Aborig Health. 2009;5:48-99. (Request with CPSBC or view with UBC)
16. Bombay A, Matheson K, Anisman H. Intergenerational Trauma: Convergence of Multiple Processes among First Nations peoples in Canada. Journ Aborig Health. 2009;5:6-47. (Request with CPSBC or view with UBC)
17. An, P. G. Burden of Difficult Encounters in Primary Care: Data From the Minimizing Error, Maximizing Outcomes Study. Arch. Intern. Med. 169, 410 (2009). (Request from CPSBC)
18. Parker-Pope, T. When Doctors Find Patients Difficult. New York Times (2009). (View)
19. Collins, S. & Long, A. Working with the psychological effects of trauma: consequences for mental health-care workers – a literature review. J. Psychiatr. Ment. Health Nurs. 10, 417–424 (2003). (Request from CPSBC)
20. Pfifferling, J.-H. & Gilley, K. Overcoming Compassion Fatigue. Fam. Pract. Manag. 7, 39 (2000). (View)
21. Tedstone JE, Tarrier N. Posttraumatic stress disorder following medical illness and treatment. Clin Phsychol Rec. 2003;23:409-448. (Request with CPSBC or view with UBC)
22. Donna L M Kurtz, Nyberg JC, Van Den Tillaart S, Mills B.  Silencing of Voice: An Act of Structural Violence: Urban Aboriginal Women Speak Out About Their Experiences with Health Care. Journ Aborig Health. 2008;4:53-63. (View with CPSBC or UBC)
23. Pascoe EA, Richman LS. Perceived Discrimination and Health: A Meta-Analytic Review. Psychol Bull. 2009;135:531-554. (View)
24. Mitchell, T. L. & Maracle, D. T. Post-Traumatic Stress and the Health Status of Aboriginal Populations in Canada. Int. J Indig Health. 2005;2:14–23. (View)
25. Brunner E. Socioeconomic determinanrs of health: Stress and the biology of inequality. 1997;314:1472-1476. (View with CPSBC or UBC)
26. Farmer P, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med. 2006;3:1686-1691. (View)
27. Browne, A J, Varcoe C, Ford-Gilboe M, Wathen C N & EQUIP Research Team. EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. J. Equity Heal. 2015;14:152. (View)
28. Centre for Effective Practice. Poverty: A Clinical Tool for Primary care Providers. Centre for Effective Practice. 2016:1-4. (View)
29. Kar, N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr. Dis. Treat. 7, 167–181 (2011).
30. Browne A J, et al. Closing the health equity gap: evidence-based strategies for primary health care organizations. J. Equity Health. 2012;11:59. (View)
31. Weich S, Patterson J, Shaw R & Stewart-Brown S. Family relationships in childhood and common psychiatric disorders in later life: systematic review of prospective studies. J. Psychiatry. 2009;194:392–398. (View)
32. Norman, R. E. et al. The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med. 2012;9,11:1-31. (View)
33. Irish, L., Kobayashi, I. & Delahanty, D. L. Long-term Physical Health Consequences of Childhood Sexual Abuse: A Meta-Analytic Review. Pediatr. Psychol. 2010;35:450–461. (View)
34. Nadine Burke Harris: How Childhood trauma affects health across a lifetime. September 2014. TED: Ideas Worth Spreading. Published September 2014. Accessed November 1, 2017. (View)

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