In this issue, we have several articles about the provision of trauma-informed care. These include the connection between adverse childhood experiences and disease, how to make your patients with trauma feel seen and heard and tips for creating a safe place for your patients.
Content Warning: This article contains references to physical abuse, sexual abuse and intimate partner violence and may be upsetting to some readers.
By Katherine O’Brien
On a sunny day in 2018, while driving on Highway 401, Pamela Jean’s airway suddenly spasmed and she found herself gasping for breath. This was not the first time she had laryngospasm, but the previous incidents had been minor. This time, however, Pamela Jean, who was alone in her vehicle, was terrified. She was eventually able to pull over to the side of the freeway and, when her breathing returned to normal, she drove to the hospital.
The ER doctor was unable to figure out what had caused the spasm and a subsequent visit with a specialist found nothing wrong with her throat. Later, Pamela Jean (who asked that her surname not be used in the article) met with her family physician, Dr. Rupa Patel, and described the terrifying incident.
Dr. Patel has seen other women present with odd choking or throat spasms similar to those experienced by Pamela Jean. She queried a history of sexual abuse and somatization.
In fact, Pamela Jean had endured years of partner abuse, and during her early life, she was sexually and physically abused and emotionally neglected. Dr. Patel, who has an interest in trauma-informed care, screened Pamela Jean for Adverse Childhood Experiences, or “ACEs” — 10 common traumatic experiences that occur in early life. Pamela Jean had experienced every ACE except having a family member in prison.
Indisputable Connection to Physical Health
Later in life, Pamela Jean developed social anxiety and post-traumatic stress disorder (PTSD) — at times she was so deeply depressed, she cut herself and attempted suicide. She experienced misophonia (extreme sound sensitivity) and back pain, as well as the laryngospasm. She believes she was spared the more severe health problems her siblings faced because of her efforts to heal from her traumatic history, which included practising meditation, visualization and yoga, and learning about the effects of trauma.
There is “incontrovertible evidence” that the more traumatic experiences people have, especially in childhood, the greater the likelihood they’re going to have mental and physical health struggles, says Dr. Dana Ross, a psychiatrist with the Trauma Therapy Program at Women’s College Hospital in Toronto.
Dr. Patel, who sits on CPSO’s Board, notes ACEs are a significant, independent risk factor for disease. In fact, she calls the association between trauma and physical illnesses “dramatic.”
Life expectancy in people who have six or more ACEs is reduced by almost 20 years, a reduction in life expectancy that is worse than smoking or uncontrolled hypertension, she says.
“The more traumatic experiences people have, especially in childhood, the greater the likelihood they’re going to have mental and physical health struggles”
In a commentary for Canadian Family Physician (CFP), co-written with two other physicians, Dr. Patel explains that “although physicians are adept at seeing the illnesses that emerge, we often fail to consider how external forces shape what hides inside the body. Among the most common and yet least visible of these are adverse childhood experiences, particularly childhood neglect and abuse. ACEs work their way into the physical body, increasing allostatic load, inflammation, dysfunction and, ultimately, disease.”
And behaviours like smoking, binge eating disorder and substance use that are used to block or suppress the pain of traumatic childhood experiences only serve to raise the stakes for illness.
Dr. Rupa Patel, family physician (Photo credit: Arash Moallemi)
Bearing Witness to Patients’ Experience
In the CFP commentary, Dr. Patel and her co-authors recommend family doctors screen patients for adverse childhood experiences the same way they screen for other risk factors. “Although one’s past cannot be changed, we can read the script to identify causes, understand patients’ experiences and intervene appropriately by applying trauma-informed care,” they write.
Dr. Patel says this therapeutic approach does not require doctors listen to a patient’s entire abuse history, but rather try to get a sense of whether the patient endured traumatic childhood experiences. Indeed, the first of the five guiding principles of trauma-informed care, as outlined in the commentary, is to bear witness to the patient’s experience of trauma, not in all its terrible detail but in its general outlines, while acknowledging the persistent and ongoing effect of this trauma on all facets of the person’s life.
Other principles include:
- Help patients feel they are in a safe space, and recognize their need for physical and emotional safety.
- Include patients in the healing process by actively involving them, which can give them a sense of agency.
- Believe in the patient’s strength and resilience, recognizing the patient as a survivor of adversity — and not as a victim.
- Incorporate processes that are sensitive to a patient’s culture, ethnicity, and personal and social identity.
Making eye contact with patients, generating warmth in interactions, and creating safe and predictable practices so your patients know what to expect is key in creating a therapeutic alliance, says Dr. Patel. This approach may take more time, but patients will usually be a bit more settled and easier to interact with, she adds. “If people feel that they are not being attended to, that can be triggering,” she says.
When a health care environment is under pressure, interactions between staff — who are dealing with their own frayed nerves — and patients can become particularly triggering. When patients with a traumatic history are faced with terseness, for example, their reaction may be related to their own history of adversity and feeling disregarded/unimportant, says Dr. Patel. People with trauma are acutely aware of other people’s emotions and tend to be hypervigilant, automatically “reading the room” for signs of danger, she adds.
“Although physicians are adept at seeing the illnesses that emerge, we often fail to consider how external forces shape what hides inside the body”
At a recent meeting, CPSO approved the Human Rights in the Provision of Health Services policy, which obliges physicians to take reasonable steps to create and foster a safe, inclusive and accessible environment by incorporating cultural humility, cultural safety, anti-racism and anti-oppression into their practices. An accompanying Advice to the Profession document points out that in adopting a trauma- and violence-informed approach to care, doctors can help create a safe environment for patients.
Dr. Patel, who is an assistant professor at Queen’s University, advises residents on the importance of establishing trust: “You’re super busy, you’re running late, but when you go into the room, you have to be present and offer unconditional positive regard. Force yourself to learn that skill [of being]… 100 percent focused on them. Patients feel that and trust can be established.”
Dr. Patel recommends asking permission before a physical exam as many people with a history of trauma have been physically or sexually violated. (In the Dialogue article, “Conducting Sensitive Exams,” CPSO medical advisor Dr. Anil Chopra explains that the more invasive the examination, the greater the need to ensure the patient understands the procedure).
Dr. Patel says she sometimes witnesses “excess emotionality” in patients when agendas clash. If an interaction becomes heated, she tries to handle it by remaining calm, and reminding herself that the patient has been triggered and they need time to become emotionally regulated again. Becoming defensive and feeling the need to justify oneself can often makes things worse, she said, adding her self-care routine is important in helping her maintain positive regard and equanimity.
Supporting Patients to Heal
Dr. Ross, who is an assistant professor at the University of Toronto, acknowledges that people’s trauma will always be a part of their life experience. Still, she says, when patients ask her if they can heal, her answer is always “absolutely.” Although the effects of trauma can be long-lasting, people can heal using different approaches, including therapy, so their symptoms become less intense and less frequent, she says. “Over time, people can begin to feel as though their trauma is a part of their life story, but doesn’t have as much dominance over how they feel about themselves, others and the world.”
As Dr. Ross notes, patients with a background of trauma can feel either overwhelmed by strong emotions or numb and shut down, and they tend to carry a lot of shame and self-blame. The trauma therapy groups that she co-leads help participants build mindful distance between their thoughts and their feelings, and to understand the complexity of their behaviours and symptoms, she says. “As people can tease that nuance apart, they can be a little bit more understanding of why they are coping in the way they’re coping, and that allows people to build a lot more self-compassion as well.”
In Pamela Jean’s case, Dr. Patel taught her self-soothing techniques, which gave her the confidence that she could take care of herself. She experienced spasms on a few more occasions after her initial visit with Dr. Patel, but each time she was able to self-soothe her way out of it, using positive messaging, like, “You can take care of this,” or “Just breathe.”
She adds: “I think everyone in the medical system, anybody who has a touchpoint with a patient with a background of trauma, including the receptionists and the [hospital] Board of Directors… should be trained in trauma-informed care.”
Now an author, consultant and international speaker, Pamela Jean has spoken to medical residents about what it is like to live with trauma. She tells them that it is not their job to fix patients who are healing from adverse childhoods. “And I think that they were surprised by the end of it [that session] that they don’t have to fix somebody who’s on a healing journey. They just need to support them.”
More Resources
American Medical Association: What Doctors Wish Patients Knew About Trauma-Informed Care
CT Mirror: The Long Reach of Childhood Trauma
EQUIP Health Care: Trauma & Violence-Informed Care Tool
Harvard Health Blog: Trauma-Informed Care: What it is, and Why it’s Important
The Impact of Early Life Trauma on Health and Disease: Ruth Lanius & Eric. Vermetten, editors, Cambridge University Press, 2011
