Many clinicians, despite knowing that trauma is common in the chronic pain community, may have consciously or unconsciously avoided asking very important trauma-related questions. This hesitation may lie in historical roots or be related to the provider’s time constraints, trepidation at “opening Pandora’s box,” or simply not feeling competent in how to care for a trauma victim. However, scholarly research around trauma continues to multiply, bolstered by the #MeToo movement, which has brought the frequency of sexual trauma to light in a very public and socially savvy way. In this column, I dive deeper into the whys and how to develop a trauma-informed approach to pain care, both individually and organizationally.
Traumatic Experiences: Definitions and Prevalence
Traumatic experiences may occur throughout one’s life span, and the impact to a person’s health may be acute or continue to be experienced for months and years after remote events. Traumatic events can include but are not limited to a wide range, from childhood, adolescent, or adult sexual traumatization, physical or emotional trauma, to natural disasters and even abusive encounters in the healthcare system.
How SAMHSA Defines Trauma
By SAMHSA’s definition: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹An individual’s own lived experience of these events or circumstances and their individual response helps to determine whether it is a traumatic event. For example, a particular event may be experienced as traumatic for one individual and not for another.
Signs and Symptoms of Trauma²
agitation
irritability, emotional swings
anxiety, depression, fear
outbursts of anger
easily startled by noise or touch
sudden sweating and/or heart palpitations
flashbacks—re-experiencing the trauma
difficulty concentrating
difficulty trusting
self-blame, guilt, or shame
feeling disconnected or numb
How an individual labels, assigns meaning to, and is disrupted physically and/or psychologically by an event(s) contributes to whether or not it is experienced as “traumatic.” Hence, the individual and not the HCP, determines whether a given event is traumatic or not, however, the individual may not recognize a connection between the traumatic events and the effects or their symptoms.¹
Trauma Across Racial, Gender, and Socioeconomic Lines
While trauma spans all races, ages, and socioeconomic statuses, some populations are exposed to trauma at higher rates and with greater frequency of repeated victimization.For example, individuals with a substance use disorder (SUD), living in chronic economic stress and poverty, are unhoused or hold refugee or immigrant status, identify as LGBTQ, or are part of a military family, disproportionately experience trauma in general and sexual trauma specifically.³ Notably, a survey of 41% of female veterans reported military sexual trauma.⁴
Consistent evidence demonstratesdisparities of intimate partner violence (IPV) in LGBTQ communities; these individuals experience much higher rates of IPV, including physical, psychological, or identity-based abuse than cis-gendered and heterosexual counterparts. In addition to minority stressors, IPV-exposed LGBTQ individuals are at increased risk for both physical health and psychological conditions including PTSD, depression, anxiety, somatic symptoms (including various forms of chronic pain and pelvic pain disorders), and substance misuse.⁵
Trauma History in the Healthcare Setting
In addition to leading to a higher risk for acute and prolonged physical and psychological health issues, trauma may induce a sense of powerlessness, fear, and hopelessness, while also triggering feelings of shame, guilt, rage, isolation, and disconnection.¹People who have experienced trauma may have anxiety about specific medical examinations and procedures or even about being in medical settings altogether.
Experiences of sexual violence have the potential to influence a person’s medical care in the long term. In one example reported in a cross-sectional study, more than 90% of women who had experienced childhood sexual abuse had a fear of medical examinations as a result of their abuse, and 64% of respondents reported that this fear caused them to avoid routine healthcare.⁶˒⁷
When people have experienced any form of trauma in their life, unfortunately, unintentional medical traumatization can easily occur, many times in the care of an unaware provider. Emphasizing the control that the patient has over their medical care is one of the foundations of a trauma-informed care approach. Such an approach aims to prevent re-traumatization by empowering survivors of gender-based violence to be in control of their own bodies.⁸
When obtaining a medical history, it is important to discuss a patient’s trauma history only to the extent that it is necessary for the provision of care. Avoid asking questions and requesting details that could retraumatize the patient. It’s important to ask about other forms of trauma, including prior medical trauma, because many patients have experienced multiple types of traumas and violence.⁹˒¹⁰
How to Implement a Trauma-Informed Care Approach
Implementing trauma-informed services can improve screening and assessment processes, treatment planning, and placement while also decreasing the risk for re-traumatization.
Educating patients about the health effects of trauma and offering them opportunities to disclose their traumatic events should be common practice. Screening for specific types of trauma including IPV, physical, emotional, or sexual trauma as a child, teen, or adult are either required or recommended by multiple agencies and organizations including: the Joint Commission, the Women’s Preventive Services Initiative, the National Academy of Medicine (formerly the Institute of Medicine), the American Medical Association, the US Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG).³
6 Principles of a Trauma-Informed Approach for Patients and Their Healthcare Team)¹
[Adapted from SAMHSA; 2014]
Safety It is essential that all people in an organization – including HCPs, staff, and the people they serve – feel both physically and psychologically safe. The organization must place the understanding of safety, as defined by those served, as a high priority.
Trustworthiness and Transparency All organizational operations and decision-making should be performed transparently with a goal of developing and maintaining trust with all those involved with the organization.
Peer Support Peers, also known as “trauma survivors,” utilize peer support and mutual self-help as key modalities for establishing safety, hope, building trust; enhancing collaboration; and incorporating their stories and lived-experiences to promote recovery and healing and to build resilience.
Collaboration and Mutuality The organization recognizes and supports that everyone has a part to play in a trauma-informed approach. Partnering and leveling of power disparities (ie, between staff and clients/patients, administrators and HCPs, healthcare providers and support staff) allows for healing to happen within relationships through a meaningful sharing of both power and decision-making.
Empowerment, Voice, and Choice The organization supports a conviction in the priority of the people served, the resilience of all people, and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma. Clients are encouraged and supported in shared decision-making and cultivating self-advocacy skills. Healthcare providers and staff are facilitators of recovery and not controllers of recovery. Organizational staff and healthcare providers are empowered to do their work with adequate organizational support.
Cultural, Historical, and Gender Issues The organization proactively moves past cultural, religious, racial, sexual orientation, and gender-identity based stereotypes and biases offering responsive services to the needs of all people it serves, while recognizing the impact of and addressing historical traumas.
Be Cognizant of Vicarious Trauma
Trauma-informed care should promote a welcome and engaging environment for patients who are trauma survivors, but it also considers staff and healthcare providers who may experience trauma in their own lives, or who may develop stress reactions and symptoms because of exposure to another individual’s traumatic experiences, commonly known as secondary trauma or vicarious trauma.³ (More on vicarious trauma.)
Clinicians and staff should learn to care for themselves, both in the moment and in the long term. Providers must learn to balance maintaining compassion and empathy while not over-identifying with or re-living patient experiences. It is important to learn the signs of professional burnout and to prioritize good self-care, including developing strong support networks professionally and personally.
Practical Takeaways
Both current trauma and history of trauma are prevalent in our society; HCPs and their teams must be proactive in providing a trauma-informed approach to care.
Clinicians should implement universal screening for current trauma and a history of trauma.
Feeling safe, both psychologically and physically, is essential to a supportive and effective therapeutic provider/patient relationship – but is most paramount in relationships with trauma survivors.
All clinicians and staff in a healthcare setting should be trained and supported in trauma-informed care.
If you find yourself struggling with the complexity and challenging presentations of people with persistent or chronic pelvic pain disorders, you are not alone. To learn more, check out additional resources available at the International Pelvic Pain Society (IPPS).