Meryl Schulman, MPH and Mariel Gingrich, MPH

May 28, 2019

Knowledge regarding the impact of trauma on individual health and behavior has become more mainstream in health care over the last several years. However, the effects of trauma on groups, organizations, and entire systems of care, are not as widely understood. The Center for Health Care Strategies (CHCS) recently spoke with Sandra Bloom, MD, associate professor of health management and policy at Drexel University’s Dornsife School of Public Health and co-founder of the Sanctuary Model, to better understand how trauma impacts health care organizations, including the patients and staff that make up those organizations, and how organizations can address trauma and get started with trauma-informed care.

Dr. Bloom has built her career around helping organizations change their culture and practices to embody trauma-informed care principles. She recently served as an advisor for Advancing Trauma-Informed Care, an initiative led by CHCS through support from the Robert Wood Johnson Foundation that sought to uncover how trauma-informed approaches can be practically implemented throughout the health care sector.

Q: How does trauma impact health care, including patients, staff, and organizations more broadly?

By not understanding how patients’ minds and emotions are affected by past experiences of trauma, providers are often led down a rabbit hole trying to figure out a physical health problem that can only be truly identified and addressed if you understand the emotional causality.

A: Because of the prevalence of exposure to trauma in the general population, many people who present to health care organizations have a trauma history. That trauma may or may not be impacting their physical health, the way they handle receiving care instructions from a provider, and the way they adhere to medications and regimens of care. Those same people are interacting with practice staff, who may have similar levels of trauma exposure. This shared experience can be beneficial because it may provide staff with a deeper understanding of what the patient has experienced, or just the reverse. For example, a staff person may lose their patience with a patient because their own experiences are triggered. So, trauma can manifest in any number of ways at the ground level where providers and non-clinical staff interact with patients.

In health care, there is also a lack of knowledge regarding psychosomatic medicine and how the body is affected by the mind. By not understanding how patients’ minds and emotions are affected by past experiences of trauma, providers are often led down a rabbit hole trying to figure out a physical health problem that can only be truly identified and addressed if you understand the emotional causality. This creates a lot of waste, because in not addressing the source of the problem, we spend a lot of time and money on procedures and investigations that are unnecessary and may not fully support the patient’s needs.

Further exacerbating this issue are the dramatic changes occurring over the last 40 years to how health care is funded. These changes have taken a huge toll on how services are provided. In physical health care, providers may only have five to 10 minutes to spend with someone, and that lack of time systematically undermines relationships and the ability of the provider to understand or connect with the patient. Today, there are generations of providers who never had the time to really get to know somebody, and all the ways their body and mind are interacting and maladapting to stressors in their environment.

Q: How can we address trauma to strengthen health care organizations and systems?

A: People in leadership positions have to change their leadership styles. Health care organizations have traditionally acted like machines with top-down regulatory systems. We have to wake up and realize that our organizations are complex living systems, and they have to be run in an entirely different way than a factory that makes widgets. For leaders, that means being a democratic leader who knows how to engage the workforce, increase staff participation, and truly empower people. If you want to increase morale, you have to get people to support the overall purpose of the organization, so that they see that as part of their individual purpose as well. That has to be modeled through leadership.

Health care systems also need to push for and provide resources for larger-scale community engagement, and health care cannot do this by itself. We often exist in these extremely separated, embattled, and conflict-laden silos. To really address issues related to trauma, systems needs to be interconnected and everyone needs to see themselves as part of that interactive, interconnected system of care that includes welfare, education, criminal justice, health care, etc. The health care provider needs the time to understand that a child is having stomachaches because dad is out of a job and drinking, and mom is working three jobs. That same provider needs support from community agencies that are best equipped to help the family. This requires connecting a lot of people and a lot of services with different funding streams and sometimes contradictory regulations.

Q: What do you feel are the benefits of adopting a trauma-informed approach?

When health care providers can take the time to get to know somebody, and they know enough about healing, they can start to support that person and help them heal.

A: For patients, the benefit is that they finally feel understood. Somebody finally gets what they are up against, and why they have the symptoms they have. When health care providers can take the time to get to know somebody, and they know enough about healing, they can start to support that person and help them heal.

At the provider level, trauma-informed care validates that health care is emotional labor, and it teaches both when to express and suppress our emotions. That’s hard work. It also encourages people to really question previous practices. “What are we doing now that we should keep doing because it is good? What do we have to stop doing? What are new things that we need to learn how to do?” The more that leadership can engage staff in looking at those questions — after having acquired a knowledge base about adversity, trauma, and chronic stress — the more engaged staff will become, and the more they will develop creative strategies that help them, help patients, and help the organization thrive.

Lastly, trauma-informed care shifts how we think about interventions. People survive traumatic experiences and adapt to great adversity. Opioid addiction is an adaptation. Beating your children or your partner are adaptive solutions – they just happen to be really maladaptive solutions. Once you start looking at the things we call symptoms as coping strategies, it completely shifts how you think about the intervention. It makes you realize that you cannot just jerk away somebody’s coping method without substituting something else.

Q: What would you recommend to health care professionals seeking to champion trauma-informed care within their organizations, but are unsure where to begin?

If you just tell people to be trauma-informed, it is not going to happen, because the real heart of trauma-informed care is a change in attitude.

A: Start by listening to your patients. Find out what kinds of experiences people have had — what do we know already or suspect? That’s how we started. We listened to people in a different way and asked different questions.

The second step is gaining support from both leadership and staff. After attending a week-long workshop on trauma-informed care, I came back, created some rudimentary slides based on what was said, got my whole practice together, and discussed it with them. I shared the knowledge with them and we started asking, “What does this mean? What do we do? How do we do it?” Today, organizations have access to so much information, but the only way you can get that information into your practice is by getting people together and eliciting interest so that they want to solve the problem in a participatory way. If you just tell people to be trauma-informed, it is not going to happen, because the real heart of trauma-informed care is a change in attitude.

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