Teagan Kuruna, MPH

November 22, 2016


A clinic serving mostly Medicaid and uninsured families is struggling to help patients keep their appointments. Its patients, who come from the surrounding community, are often either unemployed or working minimum wage jobs. Most of the adults have at least one chronic illness, often heart disease or diabetes. Many have been touched by community violence, substance abuse, mental illness, or incarceration in some way. Some grew up in abusive homes, witnessing or experiencing physical, emotional, or sexual violence.

When they come to the clinic, the patients are often stressed, and many become impatient. When last-minute changes or long waits occur, some patients shout profanities, make threats, or slam doors. Perhaps anticipating this hostility, the front-desk staff rarely make eye contact with patients, preferring to keep their gaze on the computer screen as they ask rapid-fire questions about health insurance and reasons for visiting. Their disengagement often creates more animosity and patients are often even more irritated when they enter the exam room to interact with the clinicians.

This composite sketch of a clinic in a low-income neighborhood represents many clinic waiting rooms across the United States and illustrates how trauma can impact patient engagement and the clinical environment. Recognizing the impact of trauma on health and patient engagement is a critical step that health care organizations can take in pursuit of achieving better outcomes.

Recognizing the impact of trauma on health and patient engagement is a critical step that health care organizations can take in pursuit of achieving better outcomes.What is Trauma?

Individuals and families living in poverty, such as those served by the clinic described above, are more likely to experience multiple forms of trauma. Traumatic events can include, but are not limited to:

  • Experiencing or observing physical, sexual, and emotional abuse;
  • Childhood neglect;
  • Having a family member with a mental health or substance use disorder;
  • Experiencing or witnessing violence; or
  • Sudden, unexplained separation from a loved one.

While trauma can affect anyone regardless of their socioeconomic status, many people living in poverty routinely witness violence in their community, have relatives who have been incarcerated, and experience ongoing institutional discrimination — all of which exert a toll on their health.

Trauma’s Impact on Health

Experiencing trauma causes the body to produce adrenaline and cortisol, activating normal protective processes of fight, flight, or freeze. Unresolved traumatic experiences can stimulate these responses even in non-threatening situations. Experiencing trauma, especially in childhood, can actually change a person’s brain structure, contributing to long-term physical and behavioral health problems.

Children and adults often develop coping mechanisms to alleviate the pain of trauma, some of which are classified as “health risk behaviors.” These can include eating unhealthy food or overeating, using tobacco, abusing substances, or engaging in risky sexual activities. When childhood traumatic stress goes untreated, these coping mechanisms can contribute to anxiety, social isolation, and chronic diseases like hypertension, diabetes, cancer, or substance use disorders. Often, “non-compliant” behaviors, such as taking medication erratically or not attending appointments, can also be linked back to patients’ history of trauma.

Many studies, including the original adverse childhood experiences (ACEs) study in 1998 and the Philadelphia Urban ACEs study in 2013, have shown correlations between childhood trauma and lifelong health problems. Conditions linked to trauma exposure include: chronic lung and heart diseases; liver disease, viral hepatitis, and liver cancer; autoimmune diseases; sexually transmitted infections; and depression and other mental health conditions.

What Can Health Care Organizations Do?

Health care organizations, especially those serving patients with complex needs, often have trouble engaging their patients and have high no-show rates. Patients may not consistently take their medications or follow through with recommended lifestyle changes. Considering the impact of trauma on physical and emotional health may help providers empathize with their patients and understand their patients’ behaviors, enabling more effective communication and relationship-building that may lead to better outcomes.

Shifting the question from “What’s wrong with you?” to “What happened to you?” allows health care organizations to begin addressing trauma head-on. For example, the Center for Youth Wellness uses a single-page survey to ask patients about whether and how much trauma they have experienced. This helps providers and staff better understand the magnitude of trauma — and its potential effects — patients are experiencing.

Likewise, understanding patients’ life experiences is an essential part of delivering trauma-informed care. The University of California-San Francisco Women’s HIV Program, for instance, realizes that trauma creates a serious barrier for its patients. Adopting trauma-informed approaches, like staff training and creating a safe, calm physical environment, is facilitating enable patient engagement and helping patients and staff feel more at ease in the clinic.

Health care organizations, including clinics like the one described at the beginning of this post, can take steps toward becoming trauma-informed to help create a safe environment and work toward improving patient engagement. Implementing trauma-informed approaches to care can also benefit staff — by helping them avoid work-related traumatization, organizations may be able to improve staff performance and retention.

Learn More

To learn more about trauma-informed care and emerging best practices for implementation, see Key Ingredients for Successful Trauma-Informed Care Implementation and Understanding the Effects of Trauma on Health. These publications are a product of Advancing Trauma-Informed Care, a national initiative aimed at understanding how trauma-informed approaches can be practically implemented across the health care sector, led by the Center for Health Care Strategies through support from the Robert Wood Johnson Foundation.

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