Meeting Survivors Where They Are: The Vital Role of Trauma-Informed and Competent Clinicians in Primary Care

For adult survivors of adverse childhood experiences, primary care is the entryway to treatment of post-traumatic stress disorder (PTSD). It is estimated 25% of adult primary care patients have PTSD, and they present to their provider more often with pain and non-specific physical symptoms rather than mental health issues. Physicians, even those somewhat knowledgeable about trauma and PTSD, are unlikely to assess for it in order to avoid issues they may not have the time and/or skills to sufficiently address. This is due to PTSD treatment not being a core training competency in graduate-level education and professional training being timely and expensive. Usual care for PTSD consists of medication to manage symptoms and a referral to a mental health clinician. However, substantial disparities and patient, provider, and delivery system-level barriers means survivors are unlikely to follow-through with referrals nor receive adequate treatment when they do. In this theoretical article, we review the trials and tribulations experienced by research teams and argue what is lacking is trauma-informed care. None of the trials reviewed mentioned trauma-informed care as a component of their intervention nor as a recommendation for future studies. We also outline a host of recommendations for best practice protocols that benefit patients and the collaborative care teams meeting them where they are. Trauma-informed care deepens the focus on relational, physiological, and physical safety. Attention to soothing physiological arousal through the physician-patient-clinician triad creates more positive associations toward moving forward in treatment for survivors and providers.     

Trauma-Informed Medical Care: Patient Response to a Primary Care Provider Communication Training

Trauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma’s effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs.     

An Overview of Trauma-Informed Care and Practice for Eating Disorders

ABSTRACT

This article reviews concepts and principles of trauma-informed care and trauma-informed practice for those with eating disorders (EDs). EDs are not universally recognized to be associated with traumatic events, despite substantial research evidence indicating that individuals with EDs report very high rates of childhood maltreatment, other lifetime traumatic events, as well as adverse consequences from trauma. Using national representative samples, higher prevalence rates of PTSD and other trauma-related comorbidities have been reported in those with EDs, particularly those with bulimic symptoms (binge eating and/or purging). Evidence suggests that those prone to develop EDs appear to be especially sensitive to the effects of stress/adversity and have high rates of premorbid anxiety disorders, personality traits, and neuropsychological features that predispose them to PTSD and its symptoms. This article also reviews some of the important principles for treating individuals with EDs comorbid for PTSD and other trauma-related disorders, including the necessity of moving beyond sequential treatment to the development of integrated treatment protocols. Integration of existing evidence-based treatments, including family therapy, cognitive behavioral therapy, dialectical behavior therapy, cognitive processing therapy, prolonged exposure, and eye movement desensitization reprocessing are recommended. Recent research suggests that ED clinicians view integrated treatment for individuals with ED and PTSD as a top priority, yet they have several concerns about administering such a treatment. As trauma-informed care is embraced by all clinicians and treatment programs that assess and treat eating and related disorders, better outcomes are anticipated.     

Homelessness Is Traumatic: Abuse,Victimization, and Trauma Histories of Homeless Men

Homelessness is traumatic, and trauma-informed care is an emerging best practice. Using structured interviews with day shelter clients (N = 152), this study examined trauma among homeless men. The PTSD Checklist (PCL–C) was used to assess for posttraumatic stress disorder (PTSD). Participants’ pattern of PCL–C responses suggested that 23% to 30% screened positive for PTSD. Those with positive PTSD screens had been homeless longer and were more likely to have met time criteria for chronic homelessness. They were significantly more likely to be veterans and to report violent attacks, abuse histories, and mental health problems. Importantly, only 69% of those with positive PTSD screens acknowledged current mental health problems. These individuals were much less likely to report mental health counseling in the prior year.     

Identification and Follow-Up by Primary Care Doctors of Children with PTSD After Terrorist Attacks

Abstract

Many children and adolescents were among the victims of the suicide bomb attacks in Israel since March, 2000. While the number with emotional and behavioral symptoms was expected to be high, very few children who developed terrorism-related posttraumatic stress disorder (PTSD) were actually referred to mental health professionals for assessment or treatment. Prolonged exposure to terrorism lowers even further the number of children who remain in treatment. This article discusses reasons and presents a training program for primary care providers (pediatricians, family doctors) in identifying PTSD in child victims, and for mobilizing them to carry out long-term follow-up of these children.     

Betrayal Trauma,Health Care Relationships,and Health in Patients with a Chronic Neurovascular Condition

Individuals who have been exposed to trauma are at a greater risk of developing a chronic physical health condition and use health services more frequently than individuals who have not experienced trauma. The mechanism by which trauma affects health is not fully understood, but relationships with health care providers could be important in understanding this association. The purpose of this study was to explore the relationships among betrayal trauma, health care relationships, and physical and mental health in a chronic medical population. Participants (N = 272) diagnosed with a chronic neurovascular condition (cavernous malformation) completed an online survey. Questionnaires assessed self-rated health, instances of betrayal trauma, posttraumatic stress disorder (PTSD) and depression symptoms, income, and other demographic factors, and health care relationships. Level of income and the experience of betrayal trauma predicted mental health symptoms (depression, PTSD, or both) and also predicted health care relationships. After controlling for income and previous trauma, mental health symptoms significantly predicted health care relationships. Finally, mental health symptoms, health care relationships, and income predicted self-rated health, although the associations were not straightforward. These results suggest complex interrelations among trauma, mental health, income, health care relationships, and physical health, and a model is proposed for explaining these associations.     

A Trauma-Informed Call to Action: Culturally-Informed,Multidisciplinary Theoretical and Applied Approaches to Prevention and Healing

ABSTRACT

The prevalence of trauma and its negative impact on humankind has created a burgeoning awareness of the need for systems that are trauma-informed across the lifespan. A collaborative project with the National Partnership to End Interpersonal Violence (NPEIV) sought out research as a call-to-action to mitigate the impact of trauma. The following is an introduction to a special double-issue focused on theoretical and applied approaches to using trauma-informed care in multi-disciplinary, mental and physical health, criminal justice, school-based, and community settings. Consideration is given to essential issues such as resilience, self-care, and cultural awareness.     

Task-shifting to improve the reach of mental health interventions for trauma patients: findings from a pilot study of trauma nurse training in patient-centered activity scheduling for PTSD and depression

ABSTRACT

Despite high rates of posttraumatic stress disorder (PTSD) and depression among traumatically injured patients, engagement in session-based psychotherapy early after trauma is limited due to various service utilization and readiness barriers. Task-shifting brief mental health interventions to routine trauma center providers is an understudied but potentially critical part of the continuum of care. This pilot study assessed the feasibility of training trauma nurses to engage patients in patient-centered activity scheduling based on a Behavioral Activation paradigm, which is designed to counteract dysfunctional avoidance/withdrawal behavior common among patients after injury. Nurses (N = 4) and patients (N = 40) were recruited from two level II trauma centers. A portion of a one day in-person workshop included didactics, demonstrations, and experiential activities to teach brief intervention delivery. Nurses completed pre- and posttraining standardized patient role-plays prior to and two months after training, which were coded for adherence to the intervention. Nurses also completed exit interviews to assess their perspectives on the training and addressing patient mental health concerns. Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care.     

Perceived lack of training moderates relationship between healthcare providers’ personality and sense of efficacy in trauma-informed care

ABSTRACT

Background and Objectives: Medical patients often have trauma histories that are not routinely assessed, which can adversely affect health outcomes. Despite growing awareness of this issue, there is limited understanding of factors that influence provider competency in trauma-informed care (TIC). The study examined healthcare providers’ personality traits in relation to their sense of TIC efficacy, taking into account perceived barriers to TIC and professional quality of life.

Study Design: The study used cross-sectional survey methods to examine our central hypothesis that provider personality traits and perceived barriers to TIC would be associated with TIC-efficacy, and to explore interactions among study variables.

Methods: Survey data were collected from 172 healthcare providers examining TIC knowledge, TIC-efficacy, perceived barriers to TIC, personality traits, and professional quality of life.

Results: TIC-efficacy was positively correlated with “intellectence/openness” and inversely correlated with “neuroticism” and perceived lack of training as a barrier. “Intellectence/openness” interacted with perceived lack of training to predict TIC-efficacy, suggesting that providers with lower “intellectence/openness” report greater TIC-efficacy when lack of training is not perceived as a barrier.

Conclusions: Provider personality traits and perceived barriers to TIC appear related to providers’ TIC-efficacy. Implications for overcoming barriers to TIC through training and implementation are discussed.     

Re-Storying the Trauma Narrative: Fostering Posttraumatic Growth in Cambodian Refugee Women

ABSTRACT

The purpose of this article is to provide clinical recommendations in fostering positive well-being among Cambodian refugee women living in the United States. We first present a brief overview of Cambodian refugee women’s history and cultural background to highlight their experiences of shared and gender-based trauma, as well as their process of recovery. Next, as informed by the posttraumatic growth model and evidence-based practices, we provide clinical recommendations with an emphasis on trauma-informed components and interventions influenced by feminist and narrative perspectives in facilitating the process of surviving trauma and thriving post-migration. Finally, we present a composite case illustration, highlighting cultural considerations to aid mental health providers in fostering posttraumatic growth in Cambodian refugee women.     

Trauma Exposure in Anxious Primary Care Patients

The present study examined rates of trauma exposure, clinical characteristics associated with trauma exposure, and the effect of trauma exposure on treatment outcome in a large sample of primary care patients without posttraumatic stress disorder (PTSD). Individuals without PTSD (N?=?1,263) treated as part of the CALM program (Roy-Byrne et al., Journal of the American Medical Association 303(19)1921–1928, 2010) were assessed for presence of trauma exposure. Those with and without trauma exposure were compared on baseline demographic and diagnostic information, symptom severity, and responder status six months after beginning treatment. Trauma-exposed individuals (N?=?662, 53 %) were more likely to meet diagnostic criteria for Obsessive Compulsive Disorder and had higher levels of somatic symptoms at baseline. Individuals with and without trauma exposure did not differ significantly on severity of anxiety, depression, or mental health functioning at baseline. Trauma exposure did not significantly impact treatment response. Findings suggest that adverse effects of trauma exposure in those without PTSD may include OCD and somatic anxiety symptoms. Treatment did not appear to be adversely impacted by trauma exposure. Thus, although trauma exposure is prevalent in primary care samples, results suggest that treatment of the presenting anxiety disorder is effective irrespective of trauma history.     

Enhancing Resilience Among Providers of Trauma-Informed Care: A Curriculum for Protection Against Secondary Traumatic Stress Among Non-Mental Health Professionals

Although the call to create trauma-informed services for youth has been clearly sounded, a relatively neglected part of this effort is the need to prepare non-mental health professionals to carry out trauma-informed programming in ways that protect them from secondary traumatic stress (STS). To this end, this article introduces Resilience for Trauma-Informed Professionals, a curriculum that introduces participants to techniques designed to promote resilience in the face of exposure to trauma-related material. Based on the existing evidence base regarding risk and protective factors for STS, six core elements targeted by the curriculum are described—appraisals, self-efficacy, emotional awareness, affect regulation, resilience, and prevention—as they are implemented across three stages: pre-exposure preparation, coping in the presence of trauma, and recovery in the aftermath of exposure.     

Recovering the context in posttraumatic stress disorder: The psychosocial trauma in victims of political violence and terrorism

Abstract

Throughout history, humans have frequently carried out harmful actions against one another. Often, these actions result in intensive and long lasting pain and suffering. Posttraumatic stress disorder (PTSD) diagnosis has been the theoretical tool used mostly by psychologists to understand the physical, emotional and behavioural symptoms following a traumatic experience. Due to its clinical and medical roots, PTSD diagnosis represents man in a social vacuum, a man without context, and a model of health closely tied to illness. The aim of the paper is to reintroduce the social context of human beings into trauma diagnosis, and to develop a health model that is more focused on well-being than on illness. Both points of view help us to seek a theoretical way for better understanding the psychosocial trauma that result from political violence and terrorism. Psychosocial trauma has definite roots, and destroys our inner world—the world of our most valuable meanings—infects our minds with hate against others, and breaks the social fabric we belong to.     

A Trauma-Informed Call to Action: Culturally Informed,Multi-Disciplinary Theoretical,and Applied Approaches to Prevention and Healing,Part II

The prevalence of trauma and its negative impact on humankind have created a burgeoning awareness of the need for systems that are trauma-informed across the lifespan. A collaborative project with the National Partnership to End Interpersonal Violence (NPEIV) sought out research as a call-to-action to mitigate the impact of trauma. The following is Part II of an introduction to a special double-issue focused on theoretical and applied approaches to using trauma-informed care in multi-disciplinary, mental and physical health, criminal justice, school-based, and community settings. Consideration is given to essential issues such as resilience, self-care, and intersectional cultural awareness. Introspective exploration of biases was encouraged to address barriers to implementing trauma-informed care.     

Prevalence,Detection and Correlates of PTSD in the Primary Care Setting: A Systematic Review

Research suggests that posttraumatic stress disorder (PTSD) is common, debilitating and frequently associated with comorbid health conditions, including poor functioning, and increased health care utilization. This article systematically reviewed the empirical literature on PTSD in primary care settings, focusing on prevalence, detection and correlates. Twenty-seven studies were identified for inclusion. Current PTSD prevalence in primary care patients ranged widely between 2 % to 39 %, with significant heterogeneity in estimates explained by samples with different levels of trauma exposure. Six studies found detection of PTSD by primary care physicians (PCPs) ranged from 0 % to 52 %. Studies examining associations between PTSD and sociodemographic variables yielded equivocal results. High comorbidity was reported between PTSD and other psychiatric disorders including depression and anxiety, and PTSD was associated with functional impairment or disability. Exposure to multiple types of trauma also raised the risk of PTSD. While some studies indicated that primary care patients with PTSD report higher levels of substance and alcohol abuse, somatic symptoms, pain, health complaints, and healthcare utilization, other studies did not find these associations. This review proposes that primary care settings are important for the early detection of PTSD, which can be improved through indicated screening and PCP education.     

The Primary Care Health System as a Core Resource in Response to Terrorism

Abstract

Living through a terrorist event or under threat of attack affects both mental and physical health. A nation's primary care system plays a critical role under such circumstances. This article reviews the American experience after September 11, 2001 and advocates for integration of mental and physical health services in primary care settings as a key counter-terrorism strategy. Americans put their trust in primary care providers. The nation's healthcare system must develop and implement a strategy that informs and supports primary care providers in meeting the mental health needs of a nation confronted by terrorism.     

The Role Of Attributions and Perceived Control In Recovery From Rape

Abstract

It is fitting that a volume on post-traumatic stress includes chapters on sexual assault given both the prevalence of sexual assault and its effects. Specifically, in terms of prevalence, approximately one woman in five in the United States will be raped in her lifetime (Koss, 1993).¹ In terms of the effects of sexual assault, victims experience heightened fear, anxiety, and depression for several months, and sometimes years, following an assault (see Frazier & Borgida, 1997, and Resick, 1993, for reviews). Sexual victimization affects physical health as well and is a more powerful predictor of physician visits and outpatient medical costs than other factors (e.g., age, smoking, alcohol use) known to be related to health problems (Koss, Koss, & Woodruff, 1991). Finally, sexual assault is one of the traumatic events that is most likely to lead to posttraumatic stress disorder (PTSD) (Breslau, Davis, Andreski, & Peterson, 1991; Norris, 1992; Ullman & Siegel, 1994). In a recent national study of trauma exposure and PTSD by Kessler and his colleagues (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), almost half of the women who said that a rape was their worst trauma met lifetime criteria for PTSD. This is in comparison, for example, with a PTSD prevalence rate of 5% for those whose worst event was a natural disaster.     

Supporting the Need for an Integrated System of Care for Youth with Co-occurring Traumatic Stress and Substance Abuse Problems

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.     

War trauma and infant motor,cognitive, and socioemotional development: Maternal mental health and dyadic interaction as explanatory processes

BackgroundTaking care of infants in conditions of war is highly demanding and a few studies reveal the negative impact of war trauma on maternal and infant well-being. Yet, little is known regarding the influence of trauma on infant development and the potential explanatory mechanisms. First, the present study examines how mothers’ prenatal exposure to traumatic war events is associated with infant cognitive, motor, and socioemotional development. Second, it analyses the mediating roles of maternal postpartum mental health problems, quality of dyadic mother-infant interaction, and earlier infant development (at six months) in the association between prenatal traumatic war events and infants’ developmental skills at 18 months.MethodThis prospective three-wave study involved 502 Palestinian pregnant females in their first trimester during the 2014 Gaza War and participated at delivery (T1) and when the child was six (T2;N = 392) and eighteen (T3; N = 386) months of age. Mothers reported their exposure to traumatic war events (human and material losses, horrors, and threat to life) at T1 and T2, and researchers photo-documented the extent of destruction at T1. Mothers reported infants’ language, fine- and gross-motor, and socioemotional skills at T2 and researchers tested infants’ motor, cognitive-language and socioemotional skills using the Bayley Scales of Infant development (BSID-II) at T3. Mothers reported their mental health problems (symptoms of post-traumatic stress disorder [PTSD], depression and somatization) at T2 and T3 as well as dyadic interaction quality (the emotional availability self-report, [EA-SR] brief) at T2.ResultsFirst, the structural equation model (SEM) on direct effects indicated, in contrast to our hypotheses, that maternal prenatal exposure to traumatic war events did not associate with infants’ developmental skills at T2 and predicted higher level of developmental skills at T3. Second, as hypothesized, we found two negative underlying mechanisms (paths) between high exposure and low levels of motor, cognitive-language, and socioemotional skills at T3: (1) through increased maternal mental health problems at T2, which then were associated with problems at T3, and (2) through increased maternal mental health problems at T2, which then were associated with a low quality of mother-infant-interaction and low level of infant developmental skills at T2.ConclusionImproving maternal mental health and encouraging close and positive dyadic interaction can be critical for infant sensorimotor, cognitive, and socioemotional development in war conditions.     

Social anxiety disorder in veterans affairs primary care clinics

To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers’ detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multi-site sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary care providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans.