Physical and Behavioral Health Services

The body produces adrenaline and cortisol during traumatic events, activating the normal survival responses of fight, flight or freeze. Unresolved trauma can stimulate these responses even in nonthreatening situations. Experiencing trauma, especially in childhood, can change brain architecture, causing cognitive, social and emotional delays, and can lead to long-term physical and behavioral health problems.

Complex Traumatic Stress Disorder

Individuals who have experienced traumatic events that are repetitive, chronic or prolonged; involve harm (abuse or abandonment); or occur at developmentally vulnerable times in one’s life (early childhood years when most brain development occurs) can develop a “Complex Traumatic Stress Disorder.”

Individuals with complex traumatic stress disorders can demonstrate:

  • “Learned helplessness” … they feel unable to protect themselves from harm or threats, so they feel unable change their lives in a positive way.
  • Dissociation … they use psychological and emotional distancing or numbing to protect themselves from fear and emotional pain. They appear to be zoned or spaced out, and emotionally shut down. They feel what’s happening isn’t real. They often have a lower heart rate.
  • Hyper-arousal … they need to be always ready to protect themselves or others, they’re on edge, hyp

Helplessness and isolation are the core experiences of trauma. Power and reconnections are the core experiences of recovery.

Judith Herman, M.D., author of Trauma and Recovery

Health-risk behaviors are used as coping mechanisms.

To alleviate or numb the pain of trauma, children and adults can resort to eating unhealthy food or overeating, using tobacco, abusing drugs or alcohol, or engaging in risky sexual activities. When childhood traumatic stress goes untreated, the individual can experience anxiety and shame, and their coping mechanisms can contribute to social isolation, and result in chronic diseases such as hypertension, diabetes, cancer, substance-use disorders, depression and other behavioral health challenges.

90% of clients in public behavioral health-care settings have experienced trauma

SAMHSA-HRSA Center for Integrated Health Solutions

Understanding triggers can avoid re-traumatizing patients:

Massive secretions of neuro-hormones at the time of the trauma may deeply imprint traumatic memories in the amygdala, causing “fear conditioning” where sensory information — smells, sounds, touch, sights, etc. — from past harmful or threatening events get coded and stored, causing the individual to experience these same sensory experiences as harmful or threatening.

Health and behavioral health care providers who are not trauma-informed may inadvertently re-traumatize patients by triggering memories of past abuse and feelings of fear, which can lead to angry, disruptive patient behavior, loss of trust, failure to comply with recommended medication, treatment or follow-up appointments.

Common types of triggering events include:

  • Invasive procedures
  • Removal of a patient’s clothing
  • Physical touch
  • Personal questions that may be embarrassing/distressing/triggering
  • Power dynamics of relationship
  • Gender of healthcare provider
  • Vulnerable physical positions during an exam or procedure
  • Loss of, and lack of, privacy

Trauma-Informed Care Champions: From Treaters to Healers

Center for Health Care Strategies

Childhood trauma and toxic stress impact the brain and the body.

Conditions that have been linked to trauma exposure include chronic lung and heart disease, viral hepatitis, liver cancer, autoimmune diseases, sexually transmitted infections, depression and other mental health conditions and higher rates of suicide. Many studies, including the original CDC 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.

Using a “trauma lens” may lead to better outcomes.

Patients with complex needs are often hard to engage and have high no-show rates. They may not take their medications consistently, or follow through with recommended lifestyle changes. They may avoid preventive care, show anxiety about medical procedures, or complain of chronic unexplained pain. Considering the impact of trauma on physical and emotional health, may explain certain behaviors, enabling more effective communications, and help build relationships and trust.

What is Trauma-Informed Care?

Center for Health Care Strategies

Replace “What’s wrong with you?” with “What happened to you?”

This is a key paradigm shift in trauma-informed care. Adding screenings for trauma and childhood trauma into the initial intake will provide critical information to improve patient care.

  • Create a safe and supportive environment for both patients and staff. Ensure all staff are trained in trauma and trauma-informed care, from the front desk administrative assistants to the nurses, physicians and therapists. Create a friendly, welcoming and culturally responsive environment from the waiting room to the exam room.
  • To avoid re-traumatizing patients and build greater trust and sense of safety, ask clients what feels safe for them (gender of the practitioner, any known triggers, etc.). Be proactive and transparent about what the exam, procedure, treatment or counseling session will involve (will clothes need to be removed … will they need to be touched … will other practitioners need to enter the exam room … will they need to get into any vulnerable physical positions … will they be asked sensitive questions that might be triggering, etc?). Give patients as much choice as possible in how they would like to proceed with their treatment or therapy.
  • Integrate physical and behavioral health interventions and supports. Treat the whole patient, whether through site-based collaborative physical and behavioral health services or through referrals to community-based services.
  • 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.

How childhood trauma affects health across a lifetime

Dr. Nadine Burke Harris

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