Toward a Culture of Safety, Part 3: Trauma-Informed Care

Trauma-informed care is part of the bigger picture that has less to do with what individuals are doing right or doing wrong, and more to do with how the human nervous system works. Trauma-informed care is all about safety. Trauma-informed care is also a deep rabbit hole that’s getting deeper all the time, so this post involves only a cursory treatment of what it has to do with our AERD. (POCA's AERD is here:

Quick summary: TIC is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.

In public health clinics in Portland, at least, you can’t talk about pain management without talking about trauma-informed care. There’s an overwhelming connection between Adverse Childhood Experiences (ACEs) and chronic illness, including chronic/persistent pain, later in life. (Read about ACEs here and here. Neurobiology for days!) For the purposes of this post, we’re going to focus on two elements of that intersection:

1) If you do enough pain management work in your clinic, and you’re any good at it at all, you’ll eventually be treating patients that other healthcare providers have labelled “difficult”, “manipulative” and “drug-seeking”.

There are some horrifying social dynamics at play when it comes to whose pain is taken seriously. African Americans are routinely under-treated for pain. Women, similarly. In general, “pain patients” experience stigma, and they experience more stigma based on race, gender, and class.

2) A core insight of trauma-informed care is that shaming and blaming aren’t productive responses to problems. Trauma-informed care is focused on physical, psychological, emotional and social safety — and shaming and blaming do nothing to create more safety for anyone in any of those areas.

So — if you buy in to the idea that it’s difficult to do pain management without also trying to implement trauma-informed care, and if you’re down with the notion that shaming and blaming don’t solve problems — if, say, you somehow picked all this up by osmosis as a result of hanging around with the fabulous people who work in safety-net clinics in Portland (*cough * integrative medicine *cough*) — can you see how your next step would have to be figuring out a trauma-informed response to 1) patients who report negative outcomes after acupuncture treatment, especially related to pain, and 2) errors and safety issues that might come up in your acupuncture clinic, no matter how minor?

Trauma-informed care is, on some level, all about systems. It’s not about individually providing care to fix somebody’s trauma; it’s about recognizing that systems can support empowerment, or can undermine it. For example, public schools that are adopting a trauma-informed approach are completely changing how they handle discipline and absenteeism. If you don’t understand why POCA would want an AERD, try thinking of the AERD as a system that supports our efforts to deliver trauma-informed care.

Adverse events in the clinic can be stressful and triggering, both for patients and practitioners. Consider this short list of common triggers in healthcare for people with trauma histories:

authority figures
sensory cues of past events
lack of power/control
feeling threatened or attacked
caught by surprise
feelings of vulnerability and rejection
sensory overload

and think about how it might overlap with, say, a practitioner making a clinical error. Or a patient experiencing worse symptoms after a treatment and then reporting back to their practitioner. Consider how something like an episode of needle shock could involve some of these triggers for both patients and practitioners. Trauma-informed care is meant to be implemented in 360 degrees, meaning that trauma informed systems are about safety for everybody, including practitioners.

By collecting reports of adverse events regardless of their objective severity, we’re making an effort to minimize surprises for both patients and practitioners. Helping people know what to expect is an important part of trauma-informed care. Having realistic expectations about how often a patient might have an overwhelming reaction to something that appears to us to be minor allows us to be more prepared, and also to take these reactions less personally. Knowing how often patients might be upset by a bruise, minor bleeding, or a histamine reaction is important information particularly for new practitioners. The AERD is about gathering information in a way that doesn’t shame or blame anyone. We want to understand what distresses patients in the context of acupuncture, and how often that happens.

In response to the objection to the AERD that “patients are manipulative and make things up so their reports can’t be trusted” — yes, unfortunately, that’s exactly how a lot of the larger healthcare system sees chronic pain patients. In terms of the ultimate purpose of our AERD, it doesn’t matter whether patient reports reflect “made up issues” or “inaccurate information”.  Distress is distress. Our AERD isn’t a court of law, it’s a support for navigating potentially upsetting situations with the goal of more safety for everyone.

Also, it’s a way of reclaiming safety, period. Safety isn’t just about legislation, regulation, punishment, and hierarchies like licensing boards. Safety isn’t just about the public image of acupuncture, or how much we pay for malpractice insurance. Safety is a resource that we can cultivate through communication, transparency, and realistic expectations. Safety is about relationships.

Safety is a cooperative project.

Up next: Toward a Culture of Safety: Part 4, AERD as Relationship Management

Author: lisafer

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  1. Somehow this got lost in the shuffle. So glad to have read it! So frustrating how often LAcs become just another practitioner, minimizing and dismissing clients as “problem patients.”