Trauma-Informed Care, Integrative Medicine, and Us (All of Us)

I’ve always had complicated feelings about the term “integrative medicine”. In the last year or so, they’ve gotten even more complicated because I’ve discovered that I’ve been practicing integrative medicine without realizing it. For the last two years (going on three), Working Class Acupuncture has a partnership with the Health Resilience Program of Care Oregon. Care Oregon is one of the new coordinated care organizations, and the Health Resilience Program is a means for community clinics  to partner to improve care for high risk/ high cost patients. These types of programs are becoming a big deal in health care reform. I’ve been learning an enormous amount from our relationship with Care Oregon and one of the most important parts has been learning more about trauma informed care (TIC). TIC is a core aspect of how the Health Resilience Program improves care for its high risk/high cost patients as they are navigating multiple systems and healthcare providers. Since we are working with so many Health Resilience Program clients and caseworkers, it’s very important that WCA also practice TIC; which is a way of practicing integrative medicine.

The good news is that it turns out that the community acupuncture model itself IS trauma-informed care, which explains a lot about why WCA’s relationship with the Health Resilience Program has been so easy and so natural. You can read more about that here.

But when it comes to TIC, you can always get better at it. As you may have heard if you went to any of the last two POCAfests,  a number of people in POCA are trying to do this very thing: learn how to work better with people with trauma histories, both our patients and ourselves.  We’ll be having another breakout session on TIC at the upcoming Providence POCAfest (so go register, it’s gonna be great!). Becoming trauma-informed is a process. It’s never-ending, and we can always learn and improve. It’s also a new process, so many, many healthcare providers are learning about it right now and sharing information across disciplines. If you’re looking for a new topic to geek out on, TIC has a lot to recommend it. (Including sharing the geekery with your POCA comrades!)

So speaking of that sharing-across-disciplines, two weeks ago I was lucky enough to attend two different trainings about TIC that Care Oregon put on. I want to share some things from the second one, which is titled Fundamentals of Trauma-Informed Care, developed by Laurie Lockhart of the Health Resilience Program.

One of the things that Laurie stressed in the training, and one of the reasons that learning about TIC is a cool thing for POCA, is that being trauma-informed is not just something that healthcare providers do. It is equally important for EVERY person who works in a clinic: front desk people, volunteers, and administrators. Because on one level, TIC is about understanding people. This link will get you to Laurie’s handout about trauma and the biology of the brain. The short version is that trauma, especially toxic stress in childhood, can change how the brain is wired which has profound implications for the way people behave in the world. When people with trauma histories are “triggered”, the higher centers in their brains like the cortex and the hippocampus which deal with rational behavior basically go offline and what takes over is the amygdala, which mediates fear conditioning. Oh boy. Then everything goes to hell in a handcart, as you know if you get triggered yourself or have ever dealt with a triggered person in the clinic.

Laurie had a great definition of a trigger: an external event that causes internal discomfort or distress;  a hint of past trauma; having someone being suddenly reminded of something they don’t want to remember.

And here is her list of common triggers in the healthcare setting:

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

What this list suggests is that some of what we think of as “professionalism” in healthcare can easily turn into a trigger for somebody with a trauma history, because it’s all about power and control.  One of the hard things about learning about trauma informed care is realizing that all kinds of well-intentioned behaviors and policies and approaches can completely backfire. Of course most people in healthcare don’t want to inadvertently re-traumatize or trigger other people, but it’s very easy to do, because somebody who is seeking help is automatically in a vulnerable position. This is why it’s important to recognize that becoming trauma-informed is an ongoing process; we all screw up and do things that we wish we could undo. And there are a lot of traumatized people out there. A big part of becoming trauma informed is using what my friend Suzzanne calls Universal Precautions for Trauma — it’s best to just assume everybody has a trauma history.

For POCA acupuncturists, integrative medicine doesn’t mean wearing white coats, trying to duplicate a doctor’s role and authority, trying to get our patients to cough up all kinds of intimate information, or  trying to get them to change their lifestyles or scolding them when they don’t.  In fact, integrative medicine for us means the opposite: being conscious of the ways that all those things could be a trigger. We look at all of the elements of our practice setting and try to  proactively defuse the problematic power dynamics.

And this effort absolutely includes the non-punks who work in the clinic. Laurie’s training took place at one of the county safety-net clinics, and she emphasized that the front desk has an absolutely vital role to play in the clinic being trauma-informed. The people who work at the front desk set the tone for everybody who comes in. Looking at the list of common triggers, dealing with scheduling and payment at the front desk can trigger somebody as surely as dealing with the physical and emotional sensations that arise with acupuncture, because dealing with money and time can bring up feelings of vulnerability and rejection.

For example, let’s look at what can happen when a patient is late — which as we know happens all the time. The front-desk receptor’s job is, in a sense, to protect the flow of the clinic and the punks themselves from chaos. Imagine a scenario where the receptor is a maybe a little stressed by a busy shift, and then a patient shows up late and possibly irritable. The receptor, trying to do their job, chastises the patient for being late or maybe is just curt with them about how they’ll have to wait for the punk to get to them because they missed their appointment and the shift is packed. Imagine the patient has a trauma history and they’re late because they missed a bus. They’re already feeling a lack of control; they’re already feeling vulnerable because the bus passed them by while they were frantically waving at it. The receptor’s words sound to them like shaming. They’re overwhelmed by feelings of vulnerability and rejection and powerlessness.  They’re triggered and they blow up and start yelling in the reception area, or they fall apart and can’t stop crying. Maybe they leave without getting treated at all. An onlooker might wonder what exactly happened, how the situation escalated so fast. The receptor was just trying to do what they thought was in the best interests of the clinic, right?

Trauma informed care isn’t about making excuses for problematic behavior. It isn’t saying that we want to encourage people to blow up at us, or that we can’t have good boundaries. Trauma informed care is about understanding that people’s behavior can be shaped by forces beyond their control. Trauma informed care is about reframing the question from, “Jeez, what is WRONG with this person?!?” to “I wonder what happened to this person?” In most cases, in our world, we may never know the answer, but we can safely assume that it would break our hearts.

Approaching our work through the lens of trauma informed care helps us to steer around people’s triggers and avoid situations that could escalate. If a receptor is practicing Universal Precautions for Trauma, they might be careful with a person who is late to state kindly (or at least neutrally) that the shift is very full and they may have to wait for the punk to get to them. Probably none of us is ever going to be perfect with managing our own stress and our own reactions in difficult situations, but trauma informed care gives us a different awareness and a different goal to aim for: to try to use our clinics to restore people’s dignity and humanity.

Author: lisafer

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  1. as a creative project, i’ve been coloring the pages of a brain anatomy coloring book. i noticed that the limbic brain (emotional response) is enmeshed with every other section of the brain.

    this reminds me of a time when i listened to a voicemail message and was so sure the person that left it was angry with me. i left on a meditation retreat and a week later listened to the same message and heard a completely different voice that was far from angry.

    if trauma is triggered our limbic brain takes over to save us from danger. our prefrontal cortex which decides whether something is a stick or snake shuts down and let’s the fight or flight response take over.

    i’ve learned so much from poca peeps in terms of leveling the playing field for our patients. subtle things make a huge difference and treatments truly begin in the waiting room with how a patient is greeted, oriented and informed.

    i hope this conversation continues into pocafest marin, too.