Trauma-Informed Health-Care for Providers

Ilene Naomi Rusk, PhD

Director, Healthy Brain Clinic, Colorado

303-938-9244

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The importance of Integrating Trauma-Informed Care into Functional Medicine

Adverse childhood experiences have a dose-dependent relationship with many of the chronic illnesses facing medicine today, including chronic environmental illnesses. Having a history of trauma, complex PTSD and chronic stress can influence all aspects of an individual’s life, affecting mental, physical, and emotional health, relationships, and their ability to adopt and implement health-focused habits and behaviors.

A growing body of research demonstrates the connection between a history of developmental trauma and the increase in an individual's risk for chronic physical, mental, and behavioral health issues, including dementia. Many patients with neurologic illness, mental health symptoms, neuropsychiatric illnesses such as Long-Covid, and chronic illness due to environmental toxins such as mold, have emotional trauma as a root cause, or can be ameliorated with limbic system downregulation using a multitude of strategies such as toning the vagus nerve and cultivating healthy emotional regulation skills. As the vital connections between chronic illness and past traumatic experiences begin to emerge, policymakers and healthcare providers alike are beginning to adopt a trauma-informed approach to healthcare to improve patient engagement and long-term health outcomes while lowering costs of care enhancing patient empowerment.

You can implement simple steps to build stress resilience in your patients by fostering a trauma-informed relationship with them. The qualities of this relationship foster collaboration, choice, trust, and safety for patients who may have a history of micro, macro, or complex traumas.

This document includes...

Trauma Defined
Examples of Traumatic Experiences
What does trauma look like?
What is complex PTSD?
What are the acute and chronic physiological effects of trauma?
Model for trauma-informed medical care
Symptoms of Acute Traumatic Stress
How to recognize the possibility that trauma is at the root of the problem you are seeing
Chronic Effects of Traumatic Stress
What to do for your patient who has a history of trauma
How to speak to your patients in a trauma-informed way
How to know when and how to refer by asking questions and offering gentle suggestions
What is post-traumatic growth?
Relaxation strategies that you can do in the office if your patient gets activated
Suggested Authors
List of References

Introduction

Incorporating a trauma-informed approach into your practice can improve your patient health outcomes and your well-being as well. This handout includes a brief definition of trauma in its different forms, the acute and chronic physiologic effects of trauma, and practical recommendations for physicians and other integrated clinicians looking to adopt a trauma-informed approach. Trauma recovery can be very delicate, so it needs to be approached slowly and with great care, staying carefully tuned-in to yourself and your patient. Most patients will need referrals to outside providers who are psychologists or psychotherapists specifically trained in trauma release techniques which reduce limbic system activation, diminish HPA Axis tone as well as balance the tone of the vagus nerve. The trauma relief models I prefer are Brainspotting, EMDR, Somatic Experiencing, Trauma-Informed Yoga Therapy, Vagus Nerve regulation and other data-driven approaches.

Trauma Defined.

Trauma can be defined as any event that alters how we process, react to, and recall memories, by overwhelming the individual’s central nervous system. Additionally, trauma is defined as any event in which a person feels helpless and unsafe. These experiences can result from acute trauma, like a rape or being in an earthquake, or from childhood maltreatment which is consistent (and sometimes below the radar of a person's conscious awareness. It’s not only something which happens in the brain, it’s something which happens in the body as well. It is not only an occurrence that happened in the past; instead, trauma is an event that leaves an imprint upon the body and the brain which persists to the present day. Trauma expert Bessel van der kolk says that “trauma is not the story of something that happened back then. It is the current imprint of that pain, horror, and fear living inside people.” It is an experience that one is incapable of integrating and assimilating into their life after the event (4). Trauma primarily affects areas in the brain which control automatic or basic functions that impact survival impulses. That is why so often the sleep/wake cycle, general arousal, breathing, feeding and the whole limbic system which controls memory and emotion are affected. That is also why the limbic system release techniques, or strategies to relieve trauma, are directed at calming this part of the brain. On a cellular level, it's likely that Dr Robert Naviaux’s “Cell Danger Response” speaks to what happens to the body when it perceives unrelenting threat. Trauma can result from intergenerational wounds which persist, and are transmitted culturally, behaviourally and epigenetically to offspring.

Clinical Pearl: If a patient comes to you with chronic sleep issues, and you've ruled out other etiologies, implemented successful sleep hygiene, referred for Cognitive Behavioral Therapy for Insomnia and had no success, think to refer for trauma psychotherapy.

Types of maladaptive stressors, or traumas, themselves vary. Toxic stress can originate from childhood overt traumas such as neglect, physical threat, or loss of a loved one, to everyday quiet but persistent distress, such as shame, workload, relationship conflict, pain, financial burden, or unhealthy diet. These seemingly everyday stressors must not be overlooked as they can have equally harmful effects as more overt trauma. Other contributors to stress are family responsibilities, and both personal and family health concerns. Although we react to a myriad of stressors in varying ways, one of the common pathways we all share is our biological stress response system, and trauma should be seen as a physiologic cascade which persists as a biological imprint. This imprint affects brain development, the HPA axis, hormones, the immune system, and epigenetic changes as well. The imprints of intergenerational trauma and cultural marginalization cannot be overstated. Almost any experience can cause trauma to develop when a person’s unique ability to cope is exceeded and there is no one there to help. Feeling helpless in the presence of a stressor can determine whether an event is experienced as a trauma. When our capacity for dealing with stress falters, and the normal stress recovery curve doesn’t happen, trauma manifests.

Examples of Traumatic Experiences

Growing up in an environment where nobody sees, protects, and helps you cope with the reality of life.
Gestational or birth challenges such as mental illness in the mother or malnourishment of the fetus.
Having insecure attachment relationships as a child to primary caregivers
Physical, sexual, or emotional abuse.
Any natural disaster such as being in an earthquake, hurricane, or flash flood.
A sudden, unexplained separation from a loved one.
The death of a loved one.
Childhood neglect.
Intergenerational trauma.
Discrimination, racism, and oppression.
Violence in the community, war or terrorism.
Witnessing the abuse or violation of a loved one.
Poverty.
Automobile accident.
Disorganized attachment, abandonment, neglect.

Recognize the possibility that trauma is at the root of the problem you are seeing. ask about family history of trauma, too.

People react differently to stressors of all types, and early life experiences can play a critical role in people’s physiologic “set-up” to cope with stress later in life. In the 1990s the Adverse Childhood Experiences (ACE) study, done by the CDC and the Kaiser Family Foundation, found that childhood trauma is much more common than we had realized. In addition, they concluded that experiences such as neglect and divorce are associated with adulthood behavioral problems, including substance use disorders, depression, chronic illnesses, learning disabilities and shorter lifespans, in a dose response manner. When a child was exposed to childhood abuse or household dysfunction, they had an increased risk of developing physical health issues later in life, such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease, disproportionately from those who had no early childhood adverse experiences (1). Early childhood stress can also cause mental health issues in adulthood, such as mood disorders, substance abuse, and suicidality (1, 2).

In addition, the risk for ACE’s is particularly elevated amongst certain populations that possess specific socio-cultural markers, including people who identify as BIPOC (Black, Indigenous, People of Color), lower socioeconomic status or unemployed, those with less than a high school level education, queer folk, and differently-abled individuals (3). Developmental trauma within any population can be a very subtle, persistent, and harmful risk factor that compromises one’s resilience to mental and physical illness later in life.

Clinical Pearl: Administer the ACE’s Questionnaire, review it and inquire briefly about childhood experiences and traumas. Do not delve and go slowly. Ask a more general question such as, “tell me three things about your mother”, or “three things about your father”. Patients often do not “feel stressed”, but you might notice that they carry longstanding anxiety in their bodies. This could be a clue that they are carrying old trauma patterns.

What does trauma look like?

Trauma can manifest emotionally, cognitively, and physically. Although the traumatic event may be in the distant past, someone who is traumatized may continue to experience a physiological stress response. Our brains and bodies get amped-up, ready to respond to the trauma-inducing stressor, and our nervous system remains primed to complete the trauma response. Our endogenous nervous system makes attempts at survival by reacting with either a fight, flight, freeze, or fawning response. Many patients become afraid of their environments and generalize their fear responses. This can often be seen in patients with anxiety disorders, or those with PANS or PANDAS. Other responses to trauma can be to become immobilized (freeze) or to try to please and appease those around you (fawning), in an effort to stay safe. Although the event may be over, regardless of the compensatory response to the trauma, the body does not necessarily return to equilibrium. This can look like hypervigilance, irritability, anxiety, depression, helplessness, and even numbness or dissociation. It is important to start to see your patients through this lens.

Trauma default behaviors are an indication that the body’s natural impulse to complete the trauma and find safety was thwarted. Without help, the body cannot complete the response needed to escape, fight against, or otherwise resolve the trauma it experienced. A key component in trauma healing is to complete the physiologic response which was thwarted during the traumatic incident and integrate the new narrative into conscious awareness. This installs the newly integrated information into the frontal lobes, and directs the looping away from the limbic arousal system.

When we have unresolved traumas, emotions can swing rapidly and become intense and overwhelming. These effects are often intensified when trauma develops in response to severe, acute events like war, natural disasters, or interpersonal violence. When traumatized and feeling afraid, angry, or out of control, we may withdraw, cutting off those closest to us. In the wake of wars that leave scores of veterans suffering from PTSD, the emotional and cognitive effects of trauma are well-known and widely discussed in the media. However, we often neglect to acknowledge and adequately address the toll of less severe traumas on our bodies and minds (4).

For example, children raised with a lack of emotional attunement from their parents, who are humiliated, criticized, or raised with shame and a feeling of helplessness, can experience trauma. Children can also experience trauma from a home fraught by parental arguing. In addition, in utero, perinatal and birth trauma can have a long-lasting impact upon a young nervous system. Whether very mild or pervasive, unresolved trauma is stored in the body and the brain. These clusters of trauma disorders have been described by many as complex PTSD and developmental trauma disorder.

Clinical Pearl: The magnitude of trauma varies, and for each person the lingering imprints on the nervous system are uniquely expressed. Trauma looks like anxiety in some patients, depression in others and hypersensitivity to pain in others. Obsessive health concerns can have their roots in fear and trauma as well, and interact with biological etiologies. Keep an open mind about what you're seeing in terms of symptom complaints. For example, substance abuse can be rooted in family addictive patterns, including emotional dysregulation, genetic coding, early family trauma and intergenerational trauma.

What is Complex PTSD?

Complex PTSD or C-PTSD can happen when an individual has experienced repeated or ongoing traumatic events. Although complex trauma can occur at any life stage, it often stems from developmental trauma beginning in infancy. An infant’s nervous system is entirely dependent upon caregivers to create feelings of safety, connection, and calm. When one grows up with dysregulated, abusive, or neglectful caregivers, the child’s vulnerable nervous system is shaped in order to survive.

Dr. Arielle Schwartz explains that “Most often, there is a combined wound, in which you experience deficient nurturance from loving caregivers coupled with inadequate protection from dangerous situations or people.” When a child grows up in an environment of abandonment, chaos, rejection, or fear, there is the potential for significant and chronic repercussions regarding the individual’s physical, mental, and emotional health. Oftentimes, suppressed memories of physical or sexual abuse can lead to intense emotions and bodily sensations without a well-developed way to verbally explain the traumatic experience (6). These feelings and sensations can be difficult to understand and often, their root cause can be misinterpreted as something aside from a history of trauma. Parts of the traumatic memories may be unclear or forgotten, which can evoke feels of self-doubt and low self-confidence. Past experiences of developmental trauma may be influencing the ability of your patient to take care of themselves as an adult, as this ability or lack thereof, tends to reflect how they were cared for as a child (6).

What are trauma’s acute and chronic physiological effects?

Trauma manifests as maladaptive chronic stress and overwhelms an individual’s coping capacity, leading to long term effects on health and wellbeing. This is often combined with biological root causes which need to be identified and treated, especially with chronic illnesses, such as environmental illness. Thinking may be affected by a persistent ‘brain fog” or problems can develop with focus and attention, and one may develop additional cognitive challenges. The person might become distractible, struggle to concentrate on tasks that once interested them, and they may have difficulty remembering things. The individual might forget the events surrounding the trauma, as these memories become inaccessible to our consciousness. The normal, protective responses to threats or high levels of stress, (fight, flight, fawn, or freeze), can be activated regardless of whether these threats are real or perceived. An individual with a history of trauma may continue to react with the biologic defensive response even during objectively non-threatening situations, and the Cell Danger Response (Robert Naviaux, 7) may underly this reaction.

The term adaptive stress describes the intelligent way in which the body responds to the immediacy of adverse or traumatic life experiences; however, when that stress response does not resolve, it leads to lingering symptoms. In individuals who are working with adaptive stress, the body’s coping mechanism for processing stress-inducing experiences is activated and they possess the agency to terminate or conquer the stressor. These individuals are able to complete the biologic stress response, reaching a state of relief or accomplishment and returning to homeostasis efficiently.

However, as seen in those with a history of trauma, maladaptive or chronic stress reflects long-term or unrelenting conditions of physical or mental exertion and a protracted-time when the body does not get a chance to rest or experience relief and recovery. Clinicians often see this in patients with chronic environmental illness who end up feeling an unrelenting barrage of threat from their environment. Rather than just being “stressed,” their bodies are “stressed out,” and no relief is experienced in the body or the mind. In these situations, one does have a sense of agency and cannot find calm. This is when prolonged physical, mental, and emotional strain take a physiological toll on the body and the brain. This physiological toll is where trauma comes in; when a person feels helpless in the face of adversity, a traumatic imprint happens in the brain and nervous system. Often, this stress is not even conscious. Since the brain is in continuous communication with the rest of the body through the neuroendocrine, metabolic, and immune systems, chronic stress can cause dysregulation and imbalances within all of these physiologic systems. The treatment for this is to create a calm island of safety for the patient, through small moments of relief and finding positive resources and social comforts and support.

Symptoms of Acute Traumatic Stress

(Not due to known physical condition)

Persistent Exhaustion
Confusion
Sadness
Anxiety, (can be obsessive thoughts)
Agitation
Numbness
Dissociation
Confusion
Physical arousal
blunted affect
Hyperarousal and sleep disturbances
Suicidality
Racing pulse
Nausea
Muscle cramps

Chronic Effects of Traumatic Stress

Auto-immune disorders
Hyperarousal and sleep disturbances
Ischemic heart disease
Cancer
Chronic lung disease
Skeletal fractures
Liver disease
Neurodegenerative diseases
Suicidality
Depression
Anxiety
Mood disorders
Loss of sense of self
Post-Traumatic Stress Disorder
Acute stress reaction
Adjustment disorder
Persistent Post-Concussion Syndrome

What to do for your patient who has a history of trauma.

How to speak to your patients in a trauma-informed way:

Pace your inquiry: Trauma happens too fast & too soon, so go very slowly. Encourage patients to go slowly and NOT to tell you the trauma story- “you can just tell me the headlines; I don’t need to hear the whole story.”

Pause and check-in: If you notice emotional activation, then pause and ask how the patient is feeling. What is their level of arousal, or distress from 1-10?

Pay attention: Regulate yourself- Notice your own internal experience as you are working with your patient. Whatever your patient says may cause you to feel distress, so self-care begins with self-awareness.

Track: Track yourself and the client and pay attention to signs of flooding a patient. This might look like activation or overwhelm.

Ground: Constantly return to yourself as the clinician. Feel your feet in your shoes, notice your breath patterns. Connect with your breath and try to create regular and rhythmic breathing.

Know when and how to refer by asking questions and offering gentle suggestions:

“Have you received help working with these difficult issues before?”
“Would you like help?”
“Very often, psychological and behavioral help can contribute to relieving your physical symptoms.
Would you like a referral?

What is post-traumatic growth?

Post-traumatic growth, described first by Drs. Richard Tedeschi and Lawrence Calhoun in the 1990’s is experienced when an individual comes to realize that they are stronger than they were before the experience of trauma and they grow from their suffering. Post-traumatic growth is intimately tied to one’s resilience. Resilience is simultaneously a process and an outcome. It is defined by an individual's ability to flexibly adapt and process traumatic, challenging, or adverse experiences, and return to a baseline of experience which exceeds where they were before their traums-healing work. It is not an inherent human trait; it is a skill and a set of strategies that are learned and practiced. We all have the inherent ability to grown from our challenges and rise above difficulty to evolve into a richer and wiser person on the other side. When an individual who has experienced trauma is given the opportunity to process and integrate the stressful experience, a sense of strength, self-confidence, and resilience is built, leading to post-traumatic growth.

If given sufficient support and resources, all humans have the capacity to overcome adversity and thrive in spite of it. By attending to their pain, connecting to others, believing in and orienting to one’s strengths, and taking charge of one’s life-defining narrative, post-traumatic growth is experienced. Although one might still question how they have been betrayed by the world and fear that it might happen again, like a phoenix rising from ashes, an individual who has experienced trauma can rise again. They can learn to believe that they are stronger than they thought, able to hold the complexity of the human experience and that this world contains harm and loss while also being a place of love and care. Doing the work and having the resources to heal from trauma allows for joy and hurt to coexist and for the individual to re-enter into the world ready to share their gifts.

Relaxation strategies that you can do in the office if you or your patient gets activated.

Breathing: The foundation of all effective trauma treatments involves a way for people to connect with their own nervous system and become aware of their arousal state. Before spending time talking with a patient or processing their “story,” it is essential to tune in to their physiologic state and invite them to do the same. The simplest way to do this is to slow everything down. Directing your patient to become aware of their breath is a simple way to begin the self-regulation process.

Self-Soothing: Assure patients that all emotions are real and valid and that if feelings are not processed, then they find their way into the body and are stored there. Once the person has identified the difficult emotion, encourage them to do a “Butterfly Hug”, by wrapping their arms around themselves and alternately tapping their upper arms until they are less aroused by the difficult feeling. Let the patient continue with alternate tapping as slowly or as quickly as they choose.

Grounding: Encourage the patient to feel their feet on the ground and walk them through the following steps. Notice all the sensations that your feet have and the specific contact points of your feet in their shoes or on the ground. Feel how strong your feet are, and imagine yourself walking in your favorite place in nature.

*If you like, you can notice your breathing, and as you inhale and exhale, you allow your feet to connect even more with the earth.

Orienting to Senses: Gently guide the patient through the following exercise. It is especially beneficial if patients are feeling anxious and disoriented.

“This is an exercise that allows you to connect to a calm, safe place where you are in this moment, at this time, right now. This is an exercise to stimulate your senses and your present moment awareness. This exercise will stimulate something pleasant with each of four senses; smell, hearing, vision, and touch. Begin by connecting with your breath. Breathing into a count of four, breathing out to account for slowly and rhythmically allow the impulse to breathe in to come naturally and effortlessly

Now we’re going to go through each of the four senses. I’d like you to notice something that catches your eye, something that is beautiful to you in your surroundings, right here and now. Let’s take a moment to do that “ (give the person 30 seconds or a minute to spend time with something beautiful in their environment that is pleasing to them). And now, do the same thing with something that they hear, something they smell, and something thye can touch. When it comes to touch, it’s a good idea to have people just touch their own hands or legs, taking time to savour the connection between themselves and their own bodies.

There are many simple strategies that patients can use, and bilateral auditory sounds is a simple tool accessible to everyone. I like my colleague, David Grand’s Biolateral music. I will continue to post Limbic System Release Tools and Nervous System Calming Tips on my website, IleneNaomiRusk.com

Concluding thoughts.

A trauma-informed approach to healthcare acknowledges that understanding a patient’s life experiences and the contribution of past traumas to their current acute or chronic health condition are key to improving engagement, relational quality and health outcomes while lowering recovery time. Treating underlying biological and environmental drivers needs to be done concurrently. A mindset of post traumatic growth and mind-body medicine on the part of the practitioner encourages patients to use their own social and emotional skills in their healing journey, helping them to use their feelings for diving deeper into their own unlimited potential growth. As the clinician, you are working on your own self-regulation and resilience skills as you foster post-traumatic growth in your patients. You are guiding those suffering from past trauma to heal from their emotional wounds and empowering them to see their traumas as a platform from which to grow and thrive.

Some trusted organizations who train providers in valid Trauma Relief techniques and have directories.

EMDRIA, Brainspotting, IFS, Sensorimotor Institute, TraumaHealing.org

IleneNaomiRusk.com is a resource if you need trauma-informed treatments or tips, or want a trauma-informed health consultation

Suggested Reading:

Bessel van der Kolk, MD.

The Body Keeps the Score (2015)

Arielle Schwartz, Ph.D.

The Post-Traumatic Growth Guidebook (2020)

The Complex PTSD Workbook (2017)

A Practical Guide To Complex PTSD (2020)

Nadine Burke Harris, MD

The Deepest Well: Healing the Long-Term Effects of Childhood Adversity (2018)

Janina Fisher, Ph.D.

Healing The Fragmented Selves of Trauma Survivors (2017)

Babette Rothschild

8 Keys to Safe Trauma Recovery: Take-Charge Strategies to Empower Your Healing

(2010)

Peter Levine, Ph.D.

Trauma and Memory: Brain and Body in a Search for the Living Past (2015)

In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness (2013)

Stephen Porges, PhD, The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. (2011)

References

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S., Springs, F., Friedrich, W., et al. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine 14, 245–258.
Lu, W., Mueser, K.T., Rosenberg, S.D., and Jankowski, M.K. (2008). Correlates of Adverse Childhood Experiences Among Adults with Severe Mood Disorders. Psychiatric Services 59, 1018–1026.
Merrick, M. T., Ford, D. C., Ports, K. A., & Guinn, A. S. (2018). Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatrics, 172(11), 1038–1044. https://doi.org/10.1001/jamapediatrics.2018.2537
M.D, B. van der K. (2015). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (Reprint edition). Penguin Books.
Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homeless service settings. The Open Health Services and Policy Journal, 3, 80-100. Trauma Center at JRI
Schwartz, A. (2019, October 9). Complex PTSD and Attachment Trauma. Arielle Schwartz, Ph.D. Complex PTSD and Attachment Trauma
Naviaux, Robert K, (2014). Metabolic Features of the Cell Danger Response, Mitochondrian, 6: 7-17