The Principles of Trauma-Informed Care — An Interview with Sheila Raja, PhD
Certain types of medical exams can be invasive or uncomfortable, which can result in patients avoiding them, which in turn prevents them from receiving the care they need. When patients have experienced trauma, whether it’s a survivor of sexual abuse or veteran with PTSD, for example, the discomfort — and potential aversion to necessary care — is compounded. Trauma-informed care (TIC) is an approach to healthcare, social services, and other types of support that recognizes the impact of trauma on one’s behavior and well-being and emphasizes the need to offer care that is sensitive to the needs of people who have experienced trauma while avoiding re-traumatization.
Lutech Industries is a woman-owned and operated manufacturer of digital video colposcopes, which are used to screen for cervical cancer and to document evidence after a sexual assault. With nearly a decade of working alongside OBGYNs and with SANE / SAFE (Sexual Assault Nurse Examiners / Sexual Assault Forensic Examiners), we recognize the need to be sensitive to the patient’s vulnerabilities and trauma and have incorporated that into the design of our products in a variety of ways. For example, by facilitating a shorter exam time and increasing the distance between the patient and examiner, Lutech’s LT-300 colposcope reduces patient anxiety and prevents re-traumatization, and by connecting to a tv screen or monitor, the LT-300 allows the provider to educate the patient and explain what is happening during the exam in real time, giving the patient an increased sense of control and collaboration and allowing the provider to offer a more a more trauma-informed experience.
We spoke to Sheela Raja, PhD, an associate professor at the University of Illinois at Chicago and a nationally recognized expert on the health effects of trauma and trauma-informed health care approaches, about the benefits and impact of TIC and how OBGYNs can incorporate TIC in their practices.
Q: Hello, Dr. Raja. Thank you so much for taking the time to talk with us. Before we get started, can you give us an overview of what TIC is and outline some of the guiding principles of trauma-informed care?
A: The principles of trauma-informed care (TIC), as outlined by the Substance Abuse, Mental Health and Services Administration (SAMHSA) focus on safety, trustworthiness, and transparency.
Sometimes that means establishing rapport — including peer support in your services, collaboration, and mutuality — and then giving patients empowerment, voice, and choice. There’s also an understanding that people bring to the table some very real issues around culture and history and gender. This means diversity, equity, and inclusion (DEI) also has to be part of this picture.
Certain types of exams make you feel as if you lose control. Anything that we can do to give people back a sense of control is really important. Part of that is also trustworthiness and transparency, through which we build patient education. So, we’re trying to give patients a greater sense of control, along with more knowledge of what’s going on with themselves.
Q: How is Trauma-Informed Care applied in the OBGYN setting? Are providers in that space adopting this approach, or are there still more opportunities for that?
A: There are always opportunities for improvement, but I do think that in the GYN space, providers are extremely aware of the need for this kind of approach. Providers will often say they’re treating patients who aren’t coming in for their preventive services because they have high levels of anxiety or seem to be very easily triggered during certain procedures. These providers certainly know the trauma-informed approach. But among these providers there’s also this fear, however, regarding how much they need to know about the specifics of the source of that anxiety or trauma, and how much they need to learn without being invasive.
That’s where it’s really useful to offer universal trauma precautions. It’s the idea that if you have a long-term relationship with your patients, you know them well and you are also working in an integrated system where you can ask somebody about what their history might be. You’ve got that trusting relationship and you can give what we call the "warm handoff" to the appropriate specialist or community resource if the patient endorses some kind of trauma history.
That’s because a lot of people are very resilient and heal within their own communities — that’s great. But there are many universal trauma precautions you can offer where you don’t necessarily have to know that person’s trauma history. Part of it is being able to explain: "This is how this procedure is going to go. This is what you can expect." Because if you think about it, what does trauma take away from us? It takes away our sense of control. It takes away our sense of trust. If we can build those things back with every patient, every time, then we don’t necessarily have to know all the details of what they’ve gone through in order to make that a successful appointment.
Consider an appointment where you’re asked to take off all your clothes and change into a gown for a procedure where they need to visualize only a certain portion of the body. In this case, we can return small amounts of control by having them disrobe only partially. These small things mean a lot to trauma survivors.
And you don’t have to know whether somebody is a trauma survivor to provide patient education. People are really receptive of those small behavioral ways to improve patient care. These changes don’t require a lot of extra time during an appointment.
I think that in the women’s health space, there’s a lot of opportunity here.
Q: Do you think there should be a prescreening or a universal screening that can intake this kind of information?
A: We’ve done a lot of training and writing about universal screening. It can be done well within an integrated health system where, if somebody then comes up positive on a screen, you have a behavioral health system that is culturally appropriate, linguistically appropriate, maybe doesn’t have a long waiting list, and is able to accommodate people at a cost they can afford.
All of those things are important. If we’re going to move toward screening, it’s really important that we commit to it and commit to doing it well. That includes being thoughtful about documentation and who has access to that information. Our historically marginalized populations sometimes have a justified distrust of the healthcare system. How comfortable do they feel disclosing information when they may wonder, "Does my insurance company get access to that? Could they charge me a higher premium?"
These are really important systemic questions we need to ask ourselves because when we do implement screening protocols, they need to be done very thoughtfully.
Q: What are some other elements of universal trauma precautions?
A: They can include the things we can do in the room with every patient, putting people at ease and educating them about what’s going on with their own health, and how stress takes a toll on their bodies. We can do that with every patient. Providers really resonate with that because they’re busy and have to function within a system that’s strained in a lot of ways.
Q: What are the biggest misconceptions with Trauma-Informed Care?
A: With clinicians the biggest misconception is, "I don’t have time to be asking every single one of my patients about their trauma history." But trauma-informed care can be implemented on so many different levels. As I mentioned, what are some things you can do in the room to make a patient feel more comfortable, more included, more collaborative? What kinds of education can you provide?
Trauma-informed care also includes self-care for yourself and your staff. It actually has a lot of different layers. Because if we, the clinicians, experience burnout or compassion fatigue — or even vicarious trauma ourselves — we can’t provide that collaboration, that sense of mutuality because we’re burned out.
Q: How do you see technology within the exam room helping to advance the principles of Trauma-Informed Care?
A: Even the most basic advances in technology can go hand-in-hand with the educational aspect. Show the patient the tools and explain what they do and how they’re used — not to scare them, obviously, but to show them what to expect.
Also, think of the exam room from the patient’s perspective. Is it possible for the patient to see the exam room ahead of time, so she’ll be able to see what the exam table looks like from my perspective. Then they can practice deep breathing and getting used to everything and calming themselves before entering the environment for the actual appointment.
Even including something as simple as patient education videos that follow the appointment, there’s always opportunities for the latest technology!
Lutech is a woman-owned medtech company, which is rare because only about 25% of all senior leadership roles in medtech companies are held by women. Being a woman-owned company is so important in the women’s health space, because it gives us a perspective that men don’t have, the feeling exposed and vulnerable in the stirrups, for instance.
We include that perspective in innovating technology and in tools like the colposcope, which was created almost a century ago but saw very little innovation until just recently, when we’ve been able to evolve it in a way that creates a better patient experience that aligns with the principles of TIC.