Trauma-Informed Approach in Medical Education Settings
Ruth Frydman, M.D.
Psychological trauma is common. In the United States, 61 percent of men and 51 percent of women report exposure to at least one lifetime traumatic event, and 90 percent of clients in public behavioral health care settings have experienced trauma. 1SAMHSA website: www.integration.samhsa.gov/clinical-practice/trauma 2/13/20
Psychological trauma results from “an event, set of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”2 p.7, SAMHSA.
People who have experienced trauma may feel unsafe in situations that remind them of their trauma. Trauma survivors have been in situations where they did not have a voice or safe choices. They may continue to experience shame or guilt and may tend to isolate to protect themselves.
Trauma is a violation of a person’s sense of self control and personal power. Trauma survivors are sensitive to power differences in relationships, and these power differences are inherent to healthcare settings. Lack of awareness on the part of the provider can lead to a learner or patient getting re-traumatized and breakdown in communication that can result in significant barriers to delivering care.
All of us–faculty, learners, staff, and patients–can benefit from improving the learning climate where we work, train, and receive care. Attending staff and residents are role models for medical students, so modeling trauma-informed care and relationships can have a ripple effect on learners, staff, and patients.
Learners may have experienced earlier trauma and/or maltreatment during medical education. This can impact the quality of the treatment provided if their own personal trauma history is impacted by an unhealthy work environment.
Akin to universal precautions, we can minimize trauma and re-traumatization in healthcare settings by using the following principles in our work with trainees, colleagues, and patients:
6 key principles of a trauma-informed approach:
- Safety — provide and promote physical and emotional safety in our work and teaching settings e.g. treating students with respect, avoiding giving constructive or negative feedback in ways or places that could result in public humiliation.
- Trustworthiness and Transparency — building and maintaining trust, participating in clear communication g. setting clear expectations for learners for rotation goals and accountability, giving learners timely and honest feedback, modeling clear boundaries.
- Peer Support — mutual self-help, getting feedback from peers e.g access to resources such as medical student support group, peer-to-peer type programming, time to talk with other learners who may also have struggled or be struggling.
- Collaboration and Mutuality — shared decision making, less hierarchical e.g. teacher can model and promote collaboration and mutuality in patient care for learners and can model team based leadership appropriate for learner’s level of training
- Empowerment, Voice and Choice — shared decision making, promoting resilience, supporting goals, providing choice and promoting an environment where people can share without fear of negative repercussions e.g. finding out learner’s goals for the rotation; modeling shared decision making with patients; modeling and respecting advocacy skills in learners, staff, and patients.
- Cultural, Historical, and Gender Issues — working on treating others with respect knowing that there are power differences that pervade our culture; understanding some have experienced cultural and historical trauma and that some have experienced trauma based on gender and gender identity; g not making assumptions about learners based on their background, displaying signage or symbols that show support for groups facing discrimination such as rainbow symbols or sharing preferred pronouns to increase sense of safety for LGBTQ people (must be backed up by behavior and attitudes).2
Use of this approach can help engage and empower people, as well as reduce trauma reactive anger and aggression. It can help make our teaching and clinical settings more psychologically safe.
A trauma-informed approach to teaching and clinical work is best supported when the larger organization is committed to using policies to support this. At Maine Behavioral Healthcare, we are working on becoming a trauma-informed organization.
For more information on the trauma-informed approach and trauma-informed organizations, see SAMHSA’s, Concepts on Trauma and Guidance for a Trauma-Informed Approach listed below.,2
- Substance Abuse and Mental Health Services Administration and Health Resources Services Administration. SAHMSA-HRSA Center for Integrated Health Solutions: Trauma. http://www.integration.samhsa.gov/clinical-practice/trauma. Accessed February 13, 2020.
- Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. In. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014:7, 10-11.
Questions for discussion:
Why should we have universal precautions regarding psychological trauma?
What are trauma-informed principles?
How might these principles be applied to working with learners? Please give concrete examples
What are barriers you face in implementing a trauma-informed approach? How might you address these barriers?
Goals to take away from this months tip:
-understand the high prevalence of trauma
-understand the concept of universal precautions
-develop tools for implementing the 6 principles of trauma-informed approach with respect to teaching and creating a psychologically safe learning environment