Caring for Patients with Trauma History in Collaborative Care

 Photo Credit: Courtesy of the John A. Hartford Foundation

One of the biggest misunderstandings we encounter at the AIMS Center is that Collaborative Care won’t work for people who have a history of psychological trauma. This concern is especially prevalent in Federally Qualified Health Centers (FQHCs) and community clinics who serve a largely low-income population with high numbers of patients that have suffered significant psychological trauma.

But that sentiment is far from true.

“Collaborative Care can absolutely work for patients who have a history of trauma,” says Diane Powers, Associate Director of the AIMS Center. “Collaborative Care is about helping people with whatever they are experiencing right now that is interfering with their lives, including depression and anxiety that are a result of past trauma. One of its strengths is helping people with the here and now.”

Trauma comes in many different forms and is much more prevalent than people think. Statistics vary, but the consensus is that fifty to ninety percent of adults and children are exposed to at least one psychologically traumatic event at some point in their lives. If a person feels traumatized by an event or experience – whether it’s childhood neglect, physical or emotional abuse, sudden loss of a loved one, a natural disaster, medical interventions, or something else –  then it was traumatic. On average, adults who experience trauma have nearly five traumatic events in their lifetime.

Many types of trauma increase the risk of health, social and emotional problems, and there is a direct link between childhood trauma and adult onset of chronic disease, including depression. How providers learn about their patients’ stories is extremely important and has shifted over the past ten years.

“During the initial assessment, it’s important that providers learn about a patient’s past trauma in a very intentional, contained way,” says Anna Ratzliff, Associate Director for Education at the AIMS Center. “Not doing so can lead to re-traumatization and disengagement from treatment. The recommendation is for a more structured approach than what was practiced in the past.”

Allowing the patient to tell their story in his/her own words and encouraging the patient to respond with short, concise descriptions can help clinicians talk with their patients about past trauma and safely learn their stories. It is also important to stop the discussion if the patient is having trouble containing their emotions. Discussing Past Trauma with Patients provides more advice on how to safely discuss past trauma with patients as part of an initial assessment.

Knowing about a patient’s past trauma is important as it can influence how a Collaborative Care team approaches treatment.

“A depressed patient with comorbid trauma may require different treatment than a person suffering solely from depression,” says Rita Haverkamp, a long-time care manager and consultant to the AIMS Center. “Trauma affects the way people approach potentially helpful relationships and might result in the patient being less engaged or having slower remission rates. The team needs to be aware.”

As part of the Collaborative Care model, care managers closely monitor all patients and keep an especially close watch on patients with comorbid trauma to ensure they are adjusting the treatment plan appropriately to keep the patient engaged. If a patient is not improving as expected, the team can consider evidence-based psychotherapies, such as behavioral activation (BA) or problem-solving treatment (PST), to help the patient work on behavior issues symptomatic of trauma such as avoidance.

Seeking consultation or providing a specialty care referral when the patient is not improving is imperative because the patient’s condition may be too complex for a primary care setting depending on what resources are in place.

Post-Traumatic Stress Disorder

Most trauma does not result in Post-Traumatic Stress Disorder (PTSD), another misconception frequently encountered at the AIMS Center, but an active case of PTSD requires evidence-based treatments given by someone who has current and specialized training.

PTSD is a clinical condition that requires a differential diagnosis. A screener such as the PTSD Checklist (PCL) can help with an initial diagnosis, but is not a substitution. Every clinic practicing Collaborative Care should be able to identify PTSD, but not all clinics have the capacity to offer the evidence-based care required to treat it. If they do, assessing a patient’s desire to work through their PTSD is vital when deciding on a treatment plan. If the patient sought treatment for their depression, then it is generally better to treat the depression first and then focus on the PTSD. It is also important to have regular check-ins with the team’s psychiatric consultant.

Resources

Discussing Past Trauma with Patients: a handout for how to safely discuss past trauma with patients as part of an initial assessment.

Trauma-Informed Care in Behavioral Health Services. Assists behavioral health professionals in understanding the impact and consequences for those who experience trauma. Discusses patient assessment, treatment planning strategies that support recovery, and building a trauma-informed care workforce.

SAMHSA-HRSA Center for Integrated Health Solutions: General Trauma Resources, Screening Tools and Webinars

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