Trauma-informed Community Care

Written by Kathleen Grimm, MD, internal medicine and palliative care physician practicing in Buffalo, New York.  Dr. Grimm is a 2012 NPA Copello Fellow.
The Institute of Medicine report “US Health in International Perspective: Shorter Lives, Poorer Health”  offers a sobering reflection on the state of health in this country. The poor health of U.S. citizens was seen in all ages and for many reasons, including the influence of injury and trauma. Injury and trauma cause a great deal of death and disease. The report also highlighted evidence that has been known and validated for decades: we can significantly reduce adult disease and disability by investing in the health of infants and children, and by reducing trauma and violence affecting children.
The medical and social science literature have recognized this reality for a long time, yet we continue to invest heavily in adult disease modification and not in true upstream prevention. True upstream intervention examines root cause of disease, most often based in childhood experience and the socio-ecological and life course models of health promotion. The CDC Adverse Childhood Events study  has been validated for at least twenty years. There is no question that the impact of adverse events occurring in a child’s life have significant effects on adult health.
The life course model of health integrates the health of children with their adult health status. Traumatic events that shape a child’s development can have long lasting effects, and having a multitude of these adverse events greatly increases the odds of adult disease: substance abuse, depression, heart disease, chronic lung disease, liver disease, relationship instability, sexually transmitted diseases resulting from promiscuity, and more. Studies that have examined the effects of trauma on later health demonstrate a clear need for systems of care that are trauma-informed. Trauma has become part of our social reality and needs attention in order to stem the growing public health crises of adult chronic disease.
A system of care that recognizes these early events and their effects shifts the caring relationship away from the question of “What is wrong with this person?” to one that asks, “What happened to this person?” Practitioners will be more willing to look at the source of symptoms and behaviors. Trauma-informed care recognizes that people are not ” bad” people doing “bad” things, but hurt people making poor choices. This shift in thinking builds trust, promotes behavior change, and enables shared decision making.
Trauma-informed systems work collaboratively, are multidisciplinary, and aim to ensure that social service and health care systems are not re-traumatizing an at-risk individual. A community that is trauma-informed has a foundation of caregivers who are trauma-informed, and supports organizations that build on values of safety, collaboration, and shared decision making. Trauma-informed organizations recognize the importance of self-care and the need for organizations to take care of their employees.
Trauma-informed community care will challenge current delivery models of care. For a community to work in a cohesive, trauma-informed mode, sectors must cross over, collaborate, communicate, and assure that all levels of caregivers have the training and tools to respond in trauma-informed ways. This stretches current concepts of care delivery to include those who are “first responders” in traumatic events and situations: lawyers, social workers, firefighters, EMTs, community health workers, and those in informal care networks as well.
“Primary care” should not be viewed as the purview of the health sector alone, but rather understood to include a broad network of caregivers who all focus on root cause of disease and upstream models of preventive care–the “democratization of care,” as some have called it.
The focus on true root cause and expanded networks will build partnerships and lead to resource-sharing at every level of care delivery. It will also broaden the focus of health care from an approach that is narrowly problem-based and disease reactive to one that includes a focus on health itself, especially the health and well-being of our children.