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Trauma-Informed Care Treats Injuries That Can Be Seen, Those that Can’t

The pain and aftershocks of traumatic injuries — physical and psychological — can linger for a lifetime and feed chronic illnesses

CAT Scan

Certain traumas — a broken arm or battered face — are fairly easy for healthcare providers to recognize. But sometimes no skin was broken, or the wounds have long healed, and patients still suffer for years from the physical and mental impacts of a traumatic event.

Robert Wood Johnson University Hospital is among the New Jersey healthcare organizations now seeking to improve care for patients struggling with the mental and physical fallout from all kinds of traumatic events, whether it’s the loss of a loved one, domestic abuse, chronic poverty, or the effects of flooding or other natural disasters. In addition to depression, panic, or other emotional issues, experts have found trauma can feed chronic physical ailments like diabetes and heart disease.

To reach these goals, RWJUH and others are using “trauma-informed care,” an approach that seeks to address the immediate physical injuries associated with a traumatic event, as well as the long-term behavioral and physical problems that may result. In January, the New Brunswick-based hospital led a conference that outlined the concept and kicked off a year-long effort to help hospital staff and healthcare providers elsewhere learn to better diagnose and treat patients dealing with often-hidden trauma.

(The conference also explored the local impact of human trafficking, one of many sources of trauma. While the practice may not be common in New Jersey, Gov. Chris Christie said concerns about forced labor and prostitution prompted additional enforcement and education efforts leading up to the 2014 Super Bowl, and providers want to be ready to recognize the signs if they come in contact with a victim.)

Signs of trauma are sometimes subtle

Trauma-informed care involves training staff to recognize the sometimes-subtle signs of trauma, develop trust with the patient, and carefully elicit relevant details, without causing further harm. Patients are then linked with appropriate physical and behavioral health treatments, and sometimes law enforcement.

Providers said that while trauma-informed care might involve standard treatments for physical injury and emotional abuse, for it to succeed the program must engage all hospital staff and ensure they work together to identify and help those in crisis. For example, they said a patient may feel more comfortable opening up to a friendly food aide, porter, or nurse, instead of a psychologist or physician tasked with finding the source of their pain.

“Our goal is to help people understand what trauma-informed care is and how they apply it to what they do,” explained Diana Starace, the injury prevention coordinator with RWJUH’s trauma department who is helping to coordinate the hospital’s program. “It’s getting all the providers that come in contact with the patient aware of the process.”

It’s also about encouraging providers to look beyond the obvious wounds for additional clues by watching for signs of mental distress, unusual fearfulness, or other signs that they might be — or have been — exposed to violence or other trauma. “It’s not just the injury, It’s, ‘Are there other concerns?’” explained Amber Bond, a pediatric nurse with RWJUH’s Bristol-Myers Squibb Children’s Hospital, who also works with sexual assault patients.

As many as one in five women suffer sexual abuse

According to the federal Substance Abuse and Mental Health Services Administration, which operates the National Center for Trauma-Informed Care, as many as one in five women will suffer sexual abuse during her lifetime and anywhere between 9 percent to 44 percent will face domestic abuse, depending on the definition. Natural disasters, another cause of trauma, impact nearly 19 percent of men and greater than 15 percent of women.

In New Jersey, experts have found reports of certain domestic violence incidents declined in recent years, but advocates said the victims need greater support. Reports discussed at a conference in September showed police logged more than 62,000 domestic violence cases in 2014, including 42 that involved murders, and nearly 900 rapes.

But these statistics just hint at the scope of the problem, since each incident can prompt long-term mental and physical distress.

“It starts where the injury begins, but really follows them throughout their life,” RWJUH’s Bond added. “That injury is going to heal. But what about that whole other psychological aspect? There’s physical trauma and there’s psychological trauma, too.”

According to SAMSHA, trauma is often associated with substance abuse, mental illness, or risky behaviors and has “no boundaries” when it comes to age, gender, sexual orientation, race, or economic status. In addition to the harm to individuals and families, these traumas can rip apart communities and cost society billions of dollars each year in medical costs and lost productivity.

“Trauma and violence are widespread, harmful, and costly public-health concerns,” SAMHSA’s website notes. “For this reason, the need to address trauma is increasingly seen as an important part of effective behavioral healthcare.”

Lasting impacts of childhood traumas

The program at RWJUH, a RWJ/Barnabas Health facility, is not the only effort taking hold in New Jersey. In October, Rutgers University Behavioral Health Care was awarded a $2 million five-year grant from SAMHSA to create the Children’s Center for Resilience and Trauma Recovery. There is a growing awareness that childhood traumas — including chronic issues like poverty or family violence — can have lasting impacts on many aspects of a child’s health.

The center, as part of a national network, will work with Rutgers schools of nursing, social work, and graduate psychology, as well as the New Jersey System of Care — a suite of services to help children with complex health needs overseen by the state Department of Children and Families — to train providers in the trauma-informed approach. According to the announcement, its priority was to focus on vulnerable children under age 10 and address trauma-related problems before they impact the youngster’s long-term development; information on their progress was not immediately available.

“If we can help these families early on, we can nurture their resilience to recover from trauma and use skills to promote sustained change over time,” said Dr. Kelly Moore, the grant administrator with Dr. Diana Salvador. Moore said the hope is that training clinicians will “create a sustainable workforce that is sensitive and responsive” to trauma and its impacts.

At RWJUH, Starace and her colleagues are drafting their next steps. Trauma and human trafficking were designated the theme for 2017, and the team hopes to develop lessons that can be part of the continuing education requirements for all hospital staff — and eventually others at the RWJ/Barnabas network, which includes a dozen hospitals and tens of thousands of physicians. They are also planning a training session open to other healthcare providers for May and may repeat the clinic in the fall, if there’s interest.

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