As many as a third of older adults served by our health care system have a back story of severe trauma that might be contributing to their medical problems—especially those with multiple chronic conditions, seeking mental health services or frequent flyers in emergency departments.
Trauma-informed care is a concept from psychiatry—with growing applications in health care more broadly—asserting that past experiences of trauma can have all sorts of impacts on current health. Childhood abuse and neglect, intimate partner violence, witnessing acts of violence or war—even living through natural disasters—all can lead to distressing post-traumatic stress reactions.
While trauma-informed care provides a framework for assessments and interventions, healthcare providers aren’t expected to treat their patients’ past trauma. But if medical interventions are “informed” by an understanding of that trauma and how it might have overwhelmed the person’s coping capacity, it may increase their chances of success.
A recent conference sponsored by DayBreak Adult Care Centers of Alameda explored the impact of trauma on the care of older adults and how interdisciplinary teams of health care providers can respond to it. One of DayBreak’s services is a rapid response team called to emergency departments to offer crisis intervention and case management services to patients who consent to this interaction.
The objective is to help seniors who are at high risk for hospital readmissions or have made at least three ER visits in the past six months to remain independent in the community, says Stefanie Stevens, MA, manager of the rapid response team. “Rapid response comes in when there’s a crisis. We serve people aged 60 and above, but that’s a very diverse group, including homeless older adults,” she says.
Research from the Centers for Disease Prevention and Control and elsewhere has demonstrated links between a variety of chronic conditions, including diabetes and high blood pressure, and history of trauma, Stevens says. “These are patients who have a medical problem but something is wrong socially as well. When I come in to do an assessment, I can see things that are linked to the trauma—things like depression, hoarding, addiction, or anxieties of unknown origin.” Just acknowledging it for them can relieve a lot of their symptoms, she adds.
The first step to trauma-informed care is awareness that the client has had some kind of traumatic experience—but obtaining that information in a way that doesn’t retraumatize the person. Instead of asking people what’s wrong with them, ask them what has happened to them, Stevens suggests. She points to the Substance Abuse and Mental Health Services Administration’s National Center for Trauma-Informed Care as a source for helpful resources.
“You can go into every encounter thinking that anyone who presents to you with health needs might have past trauma,” says Nancy Kusmaul, PhD, MSW, assistant professor in the Department of Social Work at the University of Maryland-Baltimore County. “You want to find out how it affects the individual. But don’t raise the issue unless you are prepared and have the capacity to respond to it,” she says.
“Our approach to trauma should be transparent and collaborative, understanding the person and where they’re coming from, and making the encounter about shared goals. When you’re talking to older adults, you need to consider their lifetime of experience, although that’s not to say every trauma experience has long-term impact.”
Kusmaul cites the foundational ACE (Adverse Childhood Experiences) study, which documented widespread incidence of childhood trauma and its impact across the age span—including greater risk for long-term disease, disability, chronic social problems and early death.
With any aging person, it’s not just about what happened earlier in life but also what’s happening to you now, Kusmaul says. That could include feelings of loss of control, chronic illness, widowhood or placement in a nursing facility—which for many older adults is a highly stressful event of its own.
A lot of trauma-informed care is just common sense, adds Joan Gillece, PhD, director of the Center for Innovation in Behavioral Health Policy and Practice at the National Association of State Mental Health Program Directors in Alexandria, VA. “We need to learn to look at these symptoms through a different lens. There’s meaning in the behaviors you see.”
Based on her experience in long-term care, Gillece says that instead of medicating or restraining patients who act out, it’s better to offer them comfort and try to see their behaviors as adaptive. “We can prevent a lot of behaviors from escalating just by being aware that behind these symptoms there’s a story.”