Research
Volume 47, No. 6, June 2018

Trauma-informed care in general practice: Findings from a women’s health centre evaluation

Miriam Brooks    Lesley Barclay    Claire Hooker   
10.31128/AJGP-11-17-4406 |   Cite this article    BIBTEX    REFER    RIS    |

Background and objectives
Trauma and adversity have serious health consequences, particularly when experienced in early life. These health consequences can be significantly lessened if young people access appropriate care when needed. In 2004, the Blue Mountains Women’s Health and Resource Centre created a Young Women’s Clinic (YWC) that began providing drop-in appointments for women aged 12–25 years with a general practitioner, nurse or counsellor, as well as a group art program.
Methods
A qualitative evaluation of services provided by the YWC was conducted, drawing on 13 years of client and staff experiences. The evaluation framework was drawn from the recommendations of the NSW Centre for Advancement of Adolescent Health, the Australian Women’s Health Network and the World Health Organization report on People-centred and integrated health services.
Results
The following principles of trauma-informed care were identified in the study: recognising the impact of trauma on consultations; tailoring consultation length to client needs; providing trauma therapy as well as physical healthcare; offering long-term, safe relationships with staff; trauma-sensitive gynaecological care; and the importance of self-care for health practitioners.
Discussion
Our findings demonstrate the importance of holistic general practice services in preventing and managing the long-term health consequences of adversity and trauma.
 

Trauma is defined as situations that ‘threaten death or serious injury, or threat to the physical integrity of self or others’ and that overwhelm a person’s coping resources.1,2 Trauma can involve experiences of physical violence, sexual violence, childhood abuse or neglect, death of a parent, serious accidents, natural disasters, terrorism, war-related trauma and medical trauma.2 Exposure to adverse social experiences and trauma is closely associated with an increased incidence of both mental and physical ill‑health.

Blue Mountains Women’s Health and Resource Centre (BMWHRC) was established in the Blue Mountains, New South Wales, in 1981. As with other women’s health centres across Australia, BMWHRC’s vision and statement of purpose reflect a social view of health that recognises the role of adversity and trauma in creating illness:3

To create a community where women, regardless of their social and cultural background, age and sexual orientation, will have knowledge and control over their bodies and their lives, living freely and safely, with access to the support they need to enhance their health and well-being. … We will be guided by principles of social justice and equity. We will actively work in partnership with others to build social structures that promote women’s rights and dignity.

In 2004, BMWHRC established a weekly after-school clinic for women aged 12–25 years. The Young Women’s Clinic (YWC) provides drop-in appointments with a nurse, counsellor or general practitioner (GP). These services are offered alongside an art group for young women. At ‘Artspace’, clients can draw, paint or collage, building social connectedness with other young women in the community. Artspace is facilitated by a youth worker or art therapist, who, when needed, refers clients to a YWC GP or counsellor. Each week, the clinic team sees 6–10 young women, and 10–20 women participate in Artspace. The initial intention of YWC was to offer sexual and reproductive healthcare. Over time, however, increasing proportions of young women presented with mental health distress, and the service adapted to meet their needs. There is significant social disadvantage in the Blue Mountains, with 33% of one local township households on low incomes, and the community faces issues similar to those in other disadvantaged areas in Australia.4 YWC is funded by Medicare bulkbilling and through partnership with community youth-oriented services. All YWC services are provided at no cost to the client.

Methods

The YWC evaluation framework was drawn from recommendations for youth-friendly services of the NSW Centre for Advancement of Adolescent Health,5–7 the World Health Organization report, People-centred and integrated healthcare,8 and the Australian Women’s Health Network best practice guidelines.9 The research was overseen by two university researchers.

The client sample consisted of one Aboriginal woman, two women from a culturally and linguistically diverse (CALD) background, 10 Anglo-Australian women and one woman living in a wheelchair. The staff sample comprised two GPs, two nurses, two counsellors, two YWC reception workers, a social work university student on placement at BMWHRC, Artspace art therapist and youth worker, and the former manager of BMWHRC. Staff from local high schools and community organisations supporting young people with mental health, housing, parenting and crisis accommodation also participated. The samples were purposively selected to cover a range of clients and staff.

Awareness of issues pertaining to gender, income, culture, sexuality and disability is a core value of trauma-informed care.10 Caring for the safety and confidentiality of these young women was a guiding principle of the evaluation, which was directed by a steering committee of BMWHRC staff. The research was approved by the Human Research Ethics Committee of the University of Sydney (reference number 2016/137). Evaluation aims were explained and consent processes followed. While 13 women participated directly, the community partner organisations spoke on behalf of their clients; therefore, the YWC experiences discussed were from a much larger number of women than the number who participated directly in the research.

Focus groups and interviews were recorded, using open-ended questions that encouraged sharing of stories with the interviewer or group. These data were transcribed. A thematic analysis of these data was conducted.11,12 Many client stories included significant adversity and trauma experiences. This study sought to explore how trauma-informed care can support recovery from adversity and illness. Pseudonyms are used for all clients.

Results

Presenting health issues

Clients presented to YWC for assistance with contraception, sexually transmissible infection (STI) screening and treatment, polycystic ovarian syndrome, Pap smears, unplanned pregnancy, period problems, vaginal conditions, antenatal care, breastfeeding issues, stress at school or at home, self-harm and suicidal thoughts, relationship violence and sexual assault. The vice-principal of a local high school spoke with great concern about the high incidence of mental health difficulties among the school’s students:

We have students with a whole range of additional needs … those could be trauma, difficulties at home, mental health issues, sexual assault, unhealthy relationships, pregnancies … A lot of referrals to YWC are for mental health concerns. Also a lot of sexual health concerns, whether that’s contraception, STI checking, or general health conversations, but time and again it is the mental health issues.

Adversity and health

YWC clients and their support workers reported exposure to multiple adversities, including death of a primary carer, chronic illness, child abuse, growing up with a household member affected by severe mental illness, intimate partner violence, low incomes and racism.

A high school learning support officer for Aboriginal students observed that young people’s health issues are often submerged by social stressors: ‘At that age they’re dealing with so many different emotions and stuff that they sometimes put their health back’. She also noted that anxiety can act as a further roadblock to accessing healthcare: ‘Anxiety in young women, I see it so much … getting them to go to that place and ask for help can be really terrifying’.

Women’s Refuge staff reported that health issues are often overlooked in families affected by domestic violence:

One of the things about domestic violence is that everything else goes on hold and you’re just in coping mode. A lot of the families that I’ve talked to, when they finally get free of violence or are contemplating leaving, there’s a whole lot of health issues that need to be addressed.

Principles of trauma-informed care identified in the data include:

  • ‘holding’:13 creating a safe space through having empathic and skilled staff

  • understanding the health consequences of trauma

  • recognising the impact of trauma on consultations

  • tailoring consultation length to client needs

  • providing trauma therapy as well as physical healthcare

  • providing trauma-sensitive gynaecological care, including empathetic, clear explanations; allowing extra time; ensuring client consent and safety throughout the procedure

  • recognising the importance of self-care for health practitioners.

Impact of trauma on a general practice consultation

Community organisation staff observed that trauma has a significant impact on patients’ experiences of consultations. They noted that GPs can assist by taking extra time, practising shared decision-making and working through health issues over a number of consultations:

A trauma background can really limit how much information people take in. Here [BMWHRC] there’ll be checking in, it’ll be made sure that women understand what information is being given, what their options are, it’s suggested they can go away and think about it, not having to make the decision now. That’s really important because a lot of the women I’ve referred have had some amount of trauma and are kind of terrified about seeing a health professional, and it just stops you being able to understand what’s going on.
– Staff member, Women’s Refuge

Allowing extra time was also valued by patients. Kaylee (age 26 years) started attending YWC when she was 20 years of age. She had just given birth to her first child at a local hospital and was referred by midwives to YWC for postnatal depression. Kaylee felt unable to raise all her health concerns during the short appointments offered at the local medical centre:

When I’d been going to the Medical Centre it was very sort of rushed, in and out, but here they gave me the time, I could actually talk about what was going on, whether it was physical or mental or otherwise … At other medical centres, if I was rushed there were things that I wouldn’t mention, which had happened a lot of times ... I don’t know what I would have done, if I had gone to another doctor who didn’t take the time, things might have been very – very different.

Delayed access to healthcare for postnatal depression has serious health consequences for a young mother and a lifelong impact on her child.14

Advocacy

YWC staff saw advocacy as another crucial aspect of trauma-informed care. GPs often wrote letters or made phone calls on behalf of clients, pressing for affordable housing, affordable care with medical specialists, as well as advocacy with Centrelink, employment agencies, schools, university and TAFE.

Building trust, long-term care

The importance of building trust and long-term relationships with health practitioners was highlighted in the YWC evaluation. YWC staff used the therapy term ‘holding’ to articulate the creation of a safe space in which people can seek help for the difficulties in their lives, in their own time.13 The YWC art therapist explained:

Part of the aim is that you create that holistic net, and it holds them, emotionally, physically and in all kinds of other ways ... A lot of the young women came with various kinds of difficulties and some quite traumatic backgrounds … Some young women, through the process of art-making and getting connected with you, as the barriers break down, might tell you something and then you could gently suggest seeing a counsellor or seeing a doctor. They might come for nine months or however long before they felt able to go out of the room and see another practitioner.

A YWC GP noted that adolescents may still be living in home situations of adversity, or may not be developmentally ready to address certain health issues:

As a doctor you want to be able to fix someone or solve their problems and then move on, but a lot of the time with Young Women’s Clinic it is about keeping them safe, reduction of harm, minimising other outside impacts on their lives until they get to a stage where they are able to move on. So that holding is a very important part of it …

This GP also observed the value of long-term relationships with clients.

Some of our clients were very vulnerable when they were younger, and moved away geographically, then came back years later. They feel this is a safe place and when they’re older, they are more able to tackle some of those issues. One of our first YWC clients, now in her early 30s, had a very complex trauma background. She recently moved back to the area and came to see me, she was very depressed and suicidal. I referred her to a lot of support services and she is now in a really positive space.

Patients recalled that safe relationships with health practitioners enabled them to access care. Kylie (age 36 years) began attending Artspace in her early 20s, as a single mother of two young children and recovering from an abusive relationship:

I was quite anxious and stressed at the beginning. He isolated me, wouldn’t let me have friends … My confidence had been bashed down … I was introduced to the YWC nurse at Parenting Young, so I started seeing her at YWC. That helped me become familiar and comfortable, then I started seeing the counsellor and GP about all the stuff I was going through.

Staff from a service looking after mental health issues in children and youth observed that trauma frequently underlies behavioural difficulties, and that respectful listening makes a significant difference:

I had one client who came to see the GP about mental health, and her sexual and reproductive health needs. She really didn’t trust services, but she kept coming here ... I remember how aggressive she was with everybody else. She could throw things, yell and shout, get really quite verbally and physically aggressive with family members, health professionals and the police, yet when she came here she left that at the door … I think it was the deep listening that she experienced here: no matter what she said, there was someone listening, not judging, not taking sides, just listening.

Alanah (age 27 years) saw long-term relationships with BMWHRC staff as integral to her recovery from mental illness related to childhood abuse and intimate partner violence:

I was really dark and depressed. I didn’t trust anyone. And, now I’m able to get out there and actually even help people who have gone through what I’ve gone through. The core of it was having the support network, because I didn’t have it in my family … I knew I could always turn to BMWHRC, that they’re going to empathise and provide that help and stability that I need to find within myself. They help me to do that, to be able to get through every day.

Trauma-sensitive gynaecological care

YWC staff observed that distress triggered by past sexual trauma can be a major barrier to women accessing cervical screening, which increases their risk of cervical cancer. The YWC receptionist recalled:

In my experience as a receptionist, many times women would call up and they would be very overdue for their Pap smears, sometimes 10, even 15 years … Women with a sexual assault history couldn’t bear the thought of somebody touching them. I remember one woman where the nurse met with her for six months, just talking about Pap smears … She had a very strong child sexual assault history and I don’t think she’d ever had a Pap smear, and she did finally get there.

Patients remembered cervical screening appointments and the experience was improved by practitioner empathy and ensuring that the patient felt in control of the process:

The YWC nurse was really respectful. A Pap smear is something that’s uncomfortable and you don’t want to be doing it, she’d talk you through it and make you feel like you have control for it to stop at any time, it was on your terms, not on the practitioner’s terms.
– Skye, age 33 years

Alanah (age 27 years) was able to access the gynaecological care she needed at YWC after experiencing repeated sexual assault within intimate partner violence:

I had a hard time with my first Pap smear, I was in pain for hours after. I told the YWC counsellor how terrified I was. She said, ‘They’ve got the Young Women’s Clinic here. They’re very, very gentle’. I found out how understanding they were, how they basically keep you informed the whole time of what’s going on ... They make you feel very comfortable in an awkward situation.

Vicarious trauma and self-care

For YWC staff, hearing stories of violence, child abuse and sexual assault was at times distressing, and frequent trauma exposure at work was a source of vicarious trauma for some. BMWHRC recognises the impact of trauma work and provides regular supervision sessions where YWC staff can debrief with a trauma specialist counsellor themselves if needed.

Discussion

The World Health Organization regards violence and trauma as a public health issue.15 Trauma exposure triggers a flight/fight/freeze response and is often associated with persisting over-activation of the amygdala and sympathetic nervous system, creating long-term symptoms of anxiety and hypervigilance.16 While trauma can cause post-traumatic stress disorder, it may also trigger depression and anxiety, self-harm and suicide. Trauma frequently underlies substance issues. Trauma may contribute to relationship problems, difficulties with parenting, interrupted vocational training, and employment difficulties with related financial disadvantage. Trauma is also directly associated with physical health problems such as heart disease.2,16–18

The impact on health is particularly notable when trauma and adversity exposure occurred early in life. The Adverse Childhood Events (ACE) research explored consequences of childhood physical, psychological or sexual abuse; violence against the mother; and growing up with household members who have substance abuse issues, mental illness, or who have been incarcerated.19 The ACE study found a graded relationship between numbers of adverse childhood events and ill-health in later life: those with four or more ACEs had much higher incidence of depression, substance problems, severe obesity, as well as ischaemic heart disease, cancer, and chronic lung and liver disease.19

Aboriginal people and Torres Strait Islander peoples in Australia have significantly higher rates of exposure to trauma,20 caused by the impact of colonisation and related intergenerational trauma.21 Women with refugee backgrounds are highly likely to have experienced trauma.22 Women with disabilities are at much higher risk of sexual assault.20

Adults Surviving Child Abuse (ASCA) reports that in Australia:

Complex trauma and its effects are often unrecognised, misdiagnosed and unaddressed … Care is fragmented with poor referral and follow up pathways. A ‘merry-go-round’ of unintegrated care risks re-traumatisation and compounding of unrecognised trauma. Escalation and entrenchment of symptoms is psychologically, financially and systemically costly.10

The young women in this study had experienced many forms of trauma and adversity. The health impact of trauma, both now and in later life, can be significantly lessened if the young person is able to access appropriate care when they need it.10

Holding

The therapeutic concept of ‘holding’ is described by Kahn:

Caregivers create holding environments through three kinds of behaviour: containment, empathic acknowledgement, and enabling perspective.13

Practitioners and community organisation staff in this study noted the importance of ‘holding’ for social inclusion of young people experiencing adversity, enabling a sense of safety so that anxiety is less of a barrier to accessing care, and dealing with issues in an age-appropriate manner. YWC staff considered trauma-sensitive care for a younger adolescent to be more about harm reduction, managing symptoms and increasing safety, whereas a young adult is more likely to be ready to address underlying psychosocial impacts through talking therapies. ASCA guidelines affirm that trauma can be resolved:

Just as damaging experiences change the brain in ways that are negative for subsequent functioning, new, positive experiences also change the brain in ways that are conducive to health.10

The guidelines emphasise the central role of safe, trusting relationships with health practitioners for trauma recovery.

Enough time

In large UK qualitative studies of GP consultations, patients often do not raise all of their health concerns, leading to poor outcomes.23 Other research indicates that when length of consultation was tailored to patient needs, GPs were more likely to offer preventive care, and to recognise and address long-term health concerns and psychosocial difficulties.24 Helpful strategies in the Australian general practice context may include working through health issues over a number of consultations, as well as booking longer appointments for young people, for cervical screening, and for patients known to have a history of trauma or mental health difficulties.

Trauma-sensitive gynaecological care

Research indicates that women with a history of sexual assault or childhood sexual abuse often experience high levels of distress during gynaecological procedures, and may avoid cervical screening altogether. When practitioners allow extra time, convey empathy and offer clear explanations of the procedure, distress levels are significantly reduced.25 Pavan Amara and colleagues set up clinics in the UK specifically for women with a history of sexual trauma.26 They recommend offering ongoing consultations in which cervical screening can be discussed, with the procedure only being performed once the woman indicates her readiness. During procedure appointments, they offer clients opportunities to withdraw consent at any point: ‘If you want me to stop, you only have to say stop’. These measures help to clearly distinguish the experience from the violence of sexual assault (personal communication, Pavan Amara). One in five Australian women has experienced sexual violence since the age of 15 years, and 12% have experienced childhood sexual abuse.20,27 GPs can offer trauma-informed gynaecological care by being alert to the possibility of trauma, relating empathically, allowing extra time, offering clear information, and ensuring patient consent and control throughout the procedure.

Trauma-informed GP as patient advocate

ASCA identifies key principles of trauma-informed care as safety, trustworthiness, choice, collaboration and empowerment.10 The themes identified in this evaluation are congruent with ASCA’s principles. By being trauma informed, GPs can be advocates for patients' trauma recovery. This includes providing emotional and physical safety, by addressing both the physical and mental health impact of trauma, creating long-term trusting relationships, practising shared decision-making with patients, facilitating informed choices, ensuring consent and patient control within gynaecological consultations, and adopting a strengths-based approach in which the impact of the trauma is addressed while personal resources and the potential for recovery are emphasised.

Self-care for health practitioners

Vicarious trauma can be associated with a multiplicity of negative responses. These include feelings of hopelessness, helplessness or never being able to do enough, hypervigilance, chronic exhaustion and physical ailments, reduced ability to empathise, anxiety, cynicism, and overuse of substances. Health practitioners can reduce this risk by regularly debriefing with a counsellor, ensuring they get adequate exercise, making time for loved ones and for recreational activities, and taking breaks from work.28

Conclusion

Trauma and adversity are a substantial cause of ill health in Australia. GPs can play an important role in caring for the health impact of trauma by recognising the role of trauma in different patient presentations, offering long-term safe relationships, allowing enough time, arranging follow-up, caring for both physical and mental health impacts, advocating for patients and practising trauma-informed gynaecology.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: Dr Brooks received grants from The Royal Australian College of General Practitioners, the University of Sydney and Blue Mountains Women’s Health and Resource Centre.
Acknowledgements
The authors of this article would like to thank BMWHRC staff for their involvement in the YWC evaluation: Dr Sam Critchley, Erica Want, Sarala Porter, Lyn Pagan, Sue Wildman, Maggie Kuypers, Maggie McNulty, Amy-Beth Hill, Clare Delany, Suzie Van Opdorp, Gina Harriwell and Shelley Oliver. We would also like to thank Dr Julie Mooney-Somers, Centre for Values Ethics and Law in Medicine at Sydney University, for her encouragement of this project. The researchers gratefully acknowledge the RACGP Foundation for their support of this project.
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