Clinic Views Patients Through Trauma-Informed Lens

Not enough pharmacists know how trauma-informed care can meaningfully transform the clinical environment and improve clinical outcomes, says Jennifer Cocohoba, clinical pharmacist at the University of California, San Francisco, Women’s HIV Program (WHP).

“It’s still a relatively new concept. And we’re struggling, I think, with how to conceptualize it and apply it” within the pharmacy profession, she said.

The Substance Abuse and Mental Health Services Administration (SAMHSA) calls trauma the result of an event or series of events a person perceives as physically or emotionally harmful and that has lasting effects on that person’s functioning and mental, physical, social, emotional, or spiritual well-being.

According to SAMHSA, trauma is a widespread, harmful, and costly public health problem, and the failure to address it significantly increases a person’s risk for mental and substance use disorders and chronic physical diseases.

Cocohoba said clinical inertia is probably the main consequence of failing to account for trauma in patients’ care plans.

“We find that many people are unable to achieve desired or optimal health outcomes because of their trauma,” she said.

WHP was founded in 1993 to address the needs of women living with HIV, and the clinic has long provided integrated physical, mental health, and social services along with antiretroviral therapy.

Despite receiving comprehensive care, many patients remained locked in a cycle of poor medication adherence and misuse of alcohol and other substances, said WHP Director Edward Matchinger.

He said he was frustrated by the inability of the clinic to help these patients.

“I didn’t really have the tools or the perspective with which to approach patients that seemed to offer a way to connect with them, a way to understand them and ... evidence-based pathways for them to heal,” he said.

Over time, the clinic staff discovered that most patient deaths weren’t caused by HIV infection but instead resulted from direct or indirect traumas — specifically, murder, depression, suicide, and addiction¹.

About a decade ago, WHP began to implement a primary care model that recognizes the effects of past and recent trauma not just on survival but also on patients’ overall health and their ability to manage their HIV infection.

“We see it as a tool with which to more effectively connect with a patient and help them achieve better health outcomes,” Matchinger said of this trauma-focused approach. “We think that it ... will create a healthcare environment that is more calm, more supportive of providers themselves, more satisfying, because providers will be able to address a lot of issues that formerly seemed out of their scope or mysterious to them.”

He said the model includes a safe, comfortable, and supportive clinic environment for patients and staff; education for patients about how traumatic experiences affect their health and how to heal from those experiences; training for staff on compassionate inquiry and response regarding patients’ recent and past trauma; and the adoption of a culture of trust, transparency, cultural humility, and peer support at the clinic².

The clinic’s website describes WHP’s transition to a trauma-informed approach to primary care and provides resources to help other clinics adopt this approach.

“The first step in any trauma-informed transition is to look where your clinic is actually traumatizing patients. Where your behavior, your policies, are actually traumatic. And then look to reverse some of that traumatizing behavior,” Matchinger said.

For example, he said, rather than scolding a patient for arriving late to an appointment, the front desk staff can empathize with the patient for having a tough day and reschedule the appointment for a better time to ensure the patient gets the care she needs.

Cocohoba routinely encounters patients with medication problems that are based on trauma. One example, she said, is a woman whose husband died of an adverse drug reaction.

“Understandably, with her trauma from that experience, it’s really difficult for her to take any pills, period,” Cocohoba said. Instead of initially putting the patient on an optimal medication regimen, Cocohoba is helping her become comfortable with tiny medication doses with the goal of later introducing the antiretroviral therapy she needs.

Cocohoba noted that pharmacies, like clinics, can be “stressful, anxiety-inducing, traumatizing places,” especially for patients who struggle with medication cost and access.

“Creating spaces where we actively try not to add to the trauma a patient’s already experiencing is something we have to think about as a profession,” she said.

Matchinger said the transition of the clinic to a trauma-informed environment has greatly benefited the staff and eliminated some of the stresses that contribute to burnout among clinicians.

“I’m just so much more hopeful,” he said.

“The culture of support and self-care amongst the clinicians ... makes the work, as challenging as it is day to day, much more deeply meaningful and rewarding,” Cocohoba added.

1. Matchinger EL, et al (2015). From treatment to healing: The promise of trauma-informed care. Women’s Health Issues 25:193-7.

2. Matchinger EL, et al (2019). From treatment to healing: Inquiry and response to recent and past trauma in adult health care. Women’s Health Issues 29:97-102.

[This news story appears in the October 1, 2019, issue of AJHP.]