Announcer

Welcome to the Academy Exchange, HIV Today and tomorrow. In this podcast, we discuss the latest advances in HIV prevention care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

But we can see the count down here. Hi, and welcome again to the Academy Exchange: HIV Today & Tomorrow. Thanks for joining us for another episode presented by my organization, the American Academy of HIV Medicine. My name is Bruce Packett and I am the Executive Director of the Academy. Our topic for today's episode is Trauma Informed Care and to our more general or casual listeners, this may be a somewhat unfamiliar concept, and it's kind of a tortured syntax too.

So we have a guest today who I hope can walk us through this concept of trauma informed care in the clinic, why health care providers need to be aware of it, especially those providers who interface with HIV infection or HIV risk in their practices and why it's helpful for clients and patients themselves to be aware of it as a concept also in their own self care and in their own lives.

Today I have Dr. Heather Quaile on the show. Dr. Quaile uses she/her pronouns and as a clinical and academic leader and entrepreneur. She's a double board certified women's health nurse practitioner and advanced forensic nurse specializing in human trafficking and female sexual health. She created and implemented a medical program, the first of its kind, an emergency stabilization for commercial sexual exploitation of youth in Georgia. Dr. Quaile was also trained and certified as a AASECT sex counselor and sexual assault nurse examiner providing sexual health education, trauma informed care, which is, of course, what we're talking about today, and information to patients of all ages. Dr. Quaile has been working in all aspects of women's health care for over 21 years, caring for women of all ages across the health illness continuum.

Welcome to the podcast, Dr. Quaile. Real glad to have your wise voice on this topic here today.

Dr. Quaile

Thank you so much for having me. Honored to be a part of it.

Bruce

Excellent. So maybe the best way to start with trauma informed care is kind of a word by word approach. Though it may seem really obvious or intuitive, can you start by talking about how trauma is generally defined as trauma itself, and especially how it's generally defined in the clinic? Because if you look at the etymology of the word trauma, at least from its roots and from its most basic understanding, you're talking about a physical wound, right? Or literal tissue damage to a human body. But its broader contemporary understanding, which probably started in late 19th century psychiatry goes well beyond the physical. Can you start by walking us through what trauma means in the clinic in its fullest sense?

Dr. Quaile

Absoutely. And so I think it's important to really kind of define it. So basically what trauma is, it refers to experiences and encounters that result in either a physical and/or a psychological stress response. And the way that this occurs is in multiple different situations or events that a person perceives that can either be physically or emotionally damaging or threatening.

 And so when I talk about these situations or events, one of the big things I'm going to point out to you is something called ACEs. We've probably heard about these as health care providers, but what they are are they are these adverse childhood experiences. And I'm not going to get into a whole lot of the weeds about it, but it's one of my hot boxes that ACEs are a list of questions.

It's about a ten questionnaire that asks questions such as, Were you ever, physically in your childhood. were you ever physically hurt by a family member? Was there divorce in the family? Were there drugs in the family? Did you go without food, shelter or clothing? And it's about ten different responses and you get a score of 0 to 10.  Four and higher shows that there is an ACE score that could be very prevalent, that could impact trauma.

So I think that's one of the things that's really important to think about is what events could have caused that. Then, besides these scores, looking at, has there ever been any kind of medical maltreatment, invasive procedures, personal experiences, any kind of exposure to people who use substances, any physical, sexual, emotional abuse, violence, poverty, racism, discrimination, oppression, loss, loss of a loved one, community violence, war, terrorism.

These are all situations and events that can lead to trauma. Also, for this podcast in particular, I really want you to think about people that are marginalized, people that have a diagnosis of HIV or a diagnosis where they have now kind of put themselves in this marginalized community, that also can potentially be a situation or event that leads to trauma.

And so when we think about this, I think it's really important to say, especially in the clinic setting, one of the things I tell a lot of my students and people that just ask me, I think the best way that you can approach it in the clinic is that you need to treat every single person that comes into your clinic as having some sort of trauma in their life.

So even in the Volvo soccer mom that walks in, that seems to have the picture perfect life, you don't know that there could be trauma in her life. And I'm sure there is because every one of us has experienced some sort of trauma. And then the other thing I also want to point out, kind of what it looks like in the clinic, I do a lot of female sexual health, so a lot of my patients come to me in pain.

 And I think it's really important to point out that pain is trauma. If you live in a state of chronic pain, whether it's a debilitating pain or other things like that also is an experience of trauma. And we really need to be recognizing that more in our practices.

Bruce

Yeah, absolutely. That's a really comprehensive start. So thank you for that. Now that we have sort of that complete definition of trauma, we know that we need a clinical framework or a series of reference points to really address trauma where it's seen. So for example, maybe if you can talk about what the Substance Abuse and Mental Health Services Administration calls the three E's.

Dr. Qualie

Absolutely. So yeah, SAMHSA, or the Substance Abuse and Mental Health Services, I'm sure you all have seen it. They have a bunch of different concepts. It's a wonderful website to go to, especially to get more informed around trauma. But in terms of the three E's, those stand for event, experience, and an effect. So when a person is exposed to a traumatic or stressful event (you're first E), how they experience it (your second E) will greatly influence those long lasting adverse effects (the third E)  of carrying that trauma. 

So many of these effects, they can include changes in their neurobiological makeup, and then that can lead to issues of difficulty coping, feelings of trust, managing their cognitive processes and really like regulating their behavior. From us in the medical standpoint, I think it's important to realize that we may experience somebody who comes into our clinic. We've never seen them before, but if they have been under care of other providers, there could even be medical treatment trauma. 

And those are things to really think about as we kind of manage these things and what their experiences are. I think it's also important about many aspects of how trauma survivors choose to engage in health care, again, is really, really influenced by those experiences.

And so when we think about patients that have experienced trauma or our HIV patients in particular, our LGBTQ population in particular really stands out to me. They may really neglect their health. They may harm themselves, they may avoid health care, they may very much not trust health care providers. And so I want you to kind of think about, as you think of these three E’s, they may also not adhere to recommended therapies of care.

So it's really important for providers to be thinking to promote care that's healing towards the recovery of these patients with those particular sets of like just that knowledge and attitude that kind of encompasses knowing the events, experience and events. And then again, you've heard me say just the experience of trauma is going to affect how people are affected by it.

They're going to have short and long term impacts of trauma and they may not be evident immediately to us. But again, if you approach every situation in your clinic that it comes from a place of potential trauma, you will be really well informed as a provider.

Bruce

Right. And as you pointed out, there are many material, social, psychological and so on, elements of trauma. But we also know, and you touched on this, there are neurobiological aspects to trauma. So again, a very real material impact on the brain as an organ and how it functions is what we're talking about here. So I'm hoping for a general listenership, assuming no background in molecular biology or neurobiology. Could you talk for just a minute about what actually happens in the brain where there is a trauma in that subject?

Dr. Quaile

Yes, absolutely. So this is a very complex topic. I mean, when you're talking about neurobiology of trauma, we could write, there's websites on it, there's millions of papers on it, it’s so deep. But to kind of explain it very, very, very top line, as simple as I can, early experiences that people have, especially traumatic ones that are going to shape your human development.

And so again, I'm going to point back to those ACE scores and how ACEs, those adverse childhood experiences, really affect and shape our human development. So as we develop the ways to cope, survive and defend ourselves against these deep and enduring wounds really kind of impacts how we present ourselves in the world. All the experiences change our brain chemistry.

Yet not all these experiences have equal impact on the brain as we know. So you have your central nervous system. It's composed of the brain and spinal cord and the most important part of the brain is to ensure our survival even under the most awful of circumstances. 

And I'm sure you all have heard, like a person has been in a physically violent relationship, emotionally. And if you think about all that they've had to do to protect themselves in that situation, until they could get out or run or anything, that is really our brain in a lot of ways working on our survival. 

We hear a lot around the self, the subconscious, and sometimes where people will go to a different place so that they almost don't remember the experiences. So that, it's a coping mechanism. It's a big coping mechanism of our brain. 

So what the brain needs to do is it needs to generate these internal signals that registers what our body needs, such as food, rest, protection, sex, shelter. All these different things. And so we have these internal signals. And it also needs to create a map of the world to kind of point us in ways to go and satisfy those needs.

But it's also there to warn individuals of dangers and opportunities and different things along the way, as well as adjusting actions based on the moment. So when we think that these short term trauma effects on the brain, when someone experiences trauma, they have this natural stress response, which I'm sure a lot of you heard is called fight or flight response.

And when you have this type of response, your body's going to release this surge of hormones. It's really going to release a big surge of cortisol and all these different things to get your body kind of moving in that direction. And they're going to affect your brain right away. 

The brain activity and your blood flow is going to increase. Your heart rate runs, and it's really kind of helping you cope. 

So to kind of explain this, the effects of the brain and the brain during flight or flight is during that flight or flight response to trauma, it's going to kind of have this adrenaline and cortisol and all these different hormones to help your body function during this event.

And it can be helpful in the short term. But if it's activated frequently for extended period of time, it can also have really negative effects on the brain in the body. And so chronic activation of these stress responses can lead to a lot of physical and mental health problems. And those kind of problems that we often can see increased heart rate, blood pressure, heightened senses, suppression of nonessential functions, such as digestion, our immune system. We release a lot of energy source stores when we're in that fight/flight, so stored glucose and fats to provide energy to those muscles. And so one of the things I also just want to talk about real briefly is when you look at that trauma and threat activation and false alarms, when it activates that response, again, it helps you cope.

But it's also really important that we also learn how to tune those responses down and how to balance it out because it can do some detriments to our body.

Bruce

Yeah, really interesting. And now that we have that really comprehensive background on the concept of trauma and its many facets, I'm hoping you can just for a minute touch on the history of sort of seeing and understanding trauma in the clinic. So historically, where did this sort of start in the health care space? I assume that maybe had something to do with soldiers on the battlefield being reintegrated and so forth.

Dr. Quaile

I think I should have said from the get go, it's fair to say we just have shortened the definition of trauma. But the real the true definition that you all probably know is PTSD or that post-traumatic stress disorder. Again, we've shortened it to trauma, but it's a really prevalent condition in the United States, and it was really commonly associated, as you said, with traumatic experiences that happen in combat.

It's probably some of the first times we really had heard about it is in combat. I think where we even heard it the most was just the Vietnam War vets coming back and how they were dealing through those things. And so it has that big military sense of it. But I also want to point out that it also can result from seeing or experiencing traumatic events.

So, again, kind of going back to that combat, we were seeing a lot of the combat war victims that were coming back that maybe didn't have something physically wounding to them, but seeing their teammates die in the field and seeing these horrible things, that's a traumatic event.

It's also really important and important to point out too that when you're seeing or experiencing these events such as sexual assault, violent crimes. When I think about sexual assault, again, it goes back to those ACE scores. If you're in a family relationship and you are seeing a parent be abusive to the other parent and a child is watching that, that can kind of form that.

Historically, we really hear about it from a point of combat, but we've gotten much better about talking about it. And everyone has some sort of trauma.

Bruce

Yeah, that makes sense. And just drawing from that bit of history, I think this is an interesting question. What can you say about disease diagnosis, like HIV, for instance, a serious disease diagnosis, and whether just the diagnosis itself can rise to the level of trauma, the way you've defined it today? Can we properly say that, for example, a client is tested for HIV and returns a positive result? Is that an example of a traumatic experience, potentially? And how can health care workers who are getting those results mitigate the trauma if it is?

Dr. Quaile

Absolutely. I think I think it holds twofold. An HIV diagnosis is absolutely traumatic, But I think we also need to go back to the concept of HIV and where that disease state came from. There is so much stigma around HIV. And most people that are living with HIV are often very much in a marginalized standpoint.

I think we've gotten better in the fact that we don't call it this gay related disease anymore, thank God, but that we see women that get it. We see people that are in heterosexual relationships that get it, IV drug users, all those different things. But when I think about the term HIV, it holds so much negative connotations.

And of course, that is absolutely going to be an experience of a traumatic event. So I think it's really important for health care providers to understand that if you're going to give someone a positive result around HIV, you need to understand what those implications mean for them. You have this disease state that now really is being looked at more of a chronic condition like diabetes and hypertension, which is awesome, because HIV really is this chronic treatable condition. And I'm hoping that takes some of that stigma away from it being what it was many, many years ago. And in that respect. 

But I also think you have to think about what does that implications mean for the person that you're giving the diagnosis to? How is this going to affect them as a person, as their relationship, as their social determinants? All those different things I think are really important to think about.

Bruce

Yeah, obviously it's really incredibly important to understand those opportunities for traumatic experiences and patients. So I'd like to pivot now to maybe some practical guidance for either health care workers or providers, but maybe also for patients seeking care too. So I think now is the appropriate time to just briefly start out this conversation. How would you define trauma informed care then sometimes rendered by the acronym TIC?

Dr. Quaile

Yeah. So I'm going to kind of just I've written it in a lot of my journal articles and we can give you access to those. But basically what trauma informed care is, is it's a strength based service delivery approach. And what that means is it's an approach to care that acknowledges the need to understand what a patient is experienced in their life, what is going on with them.

And we need to understand this as providers in order to deliver this effective care. What trauma informed care does is it has the potential to improve patient engagement, treatment adherence, health outcomes and provider, as well as staff wellness. When you integrate these comprehensive approaches, not only does it help the patients and the staff, but it provides a safe environment for everybody, for individuals as well as identifying individuals who are survivors of trauma.

So again, if you have this strength based, trauma informed care approach already established in your clinics and in your settings, not only is it going, and you come to it as everyone experiences trauma, you may not have a patient from day one when you first encounter them that's going to tell you they have trauma. But if they know that they're in a safe environment where they can talk about this, it's going to lead to being able to identify them.

And then when you identify them as survivors of trauma, how are you going to implement your practice in order to avoid retraumatization? And we'll talk about that a little bit. And so what it does is it allows you to assess their needs. It provides you with resources, referral that's going to really help facilitate recovery. And then that's also going to help you monitor the processes and the outcomes for ongoing quality care.

It's really, really crucial to have it integrated in all aspects from the moment that a patient comes in your front door all the way to discharge. And even with answering phones conversations when they come into your clinic environment, just knowing that it's a place where they can feel comfortable talking about anything and not feeling judged is really, really important. And that's really what trauma informed care encompasses.

Bruce

Yeah, for sure. And we spoke about SAMHSA’s three E's earlier to help understand the context of a person living with the trauma on their health care provider side for delivering trauma informed care. And you really kind of touched on this already. SAMHSA has put forward what they like to call the four R’s. I'm hoping you can sort of explicitly elaborate on that guidance for our listeners.

Bruce

So your 4 R’s are going to be realize, recognize, respond and resist. And so what realize means is that that first assumption is realizing, like I've been saying all along, that widespread impact of trauma and the potential ways to recovery. So if you can come into your aspect of health care with every person you encounter as realizing that everyone comes from some sort of trauma, that's the first step.

The next R is to recognize. And that is more around recognizing the signs and symptoms. And those are kind of some of the things that we talked about, maybe withdrawing and not adhering to protocols that we may give to the patient. Are they making eye contact with you, those different kinds of things in terms of recognizing that there could be trauma? Are they tearful? Are they withdrawn or are they over, are they over vigilant? Are they are they displaying like really manic and strange behaviors? Those are some of the important things to realize around signs and symptoms. 

In terms of responding. That's that third assumption is that we respond in a way in which is keeping kind of with this whole knowledge of trauma that we've been talking about.  It's really important for everyone to realize there's really just not this one size approach. Everyone is different.

So given these differences, everyone's going to experience stress and trauma differently. So even though you may have two sexual assault survivors, for example, one may have gone to therapy and has already worked through the whole experience and has basically been able to move on and to move on with life. You may have another one that went through therapy and is just not even able to get up in the morning to make herself get out of the house. So again, just realizing the different experiences that people have.  

The final R is resist. And that is about resisting to cause retraumatization. And basically it's an approach which seeks to look at that knowledge of the impact of adversity and trauma and using a preventative and a systematic approach in terms of how to support your patients, how to support others to have that positive effect on them to avoid retraumatization.

So for example, for health care providers, if you happen to know that there is a patient that has experienced trauma and they've disclosed it to you, what are things that are triggers for them? If you see the patient become withdrawn or disassociate or things like that, it's time to maybe kind of sit quietly with that patient, acknowledge that, acknowledge that they can have whatever time they need to kind of regroup themselves so that you can avoid that re traumatization.

Bruce

Really, really important stuff. And I'm just curious what other tools or resources you'd like to talk about for, you know, either health care workers interested in learning about and hopefully implementing trauma informed care or for clients or patients wanting to learn more about it.

Dr. Quaile

Yes. So a couple of colleagues and I worked with the National Clinic Training Center for Family Planning, and we created a clinician's guide for Trauma Informed Care and the guide is awesome because basically it's something, we talk about it actually in our article that we put in the magazine, but I think there even is a diagram on it.

But what it is, is it's a pocket guide and I tend to find that it's one of the best things to either laminate or have in your arsenal. It's like a little six page document. You can either laminate it, put it in there, or you can just download it on your computer. But what it does is it’s a clinical service guide for performing physical exams in like the sexual and reproductive health settings.

Because let's be honest, any time you're in those settings and you have to do any kind of exam that definitely can cause situations around retraumatizing or figuring out there could be trauma. So it kind of goes over what is trauma, how to address it in the clinical setting. The key principles around SAMHSA, the safety, the trustworthiness, peer support, all those things, it has the 4 R’s in there, things that you can do to avoid re traumatization.

And then it talks about this trauma informed care roadmap, like things that you need to be before doing and after these exams, and some questions that you may want to ask. And it also talks about different kinds of sample phrases you can use.  We spent months and months working on this. So I'm quite passionate about this tool kit.

And again, it's in that article, my colleague and I on Dr. White talk a lot about it, but I think it's just a really great resource. And then again, if you go to the Substance Abuse and Mental Health Services Administration website, they have a lot of wonderful resources around trauma informed care.

Bruce

Yeah, that's great. And we can actually put a link to that issue of the HIV Specialist magazine you reference in the show notes with the tool so that listeners have access to it. And then finally, you know, you talked about your hope for patient and health outcomes who receive that sort of comprehensive trauma informed care from their health care provider or clinic.

And since we know about these poor health outcomes related to experienced trauma, I hoping, maybe you can talk about an example where, you know, you sort of delivered these interventions and it really changed specific health outcomes or metrics for that client or patient that you served.

Dr. Quaile

Absolutely. So I think I think when you come in to something, one of the things you hear me talk about again is these ACE scores and trauma. And so what we have found is that patients that experienced trauma have a much higher risk of diabetes and hypertension and risk of suicide and other things of that nature. And I think in my clinic, I come to everything with such a trauma informed approach, I kind of come at it that everyone is a survivor. And I think that in my practice, what I have seen to be something that's been really impactful for me is, yes, I've seen some people, of course, get healthier. Their hemoglobin A1Cs go down, their blood pressure goes down. But I think part of that comes from us as providers, knowing that it is a safe space for your patients.

So my patients know once they get to know me after those first couple encounters, that they can always come and talk to me about anything. I tell them from the minute they meet me, I will probably never do an annual exam or a pap smear or a pelvic exam on you the first time you meet me, because I don't think that that is a fair thing to put you in when you're coming to meet me first.

So I want us on that same playing ground. So I think that's really impacted care for my patients. The other thing I make sure of, and we didn't talk about it in here, but I want to say I, for the clinicians that see patients to do these annual exams and have to have your patients undress. One of the most important things that you can do for your patients and I know it's hard in insurance based models, but is to try and have a communication with your patient beforehand.

I always will talk to my patient clothed on the same playing field as me. I also try to sit at that same level like I don't want there to ever feel like there's a hierarchy of how I sit maybe above a patient or below. So I put us on that same chair playing field and I always talk to them clothed, and then when they get unclothed to do the exam, I talk them through the whole exam.

They have a mirror, they can watch everything I'm doing. And then the other thing that I'm really good is before I will even tell them anything more or go back into detail around patient education, I let them get dressed. No one wants to sit there on a table half naked in a paper gown that's sweating and falling apart and ripping and talking to their provider about important things to impact their health while they're sitting there naked.

So those are those big examples that I think are so important to remember as health care providers and how that is really impacted my practice for a positive.

Bruce

Yeah, just building that trust and rapport with your patients. That's really great advice. Dr. Quaile, this has been really incredibly interesting and informative and we certainly appreciate your time today walking us through how important it is to identify trauma opportunities for trauma and to approach those clients in a really empathetic and supportive way that is beneficial to their health.

And I'll say here that it's certainly another key piece of the tapestry that will allow us to do things like, you know, functionally eliminate new transmissions of HIV in the US. So I really appreciate you being here to deliver those important messages for us. Thank you again.

Dr. Quaile

Absolutely. Thank you so much for having me.