The first principles of trauma-informed care that facilitate pattern recognition and treatment priorities in general practice are outlined below. The principles are designed to facilitate GP skills and are built on the foundational first principles of trauma-informed care developed by the Blue Knot Foundation, which include safety, trustworthiness, choice, collaboration and empowerment:
- Prioritise safety
- Foster capacity to soothe physiological arousal
- Validate person and perceptions
- Collaborate and empower
- Connect and stay involved
Safety is the overarching priority in both assessment and care-planning for those who are wounded physically, psychologically and/or relationally. This includes optimising safety in their environment (place), relationships (people), intrapersonal experiences (personhood), body (physiology) and meaning (perspective). Experienced trauma GPs would warn that safety takes precedence over detailed history-taking, and would caution against clinical processes that cause distress through retelling or reliving of traumatic experiences,21 especially for those with limited access to self-soothing or relational support.
The initial phase of any trauma-informed care involves stabilisation – facilitating safety in finances, housing and relationships, intrapersonal connection, affect regulation and even existential support.
As safety is the overarching principle of trauma-informed care and medical care, many GPs are wary of patients’ disclosing of trauma, concerned it may trigger re-experiencing and overwhelm. In every situation (even the ‘past history’ section of an assessment), the most important consideration is safety. This includes supporting stabilisation or grounding of physiological arousal in each clinical encounter and careful boundary-setting that facilitates choice and empowerment at each step of clinical conversation.
Given the prevalence of trauma in our community and its often long-term impact on health, it is important to consider trauma and to explore a person’s safety if they present with vague symptoms, multimorbidity, frequent accidents, chronic pain, hypervigilance, shut-down, hopelessness or relational distress.
It is also important for safety to identify current risks (eg are they currently in a traumatising home or peer relationship at school) or longer-term risks to their physical and mental health (including suicide risk) if they have experienced adverse childhood experiences or intimate partner abuse.
Potential questions include:
- ‘Is there anyone in your world who invades you, disconnects from you or confuses you?’5
- ‘How do you help yourself feel safe?’5
- ‘Often people who have these types of health problems are experiencing difficulties at home. Is that happening to you?’22
- ‘Sometimes these symptoms can be associated with having been hurt in the past. Did that ever happen to you?’22
Foster capacity to soothe physiological arousal
Because a key impact of trauma is dysregulation of biological stress modulation, all approaches to traumatised people should maintain awareness of physiological arousal. Helping patients learn how to self-regulate arousal, balancing input from both the rational mind and the sensory or emotional body (also called the ‘therapeutic window’,23 or ‘window of tolerance’), helps the GP and patient connect with others and self.
Physiological experiences of being overwhelmed can dysregulate a person’s capacity to self-soothe, at both a neurological and relational level. Therefore, all clinical care needs to offer an attuned responsive presence and skills-training to foster capacity to self-soothe.
Physiological regulation and affect regulation can be facilitated using both ‘bottom-up’ and ‘top-down’ approaches to soothing.
- Bottom-up approaches start with the body, and aim to soothe physiological signs of distress using techniques such as sensorimotor grounding, rhythm and movement.
- Top-down approaches work from ‘brain to body’, through techniques such as cortical use of story, dialogue, ritual and metaphor.
Therapeutic relationships are part of physiological soothing – they offer an alternative for those who may have lived their developmental years in chronic arousal, with no reliable buffering relationships that could calm them, or that could support them to calm themselves.
Bottom-up tools to soothe physiological arousal
GPs can attend to signs of physiological arousal, such as cardiac and respiratory rate, prosody (tone of voice), bodily movements and muscle tension. These signs offer natural biofeedback that can guide management of the window of tolerance.23 These physiological signs can help the GP and patient to fine-tune bodily approaches to soothing, known as grounding. Grounding uses attention to the senses of sight, sound, touch, taste, smell, interoception (perception of the body’s internal sensations) and proprioception5 to settle bodily arousal or distress.
Practical tools for grounding include mindfulness, naming sights and sounds out loud, holding an object and describing it to manage attention. Rhythmic tapping, drumming, dancing and singing can also be used to teach self-soothing – giving afferent nervous system input that is reliable and predictable and bilateral.17 The natural ways that we soothe babies through sounds, touch, rocking and patting remind us of how grounding works to soothe distress. The GP needs to be attuned to their own and their patient’s respiratory rate and subtle changes in affect, tone of voice, gaze or arousal. This tuning-in can help GPs to co-regulate patient distress. Measuring blood pressure and heart rate are practical ways GPs can appraise distress and soothe it through the ritual of medical touch.
In the consulting room, in dialogue, GPs can also use what Fisher calls ‘empathic interrupting’24 to manage storytelling intensity and content – intentionally slowing down, shifting the focus, narrowing attention or changing the topic all help the speaker manage their levels of arousal and distress. Bottom-up tools are useful for all forms of distress, including pain.
Emerging evidence of the link between physiological arousal and life story is shifting psychotherapeutic practice towards somatic or sensorimotor therapies.1 These approaches tune in to and soothe physical signs of distress from the bottom up (from the body to the brain). Therapeutic approaches that attend to physiological soothing include somatic experiencing or sensorimotor psychotherapy, eye movement desensitisation and reprocessing, brain-spotting (which uses visual fields), emotion freedom techniques (which use tapping), hypnotherapy, equine therapy and emotion-focused couple therapy.25–30 These approaches can be useful for those with linear single incident and complex trauma.
Top-down tools to soothe physiological arousal
Settling someone in distress from the ‘top-down’ (brain to body) includes the ordinary use of language and reason (so-called ‘left’ brain) and art and metaphor (so-called ‘right’ brain) to calm. When we comfort someone, we sometimes help them to organise their thinking through questions, careful listening (including noticing what is not said), tuning in to their resources or what has gone well and reflection. At other times we use distraction, or focus on a detail to move the mind away from something overwhelming.31
Top-down tools orient attention to soothe and regulate. They can widen perspective and remind of capacity – attending to positive memories, people, accomplishments, and images that are resources and strengths. Reading, writing, story-telling, dialogue and reflection are natural top-down tools that can be used every day in general practice to calm patients in distress.
Validate person and perceptions
Whole-hearted validation of the person and tuning in to their perceptions builds dignity.32 Because altered sense of self, including shame and self-loathing, is such a dominant part of the legacy of trauma, especially complex trauma, validation is a very important element of treatment. Validation does not require unquestioning belief. The priority of care is to focus on how the person’s experience (whatever they offer as their experience) has affected them, and to support them to work through the impacts of that experience.
Offering trustworthy availability for that journey is a key element of trauma-informed care.18 It is important to support the person to disclose as much or as little as they choose at any time. GPs can also provide an anchor as they clearly affirm that violence or neglect is never acceptable and reveal their concern for what the person is experiencing. They can also offer dignity, share hope and inspire the possibility of healing, based on anecdotal experience and research.
Validation can also occur as the GP repeatedly offers connection and positive regard towards parts of the person that they experience as shameful or disgusting.
When a person experiences threat to relational connection (eg in misattuned connection, disapproval, disgust, as well as violence and neglect) it causes physiological changes that are often called shame. These physical changes impact autonomic arousal that causes blushing, downward eye gaze and submissive posture. Unremitting experiences of relational disconnection or violation are neurodevelopmentally toxic.33 Without relational repair and attuned connection between parent and child, children become hypervigilant for social disconnection and lose capacity to utilise other relationships for self-soothing. They often also associate the physiological experience of shame with mistaken personal meanings that they are defective, inadequate, disgusting, ‘too much’ or ‘not enough’. Understanding shame as a result of relational disconnection helps to direct treatment towards connection, relational repair and belonging.
Therapeutic approaches that acknowledge and treat shame are central to trauma-specific therapies including self-compassion34 and internal family systems therapies.35 Trauma-specific therapies offer expertise and skills for long-term treatment of shame.
For the GP, being aware of shame-proneness as a legacy of trauma can help to manage and understand processes such as self-loathing, repeated cycles of relational breakdown and enmeshment, difficulty in bonding and attuned parenting (including breastfeeding), and cycles of perfectionism or unrelenting standards.
GPs are skilled in not shaming their patients – validating the personhood of each patient is part of the GP philosophy of care to ‘rehabilitate the patient’s sense of self’.36 Validation and connected relationship with a GP can offer a steadying relationship as the patient faces the challenge of finding a trauma-specific therapist with whom they feel safe.
Collaborate and empower
Many people who have been traumatised have had experiences of being dominated, trapped or neglected and have been abused or violated by people in a position of power. GPs need to be very mindful of maintaining interactions that offer choice, collaboration and empowering approaches.18 These approaches address a fundamental wound to personhood that can be part of the legacy of trauma. Moving from a passive sense of self to an active sense of self or agency37 contributes to recovery. This is about supporting a person to identify their strengths and enabling them to build on them. This aligns with the generalist literature that speaks of ‘enablement’ as a key goal of GP care.38
A part of empowerment is to see coping and defence mechanisms (including addictions and compulsions) as active (and often creative and determined) attempts to manage overwhelm and keep themselves safe. They make sense as ways to regulate and tolerate overwhelming physiological and relational distress. Rather than evidence of disorder, attempts to cope (no matter how successful) are evidence of bravery, determination and clever resourcefulness in that person. They can be seen as resources for recovery. They can also contribute to post-traumatic growth.39
Another aspect of empowerment includes walking with a patient through ambivalence. Any form of violation that occurs in the setting of relationship is fundamentally confusing and incoherent – ‘Why would someone who loves me or values me hurt me?’
Someone may say, for example:
‘Yes, I know my husband beats me occasionally, but in between he’s okay. He is not nasty to the children and he treats me well.’
The process of facing the reality of violation within valued connections can include denial, idealisation and defending the perpetrator; crippling self-blame, powerlessness and hopelessness; and minimising your own experience, needs or insights. Internal fragmentation and loss of trust within the self can cause even more confusion, as parts of the self cannot agree on a way forward. Part of the person wants to acknowledge the abuse and another part does not. If the perpetrator switches between different states of minds, confusion can be amplified. Fears of capacity to face life alone, longstanding endurance of violation since childhood, fears for children’s safety on custody visits after separation, and practicalities of living arrangements and finances also contribute to ambivalence about change.
Rather than judging or being demoralised by a person’s choice to stay or return to a perpetrator, GPs can seek to understand the underlying ambivalence. There may be very compelling reasons why the victim/survivor believes they cannot leave. GPs can establish trust, build self-esteem, and identify themselves as supportive agents.40 A key healing process in primary care relationships is ‘abiding’ – staying with people when others have nothing more to offer.41 Regaining confidence and emotional strength can be a gradual process, so moving out of an unsafe relationship may take years. Therefore we can say:
‘Whatever you decide to do about the situation, I will remain with you on this journey. I will keep on reminding you of your worth and offering options for help that we can explore together.’
Connect and stay involved: Healing through relationship
One of the key gifts that GPs can offer their patients is attuned, available, accessible therapeutic relationships. This involves both micro-connections in building rapport and trust, and macro-connections through planned regular appointments and practice systems that maintain relationship over time. Providing relationships with clear boundaries, tuning in to the person irrespective of their presentation and initiating connection (not just responding in crisis) all offer a healing presence.41 Relationships that offer safe, reliable and attuned connection offer an antidote to shaming, disconnecting, confusing, poorly attuned or unreliable relationships.
GPs can offer approaches to distress that acknowledge (and do not avoid) life experiences of trauma and neglect. They acknowledge the impact on physiology and health, as well as relationships and meaning. The underlying philosophy of generalism is also healing-oriented,5 pragmatic and strengths-based – seeking to ‘rehabilitate the sense of self’36 and reconnect with living life.42 Overall, GPs therefore have the capacity to offer trauma-informed care that concurrently builds safety, acknowledges and grieves pain, and seeks ongoing growth for each person. Generalist approaches to trauma can be framed as a process of building sense of safety across the whole person (from their environment to their inner-world).5
When to refer
Good-quality trauma-specific therapy is becoming more available.
Because threat is physiologically encoded, some would argue that even asymptomatic victims/survivors of trauma should be offered trauma-specific therapy. It is certainly indicated if there is physiological hyper- or hypo-arousal, chronic suicidality, self-harming, addictive processes, repeated relational breakdown, or if there is amnesia or avoidance of knowing their own pain and grief.
Any process of trauma-informed care should involve intentional connected relationships among the therapeutic team. This models reliable, attuned connection between the patient and the members of the team, which includes good-quality communication, repair of any misunderstandings, clear boundaries and roles, and resisting the process of ‘splitting of care’ around the person who is traumatised. Having good relationships with your local referral network also means that when a therapeutic relationship is not going well, you can offer planned warm referral to someone else, to prevent re-traumatising due to therapeutic rupture, or you can seek help from another member of the team to facilitate therapeutic repair.
When a patient is referred to psychological help, domestic violence social workers, counsellors or psychiatrists, their GP should remain involved in their care, just as in all other referral processes to specialists. GPs remain the generalist who continues to care for the whole person. GPs who are more skilled in psychological medicine need to carefully define their role with regard to both the patient and other team members. Sometimes GPs with a specific interest in psychological medicine may seek to offer shared care with another GP who does the more physical generalist work.