White Book

Trauma and violence informed care - Chapter 7

Trauma-informed care in general practice

      1. Trauma-informed care in general practice

‘I am a DV survivor, but trauma does not define me. I am much more than that.’
Sanda, victim/survivor, The WEAVERs Group

Good quality general practice care is trauma informed. Generalist approaches to whole-person care integrate sensitive awareness of lived experience, relationships and context, with an understanding of the acute and chronic physiological impact of threat. This awareness influences how we interact in the clinical encounter, how we understand the range of human behavioural and relational defences against threat, how we direct our interventions, and how broadly we watch for patterns of threat.

Defining trauma and abuse for the GP

From the Greek word for ‘wound’, ‘trauma’ is defined in the dictionary as ‘a deeply distressing or disturbing experience’. In medicine, ‘trauma’ also implies acute bodily injury, while in psychiatry, for insurance, legal and research purposes the definition is often limited to a verifiably life-threatening event. These definitions have inadvertently prioritised attention to objective physical and life-threatening events (including violence and disaster) in a way that may ignore more subjective processes that ‘wound’.

The focus on trauma as an event means that processes that wound humans – such as neglect, betrayal, confusion, loss of identity, ostracism, rejection, and even loss of self-respect and existential meaning – may be ignored. The distinction between trauma as an observable event (eg motor vehicle accident, life-threatening wartime or family violence incident) and trauma as process or experience (a subjective personal process of overwhelm or hopelessness) has fragmented the research and practice of trauma-informed care.

Research in child development, adult attachment, psychophysiology, interpersonal neurobiology, psychoneuroimmunology and physiological stress have firmly established the impact of subjective experience of threat on bodily health.1,2 Building on the event-based diagnosis of post-traumatic stress disorder (PTSD), which was first described because of the Vietnam War, traumatic processes in the home were named by psychiatrist, Judith Herman.3 Their lifelong impact on physical and mental health was initially confirmed by population studies conducted by Vincent Felitti and Robert Anda.4

People can be traumatised by chronic negative interpersonal processes in their homes, schools or workplaces, and/or by single incidents of assault or accident. Events and experiences can be repetitive or chronic, so both can impact physiology, autonomic arousal and sense of capacity. If an event is interpersonal, it can impact a person’s capacity to self-regulate, be soothed and be comfortable with other people.

Trauma has far-reaching impacts on physiology, meaning, relationships, sense of self, affect regulation, somatic awareness, arousal, consciousness, attention, memory and behaviour, which are relevant in general practice.5 GPs who seek to care for the whole person need to remain aware of all the ways that lived experience impacts physical and mental health – both complex processes and the more easily identified events.  

Trauma as a whole-person legacy

Trauma-informed approaches facilitate a coherent, whole-person framework that understands how social determinants of health, environmental threats (including racism and other forms of injustice) and relationship dynamics are translated into health outcomes, including multimorbidity and medically unexplained symptoms.

Trauma-informed care is not simply being willing to document life events that have been traumatic; it is care that attends to events and experiences of trauma and their sequelae or legacy.2 Trauma-informed care acknowledges subjective experiences of overwhelm, disconnection or invasion that are wounding and cause complex physiological and intrapersonal dysregulation.5 Unlike victims/survivors of single-incident trauma – where the threat is external – those who have survived chronic traumatising homes also experience internal threat, including the threat of shame. Complex trauma has been described as not only causing ‘hyperarousal and hypervigilance in relation to external danger’, but also ‘the internal threat of being unable to self-regulate, self-organise, or draw upon relationships to regain self-integrity’.6

In a situation where the person is severely overwhelmed, dissociative processes also produce shut-down, or hypo-arousal, which can be easily missed if the GP is not watching for subtle changes in affect, loss of relational connection and loss of coherence of experience.

For the GP, trauma-informed care involves awareness of relationships, development, attachment and physiology, as well as intrapsychic changes to sense of self and meaning.

Safe relationships have a central role in mediating, buffering or repairing7 the physiological impact and personal meaning of trauma. Some children never experience the restorative experience of feeling safe. Trauma can be defined as a ‘violation of an expectancy to be safe with another’8 or ‘repeatedly being left psychologically alone in unbearable emotional pain’.9 Past negative relationships directly affect the therapeutic alliance – making it both more difficult and more important to offer a restorative, safe relationship with clear boundaries in each clinical encounter. GPs offer a unique opportunity for relational repair as they can offer reliable connection over time, allowing a gradual increase in trust and safe connection.

GPs are also uniquely positioned to attend to the physical element of trauma-informed care. As well as direct injury to the body, chronic impacts of trauma leave a legacy of physiological arousal, changes in autonomic tone and consciousness, stress modulation,10 and adaptive changes in neural architecture and connectivity.11–13 As the body attempts to adapt to threat or perceived threat, especially when it is repeated (the process of allostasis),14 endocrine and cellular dysregulation, known as allostatic overload,15 contribute to long-term ill-health.16 This is directly relevant to understanding somatisation, chronic pain, inflammatory disorders, a range of other physical and mental health impacts, and unexplained symptoms.

Behavioural attempts to cope with being overwhelmed and distressed and to modulate physiological arousal due to trauma include addictions, self-harming, suicidality, obsessions, lifestyle choices (including routines and risk taking), particular romantic and parenting attachment behaviours, and attitudes towards the self. Awareness of the effects of trauma on physiological arousal has influenced the rise of somatosensory and creative approaches to trauma therapy that utilise integration of so-called ‘right’ and ‘left’ brain networks.17

Rather than seeking to document and define traumatic content, GPs can instead look for patterns that reveal the whole-person biological and biographical legacy of trauma.1 This allows the GP to identify and better attend to its various complex presentations and implications without getting distracted by its nomenclature. For GPs, recognising these patterns and using them to inform appraisal, therapeutic process, prevention and intervention is more important than documenting causality (a research task) or culpability (a legal task).

What is happening to me? The legacy of trauma in everyday practice

Seeing trauma as potentially being associated with a complex physical and relational legacy enables the GP to recognise patterns that reveal the signs of wounding or trauma, as well as the strengths of the person experiencing them, including possibilities for recovery.

The trauma-informed framework calls for a move from a pathological approach to the person (‘What is wrong with you?’) towards an acknowledgement that something has harmed the person (‘What happened to you?’).18 This has been an important distinction to make – rather than classifying disorder, this acknowledges that those who are traumatised have normal physiological, relational and intrapersonal responses to abnormal experiences.

For the GP, perhaps an additional empowering and attuned appraisal would be for both GP and patient, when safe and supported enough, to gain an understanding of these normal responses: to be alert to physical responses and ask ‘What is happening to me?’ in the present. This approach can build empathy and understanding, and allows GP and patient to attend to the present physiological and relational distress, without undue attention being placed on the search for the causative event or person. As long as safety is kept pre-eminent, this shifts priorities towards soothing, understanding and supporting current distress.

Once soothing is established, and capacity for physiological calm and restorative rest is there, then other goals of therapy become more important – these include autobiographical coherence,19 capacity for relational connection, increase in self-compassion20 and personal meaning-making in the face of traumatic experience. Again, the GP can contribute to each of these through the way they remember the person’s whole story, offer reliable relational connection, and allow existential concerns to be expressed and explored as part of ordinary care.

It is important to note that providing trauma-informed care is different from providing trauma-specific therapy with people who have experienced trauma, especially complex trauma. Therapy requires additional knowledge and training to ensure a safe therapeutic alliance and the processes needed to support recovery.

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

Prioritise safety

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.

As outlined in Table 7.1, the definition of PTSD in both the Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) and International Classification of Diseases, 11th edition (ICD-11) is limited to a linear causal link between event and symptoms. The definition of complex PTSD (CPTSD), which is found only in the ICD-11, is intentionally widened to notice the processes that traumatise, and attends to the impact on sense of self, relationships, connection to the body and meaning. This definition still does not include processes of neglect, including emotional neglect, that cause similar symptoms.

ICD-11 defines PTSD as comprised of three symptom clusters:

  1. Re-experiencing of the trauma in the here and now
  2. Avoidance of traumatic reminders
  3. A persistent sense of current threat that is manifested by exaggerated startle and hypervigilance

The DSM-5 PTSD diagnosis also acknowledges negative alterations in cognitions and mood and has a dissociative specification that acknowledges altered consciousness.

The ICD-11 CPTSD diagnostic framework adds three additional clusters to the PTSD definition that reflect ‘disturbances in self-organisation’:

  1. Affect dysregulation
  2. Negative self-concept
  3. Disturbances in relationships

Although the definition of CPTSD acknowledges the developmental disruption of self-organisation, it does not include disturbances in arousal or consciousness and memory captured in the concept of dissociation. This limitation is important to the GP, who at times needs to interpret unspoken bodily signs of distress, or care for memorial experiences that are reactivated when there is a loss of explicit or narrative memory of the original stressor.

Current single-incident (PTSD) and complex (CPTSD) trauma frameworks also do not acknowledge the physiological stress impacts of trauma on the body and long-term health. As more becomes known about biomarkers of allostatic overload43 as a side effect of chronic threat, the GP needs to be aware of the physiological impact of trauma on their patient’s lifetime health risks.

Table 7.1. Comparison of the definitions of post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) and the characteristics of trauma experienced as linear events compared with experiences
PTSD (trauma as an event) Complex PTSD (trauma as an experience)
Life-threatening incident: ‘actual or threatened death, serious injury, or sexual violence’(a) Chronic threatening process: ‘sustained, repeated or multiple forms of traumatic exposure (eg genocide campaigns, childhood sexual abuse, child soldiering, severe domestic violence, torture or slavery) reflecting loss of emotional, psychological and social resources under conditions of prolonged adversity’44
Can include disasters or accidents that do not involve people Usually happens within relationships and impacts development and self-organisation
Usually noticed as an incident of invasion or threat to integrity Can also be processes of disconnection or confusion that threaten belonging
Dominant emotion of fear reported using explicit memory Dominant experience of shame that is often encoded as implicit bodily memories
Avoidance of reminders (including thoughts or feelings or external reminders, including dissociation)(a),(b) Avoidance is also a subconscious process of inattention, minimising, numbing, altered states of consciousness,45 amnesia and dissociation(d)
Hypervigilant arousal(a),(b) Hypervigilant arousal(c)
Re-experiencing of memories and intrusion of symptoms(a),(b) Re-experiencing of memories and unconscious triggering of memorial experiences(c)
Negative alterations in cognitions or mood(a)
Self-organisation may not be affected at all
  • Affect dysregulation(c)
  • Negative self-concept(c)
  • Relationship disturbances(c) that includes altered trust and sense of belonging across generations
  • Connection to the body altered, including altered sensory awareness29 and somatisation(d)
  • Altered systems of meaning, including hopelessness and despair and post-traumatic growth39,(d)
Altered physiology – endocrine, autonomic nervous system, immunology, cellular glucose use, DNA epigenetics, ‘multisystem physiological dysregulation’46
  1. PTSD as defined in DSM-5
  2. PTSD as defined in ICD-11
  3. CPTSD as defined in ICD-11
  4. CPTSD as defined in Courtois 200421
DSM-5, Diagnostic and statistical manual of mental disorders, 5th edition; ICD-11, International Classification of Diseases, 11th edition

Although the field is expanding rapidly, and there is growing awareness of complex attachment disorders that can have lifelong impacts, at a minimum there are established adverse childhood experiences that all GPs should be aware of (refer to Table 7.2). Longitudinal prospective studies and functional brain imaging studies confirm their far-reaching impact on health.

The Adverse Childhood Experiences Study4 and the Maltreatment and Abuse Chronology of Experiences studies47 have documented these insights. Increased types, incidence or dose of adverse childhood experiences causes increased disease as a direct result of chronic physiological stress and an indirect result of coping mechanisms that attempt to reduce that arousal.

Chronic physiological arousal of the autonomic nervous system, immune and endocrine systems causes headaches, back pain, pulmonary fibrosis, osteoporosis, coronary artery disease, irritability, panic, insomnia, impaired memory and unexplained symptoms.48

Coping mechanisms that attempt to decrease arousal include overeating, alcohol and drug use, smoking, promiscuity, risk-taking, self-harm, obsessions and suicidality.4,49

Table 7.2. Adverse childhood experiences with proven physiological impacts5
Disconnection Invasion Loss of safe caregiver
  • Physical neglect(a)
  • Emotional neglect(a)
  • Non-verbal emotional abuse(b)
  • Peer physical bullying(b)
  • Emotional abuse(a)
  • Physical (including intimidation) abuse(a)
  • Sexual abuse(a)
  • Witnessing violence against siblings(b)
  • Absent parent(a)
  • Intoxicated (alcohol or drugs) parent(a)
  • Mentally unwell parent(a)
  • Incarcerated parent(a)
  • Witnessing interparental violence(a)
  • Witnessing violence against siblings(b)
  1. Direct evidence4,50,51
  2. Direct evidence13
Adapted with permission from: Taylor & Francis Group. Lynch JM. A whole person approach to wellbeing: Building sense of safety. London: Routledge, 2020.

Intergenerational trauma has been studied extensively in the attempt to understand the poor health outcomes of Indigenous and oppressed peoples worldwide. The impact of trauma across generations includes the complex trauma legacy already discussed alongside individual, family, community and national factors (Table 7.3).52

Table 7.3. Factors that impact intergenerational trauma




  • Epigenetic changes53
  • Poor sense of belonging to family, community and culture
  • Feeling of abandonment by caregivers
  • Experiences of violence
  • Loss of relationship
  • Low self-esteem
  • Unhelpful interactions with education, health and legal structures


  • Relational disconnection and confusion
  • Stories and metaphors of threat54
  • Chronic use of violence, alcohol


  • Lack of cultural transmission of culture, language, spirituality, history and traditional values
  • Low levels of communal trust and engagement


  • Popularisation of negative stereotypes through mainstream media
  • Social policies that perpetuate colonialism
  • Lack of support for community self-determination

Reproduced from Menzies P. Developing an Aboriginal healing model for intergenerational trauma. International Journal of Health Promotion and Education 2008; 46: 41-8, with permission from Taylor and Francis Group.

For more information refer to this four-minute intergenerational trauma animation.

It is normal for those in the caring profession to have experienced some form of trauma or neglect in their own past. Those experiences can lead to achieving and helping as coping mechanisms that naturally lead to the helping professions. As outlined in the chapter on self-care, it is important for each GP to acknowledge their own trauma story and the need for self-care – this might include personal therapy, creativity, movement and reflection.

It is important to build a sense of your life beyond your role as reliable helper, and beyond the experiences of your own patients. Spending time away from work, investing in other people, belonging in your wider community, and increasing your capacity to reflect through movement, nature, music, art and language are all inherently healing.

It is also important to consider your own physiological arousal – that your body will become distressed and aroused (including numbed hyperarousal or hypo-arousal) after repeatedly hearing stories of threat. Key questions (refer to Figure 7.1) you can ask to monitor your own needs when on the frontline of distress in our community include:5

  • Do you have anywhere to rest where you are not feeling threatened?
  • Do you have any online community space where you are free from threatening or distressing content?
  • In your closest relationships, is there fun, safe and warm connection?
  • Can you help your body feel calm for moments in your day?
  • Can you find comfort to still your mind and see things in perspective calmly?
  • Are you feeling safe enough in yourself to face your life tasks?
  • Do you have any meaningful way to hold onto hope in the midst of your day-to-day life?

Figure 7.1. Model of self-care<sup>5</sup>

Figure 7.1. Model of self-care5

Adapted with permission from: Taylor & Francis Group. Lynch JM. A whole person approach to wellbeing: Building sense of safety. London: Routledge, 2020.

Finally, as other helping professions routinely do, GPs, whose work is so interpersonal, can support and strengthen their own practice and personal health through regular supervision or case consultation – either within a community of practice, with a trusted psychotherapist, or with a trained generalist mental health trainer or facilitator.

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