Why psychiatric hospitals are taking a ‘trauma-informed’ approach to care

If it seems like “trauma” has become a buzzword recently, there’s a reason for that: The understanding of what trauma is, and how it affects our health, is a relatively young field of study.

Even in the field of behavioral health, the importance of trauma -- and the need to take it into consideration when treating patients -- is still a fairly recent consideration.

“Prior to the 2000s, behavioral health services didn’t pay a whole lot of attention to it,” said Kevin Ann Huckshorn, Ph.D. Huckshorn is a consultant with Wellpath Recovery Solutions, the private company that began providing consultation and support at Alaska Psychiatric Institute in 2019. Until then, Huckshorn said, trauma had been considered something that mostly affected combat veterans and survivors of intimate partner violence.

That started to change after researchers with the Centers for Disease Control and HMO Kaiser Permanente published a study that explored the lifelong impact of adverse childhood experiences, or ACEs. The ACE study found a strong correlation between childhood trauma (including factors like abuse and family instability) and adverse health outcomes in adulthood.

“All of a sudden it became clear that the issue of traumatic life experiences was not limited to people who were coming home from war or involved in domestic violence,” Huckshorn said. “It provided this huge window for us to now understand about dangerous, aggressive, self-harming behaviors in a way that we never had before.”

Trauma and the developing brain

Traumatic experiences can cause atrophy of the cerebral cortex and the frontal lobe -- what Huckshorn described as the “air traffic controller” for behavior. As a result, people who have experienced trauma may have extreme reactions to everyday occurrences.

For example, Huckshorn said, imagine you’re in a classroom and you hear a door slam. If you have a fully developed cerebral cortex and frontal lobe, your brain understands that the noise is just a door and you can return and focus. But if your brain development was impacted by trauma, your body’s “fight, flight or freeze” response is likely to be more extreme and harder to settle down.

“We know that trauma causes these brain changes,” Huckshorn said. “The overuse of their amygdala pathways causes them to be extremely overreactive to stressors and triggers. There are real, significant barriers for these individuals to learn how to emotionally self- regulate.”

That “self-regulation” is a “core task of childthood,” she added. People who have traumatic childhoods may not learn to self-regulate or self-soothe, especially if they didn’t have consistent, reassuring parenting. That inability to self-calm can pave the way to a variety of damaging behaviors, including violence, substance abuse, and self-harm.

Those extreme reactions can also be exacerbated by stressful situations -- such as being admitted to a psychiatric hospital and sensitivity to other people’s behaviors, including staff.

A trauma-informed approach to psychiatric care

Huckshorn has spent her career in behavioral health, both with Wellpath and in public hospitals. As an advocate for “trauma-informed” approaches to psychiatric treatment, she says trauma has to be taken into consideration from the moment a patient steps through the front door.

Often a person who is being admitted to an inpatient psychiatric facility is in a very vulnerable position, Huckshorn explained. They may be there against their will. They’ve had their belongings confiscated. Their movements are restricted. They’re reliant on staff members for any needs they might have, including eating and personal hygiene.

“Their fundamental human right to freedom has just been taken away,” Huckshorn said. “That’s enormous in the United States. Can you imagine how frustrating that would be? Of course some people are going to get frustrated and possibly lose control.”

Across the country, behavioral health facilities are now taking steps to minimize retraumatizing patients. One example: Restraints and seclusion, once frequently used to subdue patients, are now considered last resorts by the U.S. Substance Abuse and Mental Health Administration and the federal; Centers for Medicare and Medicaid.

But being trauma-informed goes far beyond simply avoiding practices that could be triggering.

“A trauma-informed approach incorporates three key elements,” Huckshorn said. First, “staff need to realize the really high prevalence of trauma. Second is that staff and leaders need to recognize how trauma affects all of the people coming into the program, including their own workforce. The third is responding by putting the knowledge into daily practice.”

Key to that second step is recognizing that trauma isn’t just a fact of life for patients; professionals working in the field may themselves be impacted by traumatic experiences.

“Sometimes those very experiences are what drew people to work in behavioral health,” Huckshorn said. “That’s all fine, except when it’s not.” Employees working in a psychiatric facility may even experience some of the same triggers as their patients, as well as burnout, fatigue, and retraumatization. A trauma-informed facility needs to be prepared to properly train and support staff who have experienced trauma.

“We’re much more like our patients than we’re not,” Huckshorn said.

Most importantly, she said, the organization has to commit to a top-to-bottom transformation.

“It can’t just be that a memo goes out or somebody writes some policy,” she said. “This takes conversation. It takes signage. It takes a lot of training. It changes job descriptions. It changes who we hire. It changes the language we use.”

What does trauma-informed care look like?

According to Huckshorn, trauma-informed care has to be implemented universally because there’s no way to know for sure which patients have experienced trauma. Huckshorn has seen high rates of trauma among children who grew up in foster care, people who have been incarcerated, and people who come from groups that have been impacted by historical trauma, such as Alaska Native patients -- but trauma is by no means limited to specific populations. That’s why today’s trauma-informed environment of care strives to be more safe and welcoming for all patients.

In a facility practicing trauma-informed care, patient intake starts with a trauma assessment in a safe, comfortable space -- a process that should be repeated several days later, after patients have had the chance to become more accustomed to their surroundings.

“Some people will never talk about it, but a lot will,” Huckshorn said.

Creating a welcoming environment also means thinking about how employees are presented to patients, Huckshorn said. Uniforms are often a trigger for kids and adults who have had bad experiences with the police. Tone of voice makes a significant impact. There’s an “incredible power differential” between staff and patient in a psychiatric facility, she said, and it can be exacerbated or improved by something as seemingly small as the items carried by staff members.

“We don’t need big janitorial key rings,” Huckshorn said. “What does that tell the patient? It tells them ‘I’m more important than you are, I’m more powerful than you are -- and I can get out.’”

Being trauma-informed means adopting language that’s welcoming and inclusive along with an environment that fosters comfort and healing, she said. The colors and materials used in mental health facilities, the layout of rooms and common spaces, the furniture, art on the walls, access to outdoor space, even signage can make a difference in how patients feel and consequently in how prepared they are to receive and respond to treatment.

“The mental health field uses very militaristic language,” Huckshorn said. “We talk about wards, units. We talk about surveillance, strip searches, people that work ‘in the trenches.’ We call people “needy, manipulative, attention seeking or ‘borderline’.The patients hear all this.”

Ideally, barriers between staff and patients are removed, with employees circulating like nurses do in a regular hospital setting, calling patients by their first names and treating them respectfully. Patients should have access to engaging activities so they’re not sitting around all day with nothing to do.

“Our goal is to do everything possible to make hospitalization a positive experience,” Huckshorn said.

Does trauma-informed care make a difference?

The damage done to the brain by childhood trauma can’t be easily undone, but there is a possibility that, with the right course of treatment, it can be at least partially repaired.

“Through treatment and trauma approaches, new neural pathways are actually developed,” Huckshorn said. “You can slow down this overused, very strong amygdala fight/flight/freeze function.”

In a clinical setting, that means social, environmental, and neuroregulatory intervention -- helping patients understand their feelings, verbalize them, and come up with plans to help them calm down when they get upset.

“All behavior has meaning,” Huckshorn said. “Even if that behavior is upsetting, that behavior is trying to communicate something to us. One of our goals is to try and teach our patients the real importance of understanding their body and how they trigger.”

One of the most important things a trauma-informed approach can do in a psychiatric setting, she added, is make patients feel like they are respected and involved in their care. The old power structures that dehumanize patients tend to exacerbate combative situations, not prevent them.

“The feelings of shame and humiliation are probably the most significant triggers for violence that we know of,” Huckshorn said.

The movement toward trauma-informed care is a significant step in the evolution of a field that has undergone radical structural change since the 1960s. And like other systemic changes, it’s only sustainable, Huckshorn said, if it takes place at every level within each individual organization -- a process that requires rethinking how care facilities are built, organized, and staffed.

“It’s super hard work,” Huckshorn said. “It doesn’t happen overnight. But it is happening across this country”

Presented by Wellpath Recovery Solutions in observation of Oct. 10, World Mental Health Day. Learn more at wellpathcare.com/api.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Wellpath Recovery Solutions. The ADN newsroom was not involved in its production.