Maleficence in Treatment: Dismissing Patients When They Need Providers Most
Adults who have had adverse childhood experiences (ACEs) or are victims of violent crime are often in physiological pain (Clarke, Schubiner, Clark-Smith & Abbass, 2019) and have a need for trauma informed care. However, their claims of pain are often dismissed by medical professionals (Clarke et al., 2019; Clarke, 2007) and often, the individual is released from care without treatment (Clarke, 2007; Schubiner & Betzold, 2016). That is to say, during the examination, they are met with claims that their test results did not produce any significant findings. Similarly, others are labeled as having “health anxiety.”
To clarify, patients are accused of being drug addicts who are looking for the right physician to prescribe them drugs (Buchman, Ho, and Illes, 2016; Clarke, 2007; Clarke et al., 2020; Schubiner & Betzold, 2016). Therefore, new research in the fields of integrated healthcare and neuroscience are starting to shed light on psychophysiologic manifestations of pain and how it correlates to trauma (Clarke et al., 2019).
Neurological Restructuring and Psychophysiologic Disorders
When an individual experiences a traumatic event, either directly or by witnessing it, their brain patterns are altered (Anda, 2007; Clarke et al., 2019). Moreover, the more traumatic the event is, the more neurological alterations and structural changes to the brain are made. Furthermore, some individuals develop adverse psychological disorders as a result of trauma. Meanwhile, others develop psychophysiological disorders (Anda, 2007; Clarke et al., 2019).
In both instances, it is difficult for physicians to diagnosis the underlying cause of the psychological or physiological distress (Clarke, 2007). As a result, the intersections between neurological, biological, epidemiological, and psychophysiologic disorders and trauma are resoundingly related and interwoven (Anda, 2007; Clarke et al., 2019).
The Reason for Multi-Collaborative and Trauma Informed Care
Victims of violent crimes such as domestic violence, sexual assault, and child abuse need a combination of psychological and medical care (Clarke, 2007). For example, during the initial phases of care for these individuals, there is often a mismanagement of care: medical and therapeutic providers try to assert themselves for treatment, advocates and social services professionals rendering services at inopportune times, and legal assistance and law enforcement agents gathering information they need to start the process of providing services. The patient is not generally in an appropriate condition for these mishandled processes.
Subsequently, what is lost in that process is a systematic care delivery that helps all entities to work together to reduce re-traumatization of the individual (Anda, 2007; Clarke et al., 2019; Duckworth & Folette, 2012; Klott, 2013). In addition to this, re-traumatization affirms and further restructures the neuropathways by which the brain sends and receives messages (Anda, 2007; Duckworth & Follette, 2012; Klott, 2013).
Due to these changes in the brain, the individual may behave differently than usual (Anda, 2007; Duckworth & Follette, 2012; Klott, 2013). Medical and psychological providers then begin treating the individual’s maladaptive behaviors and not the individual (Anda, 2007; Clarke, 2007; Duckworth & Follette, 2012; Klott, 2013). As a result, treatment by multiple providers is disrupted. The patient’s medical and therapeutic services halt as well as their social and legal services (Duffy, Adams, Sibbritt & Loxton, 2014).
Certainly, this is evidence of a breakdown in communication for care. Suboptimal services are rendered to patients and efficacy and efficiency is sacrificed (Duffy et al., 2014; Klott, 2013). For instance, there are many initiatives being taken to improve multi-provider care for victims of violence, re-traumatization and mismanagement of care are still an issue.
Trauma-Informed Care in Integrated Behavioral Healthcare
Doctors of Behavioral Health were created to provide an integrated healthcare solution for patients who had complex medical and psychological needs (Landoll, Maggio, Cervero & Quinlan, 2018; O’Donnell, 2012); they medical healthcare professionals, trained in the Primary Care Behavioral Health (PCBH) model.
PCBH is a care delivery system designed to meet both psychological and neurobiological needs (Landoll et al., 2018; O’Donnell, 2012). As a result of these needs, Doctors of Behavioral Health are trained in interprofessional learning environments. Therefore, they are able to handle a wide variety of patient populations (Landoll et al., 2018).
Integrated Healthcare Professionals, like the Doctor of Behavioral Health, also train other providers on how to increase positive outcomes, improve care pathway and delivery, drive down overutilization, and consequently increase both patient and provider satisfaction (Landoll et al., 2018; O’Donnell, 2012). Doctors of Behavioral Health are uniquely qualified to take care of the array of psychobiomedical needs of victims of violent crime and likewise, the needs of people with ACEs (Landoll et al., 2018).
Victims of violent crimes and patients with ACEs suffer from a variety of stress-related illnesses (Clarke et al., 2007; Schubiner & Betzold, 2016). The hallmark of these stress illnesses tends to be pain (Schubiner & Betzold, 2016). Whether emotional pain from distress or physiological pain from assault, peritraumatic responses are created.
Over time, these responses make structural changes to the brain, neurological pathways, and can create reactions caused by malfunctioning neuroendocrine and neurochemical systems (Bremmer, 2006; Bremmer, Elzinga, Schmahl, & Vermetten, 2008; Clarke, 2007; Courtois & Ford, 2009; Olff, Langeland, & Gersons, 2005). As a result, this causes structural changes to the hippocampus, amygdala, and medial prefrontal cortex. It also changes neuroendocrine and neurochemical patterns, such as the overproduction of cortisol and adrenaline.
Finally, it causes behavioral manifestations that defy diagnostic assessment. These changes make it difficult for the physician to pinpoint the causes of their pain (Bremmer, 2006; Bremmer et al., 2008; Clarke, 2007; Clarke et al., 2019; Olff et al., 2005). The patient experiences a dismissal of their presenting issues (Clarke, 2007). However, with the help of more trauma-informed integrated healthcare providers patients will experience changes in how they are treated within medical and integrated healthcare settings.
Integrated healthcare professionals, like Doctors of Behavioral Health, are changing the way we interact with patients who are victims of violent crimes or ACEs (Landoll et al., 2018; O’Donnell, 2012). These professionals are already trauma-informed and are trained in integrated healthcare services (Landoll et al., 2018). Above all, being trauma-informed is more than knowing the patient has experienced trauma. It comes with an understanding what the patient needs and knowing cultural issues that may arise.
It helps providers understand what the patients have experienced and the effects and in knowing what works for the patient in order to create a collaborative care team that meets those needs (Landoll et al., 2018; O’Donnell, 2012). If one’s place of employment does not have healthcare educators who can train providers on trauma-informed treatment of victims of violent crimes and those with ACEs, reaching out to training organizations, like Gray’s Trauma-Informed Care Services Corp, can help to train providers on how to implement trauma-informed practices and improve delivery of care.
In conclusion, victims of violence and those with ACEs have experienced enough trauma. It is time that medical facilities start appropriately educating their providers to handle patients with psychobiomedical issues, caused by trauma. There is a new approach to working with patients. This novel way of providing care pathways and delivery systems reduces re-traumatization and ensures patients’ experiences are always considered.
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