An Interview With Edward Machtinger, M.D.
From Modeling to Implementation: Helping Patient Behaviors and Choices Seem Less Mysterious
"For us, the epiphany -- and what's so exciting -- has been that understanding the impact of trauma feels like a way to be far more effective in the work that we are doing."
That sounds like a lot. Primary care clinics are already overwhelmed in many regards by the requirements placed upon them. And to some, adding screening for lifelong and recent abuse sounds like yet another task. But for us, the epiphany -- and what's so exciting -- has been that understanding the impact of trauma feels like a way to be far more effective in the work that we are doing.
To us, it helps explain why so many of our patients are still smoking crack cocaine, despite having an array of services available to them here in clinic, including therapy, social work, case management, substance abuse counseling and supportive primary care physicians. It helps explain why our waiting room is just so chaotic, and people act at times so dysfunctionally. It helps explain why some people just can't take their antiretroviral medications, despite intensive pharmacy support. Understanding the role of trauma makes these situations feel less mysterious to us. And it helps me, as a clinician, feel far more compassionate about my patients who are struggling to be healthy in their lives.
For example, when I am engaging somebody who is actively smoking crack cocaine, I now tend to say, "Of course you're smoking crack cocaine. Crack is obviously providing you with something helpful in your life. Let's talk about the good things about crack cocaine, and how it's helping you." Underlying that is my understanding that many people who are smoking crack cocaine have PTSD from having had a lifelong history of childhood sexual and physical abuse, adult sexual and physical abuse, and intimate partner violence that has led them to be profoundly anxious and isolated. And crack cocaine has been one of the few ways of coping with that. Unless we can address their underlying profound anxiety, dealing with their substance abuse and medication non-adherence and health issues is just not going to be effective.
For clinics interested in making this transition, what's the first step?
Is there a potential danger in opening a Pandora's box by not fully implementing a trauma-informed primary care approach?
The model of trauma-informed primary care that we articulate is aspirational. Very few primary care clinics or clinicians have the power to change their clinical environment to become trauma informed, initiate comprehensive screening and begin performing interventions that are evidence-based into recent and past trauma. Most of us don't have the buy-in from our institutions, the resources or power to do all of that.
I do not think it is necessary to implement a comprehensive model of trauma-informed primary care to begin utilizing the understanding of trauma and its impact on patients to help our patients heal. I think the first step would be to educate ourselves about the role trauma plays in the lives of our patients, and how our clinics themselves - the care environments -- are either helping our patients heal or triggering their trauma even further.
I think we have come to accept that frontline poverty AIDS clinics are by nature chaotic. And many of us have actually been drawn to this field because of that chaos.
What I've come to realize is that that chaos is not serving our patients, and it's not serving us, as providers, and that our clinical environment needs to acknowledge that the way we treat our patients and the way we treat each other and support one another have a big impact on how our patients respond to our medical care.
"Understanding their histories of trauma has led me to have far more effective, real conversations with patients about those issues."
The other thing I would suggest is being willing to start asking the questions. So many of us in HIV are surprised that people outside of the field of HIV are terrified to even raise the topic of HIV. People outside of the field of HIV don't want to know about someone being HIV positive, because they fear that they won't know how to handle it. And we in the field of HIV are always surprised about that, because HIV is a health condition, like any other health condition.
Similarly, even in our field, people are scared to ask about abuse. Yet most of us know how to deal with a positive response to questions about recent or past trauma -- that a danger assessment, safety planning or referrals to community organizations are the first step to help a woman who's experiencing acute intimate partner violence become more safe. Simply knowing about past abuse may help us care for our patients over time, so that their current behaviors (which may include substance addiction, or depression, or medication non-adherence) or other factors in their lives can be understood in that context. In my experience, understanding their histories of trauma has led me to have far more effective, real conversations with patients about those issues.
An Adaptable Model for the Cross-Community Need for Trauma-Informed Care
Your research has looked at a range of women, including transgender women. Have you seen that transgender women and non-transgender women are in need of a similar set of practices and services under trauma-informed primary care, or are there some areas in which transgender women's needs differ, and the response should also address them differently?
The model of trauma-informed primary care that we created with the strategy group isn't really limited to women. There's a large body of data that suggests that lifelong abuse is related to the majority of morbidity, mortality and disability across many diseases in the United States in both men and women -- including heart, lung and liver disease; obesity; diabetes; substance abuse; depression; as well as HIV.
Many transgender women, in particular, have experienced an array of traumas, some of which are unique, I believe, to being a transgender woman -- including widespread discrimination and an unacceptable level of harassment and violence that many experience on a daily basis.
I also believe that this model is appropriate for other populations of people living with HIV. For example, many young, black gay men come from communities that are very violent and who personally may have experienced sexual abuse, neglect and other personal traumas. I don't believe that the model of trauma-informed primary care is substantially different for the various types of individuals affected by trauma, including women, transgender individuals and men. Addressing trauma in all of these populations has the same exciting potential to help transform primary care from treating peoples' symptoms with medications to one that gets to the root of so many problems and is genuinely healing. I believe that this new focus has the potential to significantly improve the primary care experience for both patients and providers, which would be great.
Thanks so much for your work, and for taking time for this interview.
This transcript has been edited for clarity.
Julie "JD" Davids is the managing editor for TheBody.com and TheBodyPRO.com.
Follow JD on Twitter: @JDAtTheBody.
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