Our inattention to the emotional dimensions of health and illness is a public health perfect storm, especially for the mentally ill. This group of people experiences high rates of illness, suffers greatly, uses an enormous amount of our precious healthcare dollars, and dies 25 years earlier than the rest of us. We have the ability to unlock one of the most profound drivers of successful chronic disease management—namely the influence of traumatic experience and toxic stress and what healthcare providers can do about it.
Trauma impacts almost everyone. Its nature may vary—natural disasters, illness, death of a loved one, neglect, or at its most extreme levels, physical and/or sexual abuse. Yet there is strong evidence to suggest one thing in common: many of our seemingly intractable and most costly public health challenges can be traced to the emotional distress ultimately grounded in a traumatic experience, whatever its foundation.
The Milbank Memorial Fund study in 2010 found that “when symptoms and trauma related behaviors are left unaddressed, individuals often experience lower productivity, failed relationships, significant distress and dysfunction, difficulty caring for their children, and difficulty caring for themselves in health-promoting ways.” It went on to note that “as many as 70 percent of visits to primary care sites stem from psychosocial issues and although patients typically present with a physical health complaint, data suggests that underlying mental health or substance abuse issues are often triggering these visits.”
Need more proof? The seminal Adverse Childhood Experiences (ACE) study provides evidence of profound negative consequences of trauma on overall quality of life and clearly demonstrates that traumatic experiences are predictive of poor health outcomes in later life. In fact, multiple experiences of trauma can greatly affect the intensity of both physical and psychological symptoms. The study, conducted by Kaiser Permanente and the CDC, focused on a commercially insured population in California and began as an effort to understand obesity. The study focused in particular on the often-inextricable link between childhood maltreatment, family dysfunction, trauma, and later-life physical and mental health status and harmful health-related behaviors.
There are a number of negative ways that people cope with the emotional distress associated with traumatic experience: smoking, alcohol and drug use, unsafe sexual behaviors, overeating, and more. Each of these compensatory behaviors provides some relief—in the short term. In fact, traumatic experiences are associated with behavioral health issues and, perhaps more important, can lead directly to the behaviors that result in chronic health conditions, not necessarily because those behaviors reflect an individual’s intention but rather because they are a means by which people cope with the emotional pain caused by trauma.
Moving forward with the body of knowledge we have on traumatic experiences and its impact on health, we have the option of intervening to address the underlying cause of the person’s health impairing behaviors, to look beyond what is being presented as the “problem.” By doing so, there is a greater likelihood of addressing the person’s overarching health as well as the condition of immediate concern. To do so, however, medical training will need to become more holistic, taking on the phrase most associated with trauma-informed care—“What happened to you?” rather than the more expedient “What’s wrong with you?”
Despite every indication that the health burden of trauma exposure is high, this remains a difficult topic to address for health care providers, who often do not assess for trauma histories with their patients. Part of the reason is that trauma is a sensitive topic, almost as painful in the hearing as it is in the telling. But we must bridge this gap. Our deepening understanding of trauma and its consequences demands that providers not only understand the links between traumatic experience and health outcomes, but also begin to work collaboratively to address an individual’s whole health needs.
What we at ICL are doing is a paradigm shift in the provision of integrated medical and behavioral health care. We know that traumatic experiences are often an inevitable part of human experience. Therefore, our interventions must address the broader implications of the current mind/body split approach to care and the need for more meaningful integration. The next generation of integrated care will be one that incorporates the critical role that emotional distress plays in our lives and in our health, with services that recognize and honor an individual’s life experience and how compensatory behaviors are linked to earlier traumatic experiences.
ICL is spearheading the integration of primary and behavioral health care, as well as care coordination, throughout our multiservice agency. From care coordination to housing to PROS services, our goal is to ensure that more people with serious mental illness (SMI) have access to quality behavioral health and medical services. ICL’s model for integrated care puts consumers at the forefront, making decisions about their healthcare based on personal values and goals. ICL also works tirelessly to train our clinical and frontline staff in evidence-based, trauma-informed interventions that will support clients in receiving fully integrated care that addresses both their behavioral and medical health needs.
Through our research and firsthand experience, it has become clear that implementing trauma-informed, integrated care will lead to better client outcomes and reduced cost of care. When healthcare providers honor and acknowledge the degree to which health-related behaviors are connected to experiences of trauma, they can work with all patients, regardless of conditions or expense of treatment, to identify better ways of coping with these feelings to turn reactive habits of the heart into healthy habits that sustain the body. We have the potential to break the legacy of trauma’s impact across the spectrum of healthcare users and to facilitate more responsive outpatient care and improved overall health outcomes.
We have the potential to save lives and it is imperative that we take action now.