What is trauma-informed care?

Most people will experience at least one traumatic event during their lifetime. That means some of the patients we serve have already faced one by the time they receive a cancer diagnosis. 

These experiences can have lasting effects on how we interact with others and move through the world. And, the invisible scars left behind can make cancer treatment even more challenging. So, how do doctors care for patients who’ve faced trauma sensitively, yet effectively? 

That’s where trauma-informed care comes in.

“Trauma-informed care is an approach to health care that recognizes the signs and symptoms of trauma,” says Clinical Ethicist Maureen Pontarelli, D.Be. “When patients come to us with a history of trauma, we can be understanding and responsive to provide them with a sense of safety.”

The ‘4 Rs’ of trauma-informed care

Pontarelli notes that trauma-informed care starts with the “4 Rs.” They are:

1. Realizing that trauma affects everyone differently, and that there are many different paths to healing
2. Recognizing the signs and symptoms of trauma and the “4 F” responses to it: fight, flight, freeze (shutting down) and fawn (also known as people-pleasing)
3. Responding to the traumatized population’s needs by creating policies, procedures, training and practices that better reflect our awareness of them 
4. Resisting anything that might re-traumatize patients by triggering them with our words or actions, and being willing to make adjustments and accommodations

“In practice, that could mean something as simple as knocking on a door and waiting for a response before entering a patient’s room, or asking if now is a good time to have a particular conversation,” Pontarelli explains. “It could also mean pulling up a chair and sitting next to a patient to talk, rather than towering over them while you remain standing. The idea is to build trust with our words and actions, so we can get to a place where patients feel safe, empowered and in control.”

The six core principles of trauma-informed care

To build that foundation of trust, trauma-informed care relies on these six core principles. 

Safety

This encompasses physical, emotional, social and moral safety. It also includes psychological safety. 

“We want people to know that they can make mistakes here without fear of punishment,” says Pontarelli. “In that context, no question is ever silly or dumb.”

Empowerment/voice/choice

This is about providing the patient with choices and empowering them to engage in the decision-making process. 

“Someone who has been a victim of domestic violence may have difficulty advocating for themselves,” Pontarelli explains. “This can become ethically problematic down the road, so it’s extremely important that we use trauma-informed care techniques to empower these individuals and provide them with a sense of control over their care.”

Collaboration/mutuality

This is more about leveling the playing field and correcting power imbalances. 

“Doctors may be the experts in medicine, but everyone is an expert in their own lives,” says Pontarelli. “Patients and care teams are partners, so this is a shared decision-making situation. We’re all equals here.” 

Peer support

This is about making sure patients have the resources they need to be successful, and reducing as many of their stressors as we can. 

One example is in the communication leading up to and during a patient’s appointment. “Our goal is to be as transparent as possible to reduce any unnecessary worry,” Pontarelli says. 

Trustworthiness/transparency

This is about ensuring our interactions with patients remain honest, predictable, friendly and consistent. 

“One good example is narrating what we’re doing whenever we have to touch a patient,” suggests Pontarelli. “We might say something like, ‘I’m going to place my left hand on your lower back to help you sit up. Is that OK?,’ or, ‘Is it OK if I take your hand?’ We want to be as clear and predictable as possible.”

This is especially true for patients who have a history of sexual or physical assault or some other personal boundary violation involving consent or bodily autonomy. We want them to know that they will be treated sensitively and respectfully here.

Humility and responsiveness

This is about responding to people of all backgrounds with respect in a way that recognizes and affirms their inherent worth.

“It’s important to avoid making assumptions,” Pontarelli explains. “Even unintentionally, we may have preconceived ideas that can contribute to re‑traumatization. Using open‑ended questions and practicing active listening helps us provide care that is truly trauma‑informed.”

Trauma-informed care depends on strong communication techniques

Good communication plays an integral role in all of these situations. To foster that, healthcare workers can use the following skills to refine their delivery of trauma-informed care.

• Listening skills: Being an active listener by letting patients experience their feelings, paying attention to the volume, articulation, pitch, emphasis, and rate when they speak, and noticing body language to understand their internal frame of reference, or how they see the world.
• Understanding skills: Paraphrasing or repeating what someone has said back to them to show intellectual understanding, labeling feelings to show emotional understanding, and checking for accuracy on interpretation. 
• Questioning skills: Examining the motives behind our questions before posing them. Are we asking just to satisfy our curiosity or because the answer will actually impact someone’s care? Is it better to ask something as an open- or a close-ended question?

“The strategy I tend to use most often is asking, ‘OK. What questions do you have for me?’ instead of ‘Do you have any questions?’” says Pontarelli. “Just that simple shift in language can take the pressure off patients. It automatically assumes that they’re going to have questions, so hopefully, they won’t feel bad about not knowing something. I’d like to create a safe enough environment that they feel comfortable asking me anything.”

The connection between cancer care and trauma-informed care

Pontarelli acknowledges that the combination of cancer and trauma can make for some very heavy conversations. So, healthcare providers who are trauma-informed can address that directly. 

“It’s important to acknowledge there are risks for re-traumatization and vicarious trauma when we have these conversations,” Pontarelli says. “It’s doing a disservice to everyone involved not to acknowledge that.”

Pontarelli also notes that according to the National Institutes of Health National Cancer Institute, the rates of post-traumatic stress disorder (PTSD) among cancer patients with early-stage disease range from 3% to 4%, but that figure jumps to 35% after patients have been evaluated for cancer treatment.

“It’s really important to start implementing these practices,” she says. “UT MD Anderson has a very strong culture of caring for the whole person already,” Pontarelli notes. “But we can always do better.”

How to ensure you’re getting trauma-informed care

So, how do you make sure that you’re getting trauma-informed care, once you’ve been diagnosed with cancer? 

The simplest way is to tell your care team about the hard things you’ve experienced and how they’ve affected you, if and when you’re ready. That way, your care team can make any accommodations you might need. If they know you become frightened in tight spaces, for instance, they can offer you sedation before an MRI.

Unfortunately, many people don’t realize that they still carry the effects of trauma, so it wouldn’t even occur to them to ask for special considerations. Others might not feel comfortable discussing what has happened to them, whether due to embarrassment, shame or fear.

“It’s a tricky area,” notes Pontarelli. “Patients don’t owe us anything. So, we would never require someone to disclose a history of trauma. However, if they feel comfortable sharing, we’d encourage them to tell us about any experiences they believe are relevant — particularly those that might help us better understand their needs and provide more informed, supportive care.”

UT MD Anderson patients who wish to talk more in-depth about their traumatic experiences may also ask for a referral to Social Work or Psychiatry.

Request an appointment at UT MD Anderson online or call 1-877-632-6789.