The concept of trauma-informed practice emerged in the late 1980s and early 1990s as providers began to observe the association between mental illness and previous trauma, particularly among women receiving public mental health services. At the same time, researchers were beginning to understand the biological effects of trauma and stress. Trauma-informed practices initially gained traction in the fields of education, psychology, and behavioral health, but the concept is now taking hold in the broader medical community. Both the National Council for Behavioral Health and the Substance Abuse and Mental Health Services Administration(SAMHSA) have invested significant resources in trauma-informed care programs, and the Centers for Disease Control and Prevention has a web page devoted to trauma and trauma-related care. The National Council consults with health care organizations around the country to help improve trauma-informed practices, by ensuring that all staff can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization.
Elisseou didn’t know all of this when she began incorporating trauma-informed care into her practice. Maybe it came naturally to her; her father has an internal medicine practice in Connecticut, and her mother manages the office. She says her parents taught her and her brother and sister the importance of love and affection for one another and for others, making them kiss each other good night— “something which we despised at the time, but are now grateful for it, since we’re best friends,” she says—and to greet adults “with eye contact and a firm handshake.” As an undergrad and then a medical student in Brown’s Program in Liberal Medical Education, Elisseou began to see how she could apply these values of kindness and communication in her interactions with patients. “I made it a priority to do everything I could to make my patients feel as comfortable as possible in the interview and, particularly, during the physical exam,” she says.
As Elisseou gained appreciation for the patient interaction and information-gathering components of the physical exam during her internal medicine residency at Yale, so did her understanding of the hazards it posed to people who had previously experienced trauma. “It has the potential to expose patients to shame and vulnerability and triggers of previous trauma,” she says. Now, working with veterans, she sees patients daily who have experienced combat-related trauma, military sexual trauma, homelessness, adverse childhood experiences, and other challenging backgrounds. She recalls performing a cardiac exam on one of her first patients at the Providence VA: “I brought my stethoscope from behind my neck to in front of my face, I kind of swung it around, and the patient jumped. He almost jumped off of the exam table.”
Her work with a patient population suffering from PTSD, anxiety, and depression helped Elisseou understand the possible benefits of a trauma-sensitive approach. “[The physical exam] has the potential to reinforce the sentiment of care and establish rapport between physician and patient,” she says. “I wanted to create a safe space in the examination room where all patients felt comfortable, so we could establish a therapeutic alliance and work toward healing.” When she began teaching a small group section in the first-year Doctoring course in 2014, she incorporated many of the techniques she had developed.
Though she worked hard to use exam techniques specifically tailored to avoid re-traumatization of patients in her practice, Elisseou didn’t hear the term “trauma informed” until last year, when Meghna Nandi MD’20 and Srav Puranam MD’20 approached her after she led a workshop about the physical exam in trauma survivors. They explained to Elisseou that many of her clinical techniques fit into the formal conception of trauma-informed care: fostering feelings of safety, autonomy, and trust in the patient-physician relationship. “There was so much alignment,” Puranam says.