Spotlight Series: Karen Johnson, MSW, LCSW

Implementing Trauma-Informed Approaches to Support Patients and Care Teams

Karen Johnson, MSW, LCSW, has spent over a decade working to advance  trauma-informed approaches through her work at SaintA in Milwaukee, WI, as the Director of Trauma Informed Services for the National Council for Behavioral Health, and currently as principal at Trauma-Informed Lens Consulting.

The last seven months have not been easy for primary care providers. We are grappling with the realities of a global pandemic that has changed how we work, interact with each other and serve our patients. We have confronted challenges such as an economic downturn and devastating environmental events, like the recent wildfires in California. We have also faced a reckoning with the age-old scourge of systemic racism. There has been an increase in stress, anxiety, grief, and loss across the country. We also know most of our patients and many staff have experienced adversity and toxic stress. As our patient needs are heightened during this trying time, so are the needs of staff living through these same challenges.

Prior to the COVID-19 public health emergency, primary care organizations were already experiencing challenges such as burnout, vicarious trauma, and high turnover. Even in the best of conditions, this is complex work that can be rewarding but also exhausting. Leaders are facing the question of what to hold onto and what to change.

I have been privileged to work with trauma-informed approaches over the last twelve years, both on the provider side and with the National Council for Behavioral Health. In the September 2020 ACEs Aware webinar, I outlined an approach for organizational trauma-informed resilience that was gaining tremendous speed before COVID-19 and is now more relevant than ever.

A trauma-informed resilience-oriented approach creates safe environments for patients and staff that promote healing and recovery by always prioritizing people’s dignity, voice, and self-empowerment. It provides a pathway for building individual and organizational resilience and responding to the needs of staff and patients. It lays the foundation for successfully implementing screening for Adverse Childhood Experiences (ACEs) and toxic stress, because when staff understand the prevalence and impact of childhood adversity and toxic stress, and the urgent need to address it, they are more ready to ensure that they are screening patients in a compassionate person-centered way.

Trauma-informed primary care is patient-centered care that can improve the health and well-being of patients and their families. It improves clinical decision-making by incorporating knowledge of the health impacts of toxic stress and trauma into our responses and treatment planning. It supports the building of collaborative care networks focused on prevention, integration of behavioral health, case management, and care coordination services. Finally, it creates environments in which providers and staff experience compassionate resilience, so they can stay healthy and do this fulfilling and challenging work.

What are the components of a trauma-informed approach? We understand the prevalence of trauma and adversity and their impacts on health and behavior. We train all staff on trauma-informed care best practices, from the chief medical officer to those providing direct care. We integrate knowledge about trauma adversity and resilience into all policies, practices, procedures and treatment planning. And we always approach patients and staff with compassion and non-judgmental support to avoid re-traumatization.

There are two important tenets of a trauma-informed approach that can facilitate this shift in our service delivery. The first is changing the question “what is wrong with you?” to “what happened to you?” This reframing requires us to honor strengths in an individual and move away from believing someone is broken or weak. We embrace the belief that an individual’s health is impacted by the events in their lives, and healing and recovery is possible.

The second tenet is the assumption that everyone is doing the best they can. This is important in our work with both patients and staff, but may be most impactful in our work with staff. It doesn’t mean we don’t hold ourselves and others accountable; it means that as we strive for excellence, we bring into the workplace grace, compassion, and empathy, all of which are critical for combating burnout and building individual and organizational resilience.

Both tenants require us to see and honor a person’s resilience and strength. An organization entering in this process, or one that is well along in the journey, must be committed to honoring this perspective.

The effectiveness and sustainability of this approach depends on a foundation of core principles to inform the clinic’s physical setting, activities, and relationships. We strive to ensure physical and emotional safety for all patients and staff. We work to build trust between providers and patients through intentional relationship building. Utilizing reflective listening and motivational interviewing skills ensures that we listen to understand, not only to respond, and recognize each patient and staff member’s positive assets and resilience.

We also need to ensure provider and patient collaboration by bringing patients into the treatment process and discussing mutually agreed upon goals for treatment, which can help us identify new opportunities and methods for healing.

And finally, we must provide care that is sensitive to the patient’s racial, ethnic, and cultural background and gender identity. As we become trauma-informed, we strive to practice cultural humility, which requires us to embrace every person’s individual culture and focus on self-reflection and our own lifelong learning. We align policies, practices, and procedures to be responsive to diverse needs. We must be curious about how people across all sectors and groups are impacted by current events and ensure everyone is invited to contribute to the solutions.

What are the steps, tools, and resources needed to make this profound shift to trauma-informed, resilience-oriented practices? The National Council for Behavioral Health in partnership with Kaiser Permanente created a change package over a three-year period to attempt to answer this question. It was developed by a practice transformation team of national experts and tested in a learning community of primary care clinics over 14 months. I share it as one tool available to organizations that are embarking on this change journey or who are already on it. A trauma-informed initiative can feel overwhelming, but there are resources to guide you through this evolutionary process and help you through one step at a time.

Ultimately, this work is about being human with each other. Implementing change in any organization is challenging, especially in a fast-paced primary care setting. You have been moving mountains to meet the needs of your patients, staff, organizations and your own families, but storms remain ahead. Health care teams have demonstrated incredible resilience in these past months and will continue to do so. The trauma-informed approach can strengthen your capacity at all levels to be resilient. As you move forward, practice self-compassion. Please remember you’re doing the best you can, and that is enough.

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Hear more from Karen Johnson in the ACEs Aware webinar “Assessing Readiness & Building Resilience in the Clinical Workforce: A Foundation for ACE Screening Integration.”