Developing Trauma Informed Integrated Care: Just Like in the Movies

Heather C. Forkey, MD, FAAP

May 4, 2018

“You complete me.” I just said that. Really. And not to my husband, but to Wynne, the mental health provider I now provide trauma informed integrated care with.

She was a little startled, but she knew both what I meant…and that I’m likely to say outrageous things. If a line from a rom-com movie fits, maybe it’s because these movies highlight relationships. Relational health, or the back and forth between the child and the caregiver, is the critical piece of both resilience formation and trauma or toxic stress. Relationship is also the critical piece for those in medicine and mental health working together to treat trauma. But forging this relationship was often a drama.

“You had me at hello.” Beth, another of the 3 mental health providers in my community who have become integral to our practice, came to meet with our medical team 6 years ago. One of the first providers in our community trained in trauma focused cognitive behavioral therapy (TF-CBT), she had heard of our clinic for children in foster care. I had just learned about Adverse Childhood Experiences (ACEs) and toxic stress, and was beginning to understand that all therapy was not the same.

Beth’s description of trauma-informed therapy was like a siren song for me. I had been frustrated in my efforts to meet the mental health needs of the children we saw. Now I was flushed with the thrill of finally having someone who could help us best serve our patients. Soon she began to feel overwhelmed by the volume of my many referrals.

"You make me want to be a better (wo)man" During one particular referral phone call, Beth asked me what exactly I was referring the latest patient for. "She really needs TF-CBT," Beth pushed, "but what trauma symptoms does she have?" I responded again, somewhat frustrated by Beth's apparent lack of understanding that this patient had been neglected and had a mother who was substance using. Beth, similarly exasperated with me, said, "right, but what symptoms of trauma does she have – do you think she's dissociating, having avoidance or intrusion?"

I was confounded. I didn't really know what those words meant, and certainly they were not part of my vocabulary. As she explained these terms to me, I realized that Beth's language was more accurate in describing trauma symptoms than mine.

If this integrated care relationship was going to work, I needed to understand these terms and concepts. As I did so, I grew in my understanding of trauma and how best to identify it. Dissociation is not a term I learned in training, but hiding inside oneself is a common reaction to trauma. Avoidance looks a lot like depression, but isn't. Understanding the words allowed me to recognize the symptoms. We created a referral form I could send with symptoms organized around specific trauma responses. With this crutch I was able to identify the children best served by her services, and send them with a more precise description of their needs.

‚Äč"Beth’s description of trauma-informed therapy was like a siren song for me. I had been frustrated in my efforts to meet the mental health needs of the children we saw. Now I was flushed with the thrill of finally having someone who could help us better serve our patients.”

"There's a hole in this cake." A year or so later, I was working with Beth's colleague Genevieve, and we noted tension between our office staffs. Our intake styles, goals, schedules, and hours were all at odds. We set up team meetings to go over cases. Genevieve and I did most of the talking early on, modeling how each team could contribute. Somewhere in the third meeting (maybe over cake and coffee), the back and forth became easier, and the cultural differences began to fall away with the common goal.

"I wish I knew how to quit you." We kept our own offices for years, until six months ago, when Genevieve and Wynne "moved in" with us to provide onsite mental health services three days a week. Co-locating our services was the natural next step in our integration of care. Recognizing and discussing the cases with shared vocabulary and common blended culture has made our care of the patients seamless. My team is as comfortable speaking to Genevieve or Wynne about a case as they are speaking to me. In fact, at this point, not being in the same space had become cumbersome. I need my mental health colleagues, and they need me, and the kids need us all, working together, communicating effectively, with blended cultures, and now in a stable (medical) home.

"I'll have what she's having." Trauma-informed integrated care means that medical and mental health services communicate and collaborate in a way which enhances the services each provide. For Genevieve, Wynne, Beth and for me, what makes this possible is that we all get excited about what the other does and can weave elements of the other's role into our own. Learning to do that was a process, a plot which unfolded. In fact, this dialogue helped us create our own (e)motion picture!

*The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.

About the Author

Heather C. Forkey, MD, FAAP

Heather C. Forkey, MD, FAAP, serves on the Executive Committee of the American Academy of Pediatrics Council on Foster Care, Adoption, and Kinship Care. She is an Associate Professor of Pediatrics at the University of Massachusetts Medical School and was recently named as The Joy McCann Professor for Women in Medicine. In her institutional roles as Division Director for the Child Protection Program and as Director of the Foster Children Evaluation Service (FaCES) of the UMass Memorial Children’s Medical Center, Dr. Forkey leads programs to address the needs of children who are victims of abuse, neglect and emotional trauma. In addition to her clinical work, Dr. Forkey has been the recipient of local and federal grants to address issues of children in foster care and to translate promising practices to address physical and mental health needs of children who have been traumatized. Dr. Forkey also serves on the Steering Committee and multiple other roles for the National Child Traumatic Stress Network.