Edward Machtinger, M.D.: Clinics can heal or retraumatize

Much of the mental illness and substance use that drive poor health outcomes among women with HIV also challenge primary care broadly, and both conditions are typically rooted in trauma, according to Edward Machtinger, M.D., professor of medicine at the University of California, San Francisco, director of the Center to Advance Trauma-Informed Healthcare and codirector of the university's Women's HIV Program.

In this video, he explains what trauma-informed care means and why it is essential to treating patients whose health is shaped by past trauma.

He pointed to a Centers for Disease Control and Prevention study on adverse childhood experiences, which found that 40% of adult depression is directly attributable to just 10 categories of childhood trauma, a figure that does not account for other forms of childhood or adult trauma. Substance use and mental illness, he said, both stem largely from trauma and often lead to further trauma, including additional violence and abuse.

That trauma history frequently shapes how patients behave in clinical settings, he said. Patients with trauma and post-traumatic stress disorder can appear distrustful, reactive or dissociative, behaviors that providers and front-desk staff often misread as hostility, danger or disrespect, escalating routine interactions into conflict. Recognizing trauma as the underlying cause helps clinicians respond with more patience and compassion rather than reacting to behavior they do not understand.

The two principal attributes of trauma-informed care, he said, are safety and connection: helping patients feel emotionally safe in a clinic, focusing care on their immediate safety and life risks, and building a trusting, transparent relationship in which patients can reveal what is actually threatening their health, which is often more serious than the concern that brought them into the appointment.

Machtinger is the senior author of “Causes of Death of Women With HIV: Discordance Between Interdisciplinary Primary Care Teams and Death Certificates,” recently published in the Journal of Acquired Immune Deficiency Syndromes, part of a broader body of research examining how women with HIV are cared for and understood by their treatment teams.