VCU news

By Geoff LoCicero
VCU School of Social Work

The inspiration for Virginia Commonwealth University assistant professor Adrienne Baldwin-White’s recently released mobile app was as simple as a doctor’s visit that expectant mothers make every day.

Baldwin-White, Ph.D., who joined the School of Social Work in August 2022, can trace the origin of the app, T.I.M.E. (Trauma Informed Medicine Education), to an awkward encounter with her OB-GYN when she was living in Arizona during graduate school around 2018. Despite a new requirement that physicians check with patients about domestic violence and safety in their homes, Baldwin-White’s doctor failed to ask about a history of sexual assault during an appointment.

“When you’re seeing an obstetrician or gynecologist, there are a lot of things that happen during your examination that can trigger a trauma response from a sexual assault,” Baldwin-White said. “I thought it was really interesting that she didn’t ask.”

So Baldwin-White posed her own question to her doctor: Why didn’t you ask?

“She was very honest with me; she just looked at me and was like, ‘Because I don’t know what to say if (patients) say yes.’ So it was not a lack of wanting to help or a lack of understanding that this was important,” Baldwin-White said. “In my mind, I thought, ‘I can help with that.’”

She started by creating a brochure for patients and, realizing there was a larger need, envisioned that a tutorial on trauma-informed care could benefit physicians and other health care workers in any setting. “I decided that an app would be a good means of communicating information,” Baldwin-White said. “I asked my doctor if she would use an app in her practice and she said yes because it would be easy to access that information.”

Collaborating to develop the app

After graduating from Arizona State with her Ph.D. in social work, Baldwin-White started on the app project as a first-time faculty member at the University of Georgia. The challenges were funding and technical expertise, and Baldwin-White used a variety of student-led resources to solve the latter.

“From creating the very first app to the published app, very little content changed,” she said. “We’ve had three iterations of the app, and there were two user interface proposals that were developed so that the app was something that was visually appealing and would actually present the content well.”

A pre-med student, Sachi Shastri, and a UGA social work colleague, Jennifer Elkins, contributed to the trauma-informed content development. Elkins contributed a 2 1/2-minute video primer on trauma in the app, which also includes sections on the impact of trauma, best practices for providing trauma-informed care and forensic exams, how to set up an exam space that is trauma-informed and self-care tips for providers.

Completed at the end of the fall 2022 semester, the app was released earlier this spring in the App Store. In addition to its content, there is a space for professionals to connect, share resources and serve as sounding boards for one another.

VCU funded the final phase of the app, and the draw of the fully integrated medical school with VCU School of Medicine – the University of Georgia has a medical partnership with Augusta (Georgia) University – also was appealing as a testing ground with medical students and providers.

While she was awaiting approval by VCU’s Institutional Review Board for usability and feasibility testing, Baldwin-White worked with Fidelma B. Rigby, M.D., a professor in the Department of Obstetrics and Gynecology at the School of Medicine, for presentations on the app with VCU medical students.

“Medical schools are really open to what I’m doing,” Baldwin-White said. “Medical students were more open about talking to me about trauma-informed care in the early development process than practicing physicians. It was actually pretty difficult as a professor to get physicians to take time to talk to me. Medical students understand the importance of trauma-informed care in medicine, and they want to learn the tools they need in order to do that.

“In medical education, there is more of an understanding that treating a patient is more than just being there. You have to understand that there are traumas that (patients) have experienced that affect whether or not they will accept your treatment, whether or not they’ll actually go to the doctor. There are other areas of trauma-informed practice, like trauma-informed education, trauma-informed policing, that are starting to emerge. Many medical students are familiar with this, so we don't have to convince them. They already know, and it's just trying to create something that they can and will actually use.”

Shastri, now a second-year medical student in Georgia, credits Baldwin-White for introducing her to the need for a trauma-informed approach. “I’ve been obsessed with it ever since; it’s my personal mission,” she said. “I will take any opportunity to make sure that everyone is at least aware of it.”

Rigby is helping organize fourth-year VCU medical students for pre-study feedback and efficacy testing.

“I think (the app) is a great idea,” she said. “I think we need all the tools we can get to help with trauma-informed care. The new generation of students, that’s an arena they feel very comfortable accessing and using.”

Rigby is also intrigued by the app’s community feature, a virtual space for “folks to talk to each other and share best practices.”

Baldwin-White sees the benefits of this secure environment for professionals to share knowledge. “If providers have a general question about how to approach clients in a trauma-informed way, they can build community with other doctors who are trying to do the same,” she said. “They can share research and literature with one another by making attachments and sending articles.”

She sees the potential to expand and provide additional content focused on providers working with human trafficking survivors, which is Rigby’s area of expertise.

“The best (trauma-informed) practices apply to the patient who seemingly has no issues or she’s not telling you, versus the patient who you know ahead of time has multiple issues,” Rigby said. “What’s wonderful about trauma-informed care is that it will help with every patient interaction you have, especially if they have sexual-assault or human-trafficking problems.”

Increased awareness and better supports

Safe Harbor, a Richmond nonprofit serving survivors of sexual and domestic violence and human trafficking, takes a trauma-informed approach by deferring to clients as “the experts of their own situations” and not judging or issuing mandates, said Liz Timmons, the agency’s assistant clinical director. “It’s about respecting clients’ autonomy and self-determination, and that they have very good reasons for whatever decisions they make.”

RAINN, the Rape, Abuse & Incest National Network, reports that every 68 seconds, an American is sexually assaulted and that one in six women has been the victim of an attempted or completed rape in their lifetime. Transgender students and Native Americans are disproportionately at-risk, according to RAINN.

Timmons, who earned her Master of Social Work degree from VCU in 2016, says increased awareness and better supports, such as Baldwin-White’s app, will help survivors feel more comfortable reporting assaults.

“We have to get comfortable with this idea that it's going to look worse before it actually gets better,” she said. “Meaning, the goal initially is for people to report more, for them to trust in the system for things to be done. And that's going to look like, ‘Oh, my God, they're all these sexual assaults … oh, my gosh, these numbers over here are skyrocketing!’ Not that it's happening any more or any less than it already was. We're just bringing more awareness to it and hopefully doing something about it.”

Timmons says sexual assault survivors are “highly likely” to experience trauma and that “trauma looks different for everybody.” In the case of post-traumatic stress disorder, PTSD, it “can show up immediately or it can take weeks, months or years to manifest as obvious symptoms or obvious impacts.”

Trauma-informed health care providers can measure improvements in patients by using a 20-question trauma scale to check symptoms, Timmons said. Positive outcomes can include a reduction of classic PTSD symptoms such as nightmares, panic attacks, and depressive and anxiety symptoms, or an increase in self-esteem and self-efficacy.

Timmons, echoing Baldwin-White’s experience, related how she is pregnant and recently had her first OB appointment with her husband.

“Let me preface this with saying, I have a healthy marriage and a supportive husband, but the doctor never asked any questions around abuse and never separated us. When I looked at (the digital app) MyChart after the fact, it said that I had denied there was any abuse, but there were no questions asked (during the appointment),” she said, her voice rising with exasperation. “And, you know, abuse doesn’t look a particular way. … It’s super important to ask those questions every time.”

Baldwin-White’s app aims to make it easier for health care providers to feel confident enough to ask those difficult questions. “Having a trauma-informed approach means you can actually do your job better as a doctor,” she said.