Trauma Informed Care in Practice

Trauma Informed Care: when every part of a service is assessed and potentially modified to include an understanding of the emotional issues, expectations, and special needs that a trauma survivor may have in a healthcare setting.[1],[2]

Trauma survivors have unique healthcare needs. For various reasons – including time pressures, lack of awareness of these needs, lack of education about trauma informed care techniques, and stigma that labels survivors as “difficult” – these needs are often not met in the current healthcare system. While I’ve discussed previously the implications of trauma-informed care, many providers may not know what to do to help survivors. Below are some practical trauma informed suggestions offered by experts that can be taken to help survivors in medical encounters.

  • Be sensitive, patient, sympathetic, and compassionate.

  • Offer a calming, soothing office environment. This includes the entire office from the waiting room to the exam room and involves all staff in the clinic from the front desk personnel to billing to nurses to the doctor (See post on Staff Encounters).
  • Because waiting for appointments maybe particularly difficult for survivors, provide a realistic estimate of the length of wait time. And if you do escort them back to the room, ask if they prefer the door open, closed, or ajar while they are waiting.
  • Respect the survivor by promoting the approach that the survivor is the expert on their life and should be acknowledged as such.
    • Survivors may be extra sensitive to disrespect. Abuse and trauma can make survivors feel reduced to less than human as their boundaries and autonomy are violated. Being heard by providers can help survivors feel respected.
  • Validate any concerns the survivor might have as understandable and normal.
  • Be flexible about the survivor having a support person in the room with them. Offices may even want to post signs indicating that survivors can have someone with them at all times. Providers should also verbally reinforce that having someone with the survivor is okay and be supportive of these requests as they are not personal.
  • Provide relaxed, unhurried attention to the survivor.
    • Time pressures in healthcare that limit providers’ time often leaves survivors feeling like an objects – just another patient – which can lead to feelings of being devalued and depersonalized.
    • Being rushed can affect survivors’ sense of safety and undermines care.
    • While it is hard to make extra time for patients, feeling heard can be the most important part of care.
  • Give the survivor as much control and choice as possible about what happens and when.
  • Be clear about who will be in the room with the survivor and who will be performing assessments and procedures. Some doctors may have a physician’s assistant perform an assessment instead of performing it themselves or may ask nurses or students into the room. This may be overwhelming for a survivor who only prepared to discuss their issues with the provider with whom they made the appointment.
  • Ask whether the survivor prefers a specific gender provider to perform an assessment. Do not assume that a survivor of one gender prefers to be examined by a provider of the same gender. For instance, females may not necessarily find more comfort in a female nurse or doctor performing an assessment. Give the survivor the choice if possible in who will do the assessment.
  • Skillful communication
    • Ask the survivor for suggestions on how to make the visit more comfortable.
    • Pay attention to and respond to the patient’s body language and nonverbal cues. (discussed in more detail below)
    • Talk over concerns and procedures before asking the survivor to disrobe.
    • If possible provide, pamphlets in the waiting room on “what to expect” for different procedures.
    • Explain what each procedure is, why it is needed, and obtain the survivor’s consent. In other words, “Inform before performing.”
      • Remember that even if a provider has done this procedure before with the survivor, consent on one visit does not mean that the survivor consents the next time. The ability to tolerate a treatment may change over time.
      • No procedure or examination is routine.
    • If the procedure involves instruments, like a speculum, offer the survivor a chance to see and handle it if they would like. Similarly, if the procedure involves topicals or substances like ultrasound gel, know that this may trigger survivors and they may need to be given a chance to feel or see the substance.
    • Ask the survivor if they are ready to begin. Be clear that the survivor can pause or end the exam or procedure at any time.
    • Encourage questions. Ask the survivor if they are worried about any aspect of the exam or medical intervention.
  • Maintain a personable, friendly manner. Be straightforward and generous with information.
  • Encourage the survivor to do what makes them feel most comfortable wherever possible such as: wearing a coat, listening to music during the procedure, adjusting the lights, or negotiating the angle of the exam table.
  • Be aware that body position during the exam can have a significant impact on the survivor. For example, lying on one’s back or sitting with someone behind them. Maintaining visual contact might help some survivors as well as amending how a procedure or evaluation may be performed.
  • Offer as much privacy as possible including:
    • Knocking and waiting for permission before entering the exam room.
    • Providing gowns for all sizes of patients.
    • Keeping the patient covered as much as possible.
    • Waiting until the patient is dressed and sitting to discuss sensitive information.
  • Discuss and be open to delaying or omitting testing and procedures that are not absolutely necessary which could cause unnecessary trauma.
  • Allow for specialized communication plans between visits. Because of the sensitive nature of trauma, survivors may need different methods of communication other than calling the front desk or using a portal. Calling the front desk or using a portal may mean another individual is allowed to see the messages which the survivor would not want them to see. Allow for:
    • Direct Email: This is HIPAA compliant and in fact providers must accommodate any request for accommodation by email per 45 CFR 164.522(b).
    • Direct Phone Line: Providing a direct contact number to either a trusted nurse, medical assistant, or the provider directly. And discuss expectations for when calls will be returned.
  • Create carefully coordinated interdisciplinary care teams and make sensitive, confidential, and informed referrals in partnerships with the survivor.
  • Be willing to admit mistakes and accept accountability for decision making.

Provider Reactions

Providers also need to be aware of their own responses. Some providers may have negative feelings about these patients which may be indicative of negative transference. However, providers should try to acknowledge those feelings and work to ensure that does not impact treatment. Common issues providers may face include:

  • Fears of being overwhelmed or making bad decisions.
  • Feelings of helplessness and inadequacy if a provider can’t “fix” or predict outcomes,
  • Frustration with survivors for not responding to a provider’s request,
  • Lack of attention to a provider’s own personal history and vicarious trauma,
  • A need to avoid, dismiss, blame, label, or control the survivor.

Recognizing Nonverbal Cues

It is also helpful if providers can observe body language and respond to nonverbal cues. These cues may be indicative of possible trigger reactions and can include reactions such as:

  • becoming stiff,
  • cringing,
  • pulling away,
  • shaking, startling,
  • crying,
  • becoming disoriented or confused,
  • excessive modesty,
  • twitchy toes or arching back during examination,
  • sweating.

Providers can help ease these reactions by normalizing the experience, saying something like:

“You seem a little anxious, it is very common for people to feel nervous in these kinds of situations. For some people this anxiety could be due to some physical or sexual abuse that happened in their past. Has this ever happened to you?”

In these situations, providers may even consider stopping the exam and asking whether they would be more comfortable talking about their discomfort or perhaps rescheduling the exam for another day.

If a Survivor is Triggered

If a survivor shows signs of being triggered, providers can help by:

  • Reminding the survivor of where they are and that they are in a safe place.
  • Encouraging the survivor to take slow deep breaths and ask them to look at the provider (or their support person if they brought on) and keep them in focus.
  • Asking the survivor how they are feeling using a calm voice, being sure not to inundate them with questions and avoid touching them.
  • If the survivor has disclosed past abuse, reassure them that treatment can sometimes trigger flashbacks or emotional responses and that this is not uncommon.
  • If the survivor experiences a strong emotional reaction, reassure them that it is okay to feel strong emotions like being angry, sad, afraid, or disgusted.

Seeing the Survivors as a Whole Person

These are just a few trauma informed care suggestions to help trauma survivors survive medical encounters. Survivors need special accommodations for medical care, which they are often not afforded. Providers and staff are inclined to say, “This is how we do it for every patient,” instead of considering the specific needs of the individual before them. Seeing the survivor as a whole person – including their physical and mental care needs – can help providers see that they may need providers to alter their care routines. As noted above, this may be difficult for providers who have time pressures, but this can make all the difference in care.

Survivors who ask for accommodations like the above should not be seen as “demanding” or “difficult” but as individuals who are advocating for the best care for them. Survivors are trying to minimize further trauma and protect their minds and bodies while enduring medical encounters that may be very difficult for them. Understanding why a survivor is asking for these accommodations may reframe these requests as a means of patient engagement and establish trust between the provider and patient.

If a survivor has a bad medical encounter it may result in their inability to seek care in the future. Retraumaitization can trigger survivors who already find it hard to relinquish bodily autonomy to an authority figure, like a doctor or nurse. Having compassion for this vulnerability can ensure that survivors do not delay care and feel safe. In fact, it can even help heal past trauma.

Trauma Informed Care Series:

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Sources:

[1] The Western Massachusetts Consortium. Trauma Survivors in Medical and Dental Settings. Trauma-Informed Practice Series. Found at: https://www.integration.samhsa.gov/clinical-practice/Trauma_Survivors_in_Medical_and_Dental_Settings.pdf.

[2] Raja S, Hasnain M, Hoersch M, Gove-Yin S, Rajagopalan C. Trauma Informed Care in Medicine. Family & Community Health. 2015;38(3):216–26. Found at: https://insights.ovid.com/pubmed?pmid=26017000.

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