Trauma Informed Care

Current events are bringing awareness to trauma and its lasting effects on the mind and body.  But few are talking about the implications this has for trauma survivors in seeking care and the lack of trauma informed care in medicine.

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 informed care needs to be a central aspect of these discussions as trauma lasts a lifetime but few health care providers are well trained in the trauma-informed care approaches. This means that many with a history of trauma – which can include medical trauma, domestic violence, childhood abuse, sexual assault, and more – can face retraumitization when seeking care. Unfortunately, this population often needs more care as trauma brings chronic physical and psychological illnesses or to address injuries caused by trauma (even long after the traumatic incident).

When Trauma Survivors Seek Care

Trauma isn’t rare. Statistics show that trauma is pervasive. According to the US National Center for PTSD, about 60% of men and 50% of women experience at least one trauma in their lives and about 8% of the American population suffers from Post Traumatic Stress Disorder (PTSD).[3]  While not all trauma results in PTSD, all trauma should be respected when providing care as trauma manifests differently for each individual and comes in many forms.

For a survivor, the anxiety of seeking care may be so overwhelming that they avoid medical care all together.[4] However, when providers respond “in a trauma-sensitive, person-centered way, patients feel safer disclosing, are more likely to access services, and are more likely to find treatment helpful.”[5]  It is thus critical for providers to ask about abuse, make it safe for survivors to disclose their experiences, respond compassionately, tailor services to individual needs, and offer appropriate referrals.[6] Again, “without trauma framework, services may be retraumatizing.”[7]

If a survivor does seek care, office visits may amplify anxious feelings, “unbearably intense emotions,” and trigger “memories of trauma including physical pain by an authority.”[8]  It is important to remember the “dynamics of power and control in the perpetration of [abuse] and its relevance in the health care setting.”[9]  Trauma is often inflicted by someone in position of authority over or with more power than the victim – this can include parents, law enforcement, doctors, romantic partners, and community leaders, among others. Thus, it is crucial to acknowledge “the idea of power differentials and use of control or misuse of authority by perpetrators. Within the medical model, health care professionals are by definition the power holders and, beyond this, may choose to present as more or less authoritarian.[10] For medical professionals to help trauma survivors, research suggests they take a “nonauthoritarian stance” thus “relinquishing of ‘power’ in favor of partnership with the patient.”[11]

What may seem a “simple office visit” may indeed “trigger memories of past abuse; generating overwhelming feelings of helplessness and fear of physical harm.  In fact, “examinations and procedures that health care providers might consider innocuous or routine can be distressing for survivors, because they may be reminiscent of the original trauma.[12]  Furthermore “exclusive focus on the body, lack of control, invasion of personal boundaries, exposure, vulnerability, pain, and sense of powerlessness are common experiences in the health care environment and may be extremely difficult for survivors because they can mirror aspects of past abuse. An appreciation of the dynamics and long-term effects of [abuse] is the first step toward a better understanding of survivors’ needs and responses to care.”[13]

What is Difficult for Survivors?

Seeking care can be hard for survivors because “some health care providers are not always sensitive to the ways that trauma can impact health or they may seem rushed, making it hard to connect.”[14]

The experience of being traumatized carries with it, by definition:

  • Intense, overwhelming feelings
  • Feeling powerless or helpless to protect oneself
  • A fear of loss of life or bodily injury.”[15]

All of which can be evoked in a medical setting.

Survivors may experience flashbacks, panic, depression, difficulty trusting, and other effects of the abuse or assault.[16]  Many aspects of care may be triggering for survivors of abuse because they “remind the patient of the original traumatic experience.”[17]  This includes:

  • Examinations: Being in an exposed, vulnerable position. The close proximity of the doctor, being touched, invasion of privacy when asked about personal habits and family history.[18]
  • Procedures that mimic previous trauma: Invasive procedures, physical or chemical restraint, mouth blocked open.[19]
  • Student training: Doctors discussing the “case” with a medical student in front of the patient may be experienced as being treated as an “object.”[20]

Many survivors may become overwhelmed in the office and may behave as though they were currently being abused.[21]  These behaviors may come in the form of crying, becoming angry, or shutting down emotionally.[22]  Additionally, a survivor “may become unresponsive and unable to give an adequate history or description of her problems.”[23]

Finally, for a survivor, seeing a health care provider means the survivor must paying attention to what’s going on in their body which might be difficult for them for many reasons.[24]  To cope with stress or anxiety, survivors may distance themselves or dissociate, which can make it hard to feel what’s going on in their body.[25]  While dissociation is a tool that survivors develop to continue functioning despite the trauma suffered, it can have an enormous effect on care including the ability to be present to take in and process information, or say what a survivor needs.[26]  Such dissociation may not be within the survivor’s control as visits that trigger survivors may result in dissociation despite their efforts to stay present.[27]

Barriers to Care Presented by Healthcare Providers

Survivors may encounter several barriers to receiving care that can come from providers themselves, including “misinformation or misunderstanding about the nature and long-term effects of [abuse] for the adult patient and a lack of recognition for the need to assess [abuse] history in adults.”[28]  Other barriers may include:

  • “A lack of tools for assessment and intervention,
  • Difficulty in appropriately responding to disclosure,
  • Time constraints,
  • Fear,
  • Victim blaming,
  • Avoidance of the issue because of the providers’ own issues.”[29]

These barriers may result in the provider making inadequate diagnoses, misdiagnoses, and labeling survivors as “difficult” because of their trauma reactions and problems in the doctor-patient relationship.[30]  They may also “result in a feeling of revictimization and a perpetuation of the secrecy that overshadows abuse, continuing rather than interrupting the cycle of trauma.”[31]

Providers’ Role Can Aid in Healing

Providers have the “invaluable opportunity to interrupt the cycle of abuse in our society by creating a new pattern of health and well-being.”[32]  Positive experiences can help survivors heal from past abuse, for, “it is helpful to experience a validating authority figure who gives the person as much control and choice about the experience as possible.”[33] When experiences are empowering and compassionate, it can counteract feelings of helplessness that they may have felt in the past and fear in the present.[34]

A key to a positive healthcare experience is to help the survivor feel safe and decrease “feelings of vulnerability or loss of control.”[35]  Providers may need to “work to change the situation and the stimuli rather than asking patients to change their reactions to the stimuli.”[36]

Trauma survivors may have a wealth of needs that do not fit neatly into the current healthcare system. These individuals are often derogatorily labeled as “difficult”, “demanding”, “non-compliant”, “manipulative”, “attention seeking”, or even “rude” by providers who misunderstand their needs or underestimate the depth of trauma and its lasting effects. Reframing a trauma survivor’s reactions to care through the lens that the survivor may be reliving past trauma and/or may be defensive and actively trying to avoid trauma can help decrease provider tension and allow for more compassionate treatment.

Compassion for survivors is ultimately what is needed most. For there is no salve to ease the tenderness of vulnerability but compassion.

____________________________________________________

[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.

[3] U.S. Department of Veterans’ Affairs, National Center for PTSD. Found at https://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp. Accessed on Feb 23, 2018.

[4] Supra note 1.

[5] Warshaw, C. (2014). Trauma-informed services: Implications for Healthcare Providers and Systems. Lynne Stevens Memorial Lecture. Warshaw, C. (2014). Trauma-informed services: Implications for Healthcare Providers and Systems. Lynne Stevens Memorial Lecture. Found at: https://www.bu.edu/familymed/files/2014/06/BMCLynneStevensMemorialLecture51314Handout.pdf.

[6] Warshaw, C. (2014). Trauma-informed services: Implications for Healthcare Providers and Systems. Lynne Stevens Memorial Lecture. Found at: https://www.bu.edu/familymed/files/2014/06/BMCLynneStevensMemorialLecture51314Handout.pdf.

[7] Id.

[8] Supra note 1.

[9] Havig K. The Health Care Experiences of Adult Survivors of Child Sexual Abuse. Trauma, Violence, & Abuse. 2008;9(1):19–33. Found at: http://journals.sagepub.com/doi/abs/10.1177/1524838007309805.

[10] Id.

[11] Id.

[12] Schachter, C., et. al. (2008) Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse. Ottawa: Public Health Agency of Canada. Found at: https://www.integration.samhsa.gov/clinical-practice/handbook-sensitivve-practices4healthcare.pdf.

[13] Id.

[14] A Health Care Guide for Survivors of Domestic and Sexual Violence. Futures Without Violence brochure. National Center on Domestic Violence, Trauma & Mental Health. Found at: https://secure3.convio.net/fvpf/site/Ecommerce/1872867814?VIEW_PRODUCT=true&product_id=2881&store_id=1241.

[15] Supra note 1.

[16] A Message for Health Care Providers Concerning Survivors of Sexual Abuse/Assault. Prince Edward Island Rape and Sexual Assault Centre. Found at: http://www.peirsac.org/peirsacui/er/educational_resources12.pdf.

[17] Supra note 1.

[18] Id.

[19] Id.

[20] Id.

[21] Id.

[22] Id.

[23] Id.

[24] Supra note 14.

[25] Id.

[26] Id.

[27] Id.

[28] Supra note 9.

[29] Id.

[30] Id.

[31] Id.

[32] Id.

[33] Supra note 1.

[34] Id.

[35] Supra note 9.

[36] Id.

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One Response to Trauma Informed Care

  1. […] 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. […]

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