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 should be a foundation of all healthcare interactions. Disclosure is the first step in helping health care providers practice trauma informed care. Understanding the importance of disclosure, what inhibits or facilitates disclosure, when and how to ask about disclosure, and how to respond can help develop a strong and trusting doctor-patient relationship. Knowing how to help patients transfer care to new providers can continue strengthening these relationships and promote healing for the survivor.
Before reading this post, I suggest going back and reading earlier posts on this subject:
Disclosure
Regardless of whether health care providers do or don’t know of a patient’s trauma history, trauma informed care should be the standard of care for all patients. However, trauma informed care is particularly important for survivors. Research shows that “survivors’ health care experiences can be enhanced or diminished by providers’ ability to elicit and receive [information about trauma] and to incorporate this knowledge into their interactions with patients and the environment in which care takes place.”3 However, many health care providers do not routinely inquire about [trauma], its long-term effects are under recognized, its related health problems are misdiagnosed, and it is not met with a sensitive, integrated treatment response.”2 In other words, it is important for survivors to be able to disclose their trauma history to providers to ensure they receive the best care.
Many survivors feel “a discussion about disclosure would help them to feel as if the provider would be best equipped to offer sensitivity and understanding about [abuse] and its effects.”3 Knowing that a patient has experienced trauma can impact care in myriad ways. For instance, it can help health care providers understand that “noncompliance” “is often not an indicator of a patient’s intent or commitment but rather is more significantly related to conflicted feelings about treating and caring for [their] body.”3 Moreover, disclosure can result in a better working relationship and even decreases the tendency for survivors to cancel appointments.3
Understanding trauma not only improves care, but not understanding trauma can actively harm care. Some suggest when providers fail to acknowledge trauma that survivors have to medical care, they may be “complicit in this continued suffering, for survivors may relive their traumas rather than discussing them in safety.”3 Thus disclosure is very important, though of course a very difficult subject.
Inhibiting factors for disclosure
There are several factors that may preclude disclosures including “past experiences with health care that were characterized by provider embarrassment, repulsion, pity, disinterest, and avoidance toward the abuse history.”3 Some survivors are hesitant to disclose their trauma because of they’ve experienced rejection in the past.3 As a result of this rejection, the symptoms that precipitated treatment worsened.3 Providers often label survivors as difficult “because of reactions and relational struggles related to [their trauma] and the distress caused by lack of understanding of [trauma] dynamics and effects by others.”3
The demeanor of the health care provider matters. It is important to remember the “dynamics of power and control in the perpetration of [abuse] and its relevance in the health care setting.”3 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.”3 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.”3 Given “the connection between an authoritarian demeanor of providers and characteristics of abusers,” researchers emphasize providers need to keep this dynamic in mind and be sensitive when taking a patient’s history.3
If providers want to ensure the best care for survivors, they must be aware of any explicit or implicit biases that might lend them to reacting negatively to disclosure or to patients who may seem “difficult.” It becomes important for providers to ask “what happened to this person” instead of “what is wrong with this person” in order to be open to disclosure.
Facilitating factors for disclosure
Facilitating factors for disclosure include:3
- An atmosphere of openness, professionalism, sensitivity, and concern;
- Providers who initiate active and routine inquiry of trauma for both genders;
- Providers who are prepared to listen to the experience of survivors without revictimizing, blaming, dismissal, or judgment;
- Providers who present as less authoritarian; and
- Allowing enough time for disclosure and discussion.
And most importantly, if a disclosure is made, providers must “demonstrate belief in both the survivor’s history of [trauma] and the reality of its effects on health and health care…”3
When to ask about trauma
All providers should ask their patients about trauma as a matter of course (see below as to how). Once a provider has established some rapport and trust with a patient, they may be able to ask patients whether they have a history of abuse.1,4 Before engaging in this discussion, however, a provider should be sure that they feel somewhat comfortable discussing the topic and they can provide an environment where the patient feels safe.1 Additionally, providers need to have sufficient time to begin to discuss issues of abuse and should have resources to offer the patient for psychological assistance.3
It may be particularly prudent to ask whether a patient has a history of trauma if they present with diagnoses like: chronic pain syndrome, chronic pelvic pain, IBS, PTSD, eating disorders in adolescence, depression, headaches, obesity, substance use behaviors, have been through multiple medical procedures.1 It may also be important to consider asking about trauma if a patient shows a difficulty in establishing trust or feelings of helplessness, shame, or guilt or has difficulty with medical procedures.1
How to ask about trauma
Asking about trauma can be a delicate subject. While there may be discomfort associated with asking about past trauma, especially sexual abuse, providers may see patients “relieved by the unlocking of secrets” and it may help providers as “complex cases become clear.”3
Providers can normalize questions about trauma “by explaining [to survivors] that this is a routine question” that they ask all patients and “that it may be important to the survivor’s physical or mental health.”1 Providers may incorporate questions in their intake paperwork. For instance, they may just have a line on the paperwork that asks “Have you experienced any trauma in your life?” much like they would ask if a person has been diagnosed with heart disease. Asking it in this context can ensure that survivors who are not able to verbally express their trauma nonetheless have a way to indicate to the provider that extra sensitivity is particularly important for that patient.
There are many ways for a provider to verbally ask about trauma. These can include:1
- “It is not uncommon for a person to have been emotionally, physically, or sexually victimized at some time in their life, and this can affect their health many years later. Has this ever happened to you?”
- “Are there any experiences not yet discussed that have been particularly difficult or painful for you?”
- “Have there been any traumatic experiences or major losses in your life?”
Remember that “Like healing, disclosure is not necessarily a linear process, nor can it always be accomplished via a one-time inquiry.”3 It may take time for survivors to feel safe enough to disclose and they may not be able to disclose all of the trauma they have experienced. Further, their ability to talk about their trauma may vary per visit. It is important not to push survivors to talk about their trauma, which may be triggering or serve to revictimize, but to allow them to share what they need to, when they need to. Being open to disclosure at any time will help providers be able to respond appropriately to disclosure.
Responding to disclosure
The appropriate response to disclosure is vital. Providers must validate the survivor’s experience. Providers can consider responding to disclosure with compassion by telling the survivor: 1
- “I’m sorry this happened to you. Please know you are not alone and it is not your fault. Your experience must have been very frightening, and it would not be uncommon to feel angry, embarrassed, and fearful afterward.”
- “I am very sorry that happened to you. And I am very glad that you felt able to tell me. Is there any way I can help now?”
Additionally, providers should enquire into whether a patient is currently safe or enduring trauma in the present, like abuse. Asking about social support systems the patient may have to cope with trauma can help providers understand how best they can supplement that support or if the survivor needs to be connected to supports.
As noted above, providers need to be aware of their own biases in order to be able to respond to disclosure appropriately. If providers convey a negative message to the survivor, “the survivor may re-experience the feelings associated with abuse such as betrayal, stigmatization, and powerlessness.”1 The negative message may not even need be specific or verbal. Survivors can feel when a provider is uncomfortable with disclosure. They will notice when providers do not take the time to listen, are unable to respond to the disclosure, or even brush off the disclosure. Dismissive suggestions (e.g. “well you should do yoga”) or comparisons to other patients they treated with trauma (e.g. “I once had a patient with trauma and they were able to handle procedures just fine.”) will serve to rupture the doctor-patient relationship and negatively impact survivors’ care.
Providers who take the time to learn trauma informed principles and put them into practice, including when and how to ask about trauma, can make a huge difference. For, “When disclosure is received and acted upon in a sensitive, therapeutic manner, the survivor is empowered and can enter into an effective therapeutic alliance.”1
Transfer of care
At times, providers will need to transfer care of a patient to another. If this occurs, particularly without prior notice, it “can evoke feelings of abandonment and erode trust”2 especially as survivors face disclosing their trauma again. This may happen when a provider retires, moves, or even leaves for vacation or maternity leave, among other absences. Experts recommend that, when possible, patients be given a choice of providers when being transferred.2 Providers should also let survivors know well in advance of their plans that may require transferring care. This allows survivors the option of making alternative arrangements for their care.2
Additionally, according to experts, it is best when providers are able to introduce survivors to the practitioner who is taking over.2 This should be accompanied by a “discussion about what information regarding past [trauma] the individual consents to be given” to the new provider.”2 And if transfer of care will be permanent, providers “should ensure that the new colleague is knowledgeable about interpersonal violence and the sensitive care of survivors.”2
Similarly, if providers are referring survivors to specialists, they should consider discussing this transition in care with the survivor and offer to discuss the survivor’s case with the specialist and what information to disclose. Coordination of care in this way can help ensure that survivors continue to receive trauma informed care and develop trust between survivor and all care providers.
All transitions in care are important for survivors and can make the difference between continuity of care and disruption in care. Focusing on establishing trust between the survivor and new provider will ensure that survivors continue to heal in their medical care and get the care they need. Remember, it is already difficult for survivors to seek care, and that the anxiety of seeking care may be so overwhelming that they may avoid medical care all together.5 If transitions in care are not handled sensitively, it can mean they do not continue care or may face retraumatization.
Helping create a sense of safety for survivors, including through receptive environments for disclosure and ensuring transfers to other providers are undertaken with great care, can be healing. All health care providers should consider how to implement trauma informed care in their practices in order to facilitate this healing process.
Feeling heard and understood, experiencing compassion and kindness – these are as impactful as any medicine a provider may administer.
Trauma Informed Care Series:
- Trauma Informed Care Principles
- Trauma Informed Care in Practice
- Trauma Informed Care – Disclosures and Care Transitions
- Trauma Informed Care – Non-Clinical Staff Encounters
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Citations:
- Childhood Sexual Abuse History Management Strategies found at http://www.csacliniciansguide.net
- Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse was researched and written by Candice L. Schachter, Carol A. Stalker, Eli Teram, Gerri C. Lasiuk and Alanna Danilkewich. See also Havig K. The Health Care Experiences of Adult Survivors of Child Sexual Abuse. Trauma, Violence, & Abuse. 2008;9(1):19–33. Found at: https://www.researchgate.net/publication/256454689_Handbook_on_Sensitive_Practice_for_Health_Care_Practitioners_2009 (pdf)
- 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
- 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.
- 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.
[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.
