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, and inviting office environment.
    • From the waiting room to the exam room, all aspects of care should be trauma informed. This includes training involves all staff in the clinic from the front desk personnel to billing to nurses to the doctor (see post on Staff Encounters).
    • Set up waiting rooms to minimize noise (especially from TVs, music, or slamming doors), harsh lighting, intrusive scents (like air fresheners), cramped seating, and chaos.
    • Have clear signage to direct survivors to amenities like bathrooms.
  • Ensure a culture of inclusivity.
    • Practice cultural humility, recognizing the unique aspects of cultural identities and aspects of power and privilege (or lack thereof). This means staff need to be open, self-aware and open to self-critique, encourage supportive interactions that may require them to take a different perspective, and commit to lifelong learning about cultural differences.
    • Have inclusive signs and literature throughout the office that depict diverse identities including race, disability, ages, and LGBTQ+ people.
    • Make paperwork gender neutral or gender inclusive. Forms that ask a patient to identify as male or female may exclude people who identify themselves along the gender spectrum or may make trans people feel uncomfortable. Sections of forms that say “for females only” may similarly not be appropriate and can be replaced by terminology like “if appropriate, please answer the following.”
    • Ensure survivors are being addressed by their preferred name and pronouns. Recognize that the name and sex on an insurance card or other official documents may not be the preferred name or correlate with the preferred pronouns of the survivor. A place on forms to indicate a preferred name and pronouns should be standard as well as entering a preferred name in the electronic medical record.
  • Because waiting for appointments maybe particularly difficult for survivors, provide a realistic estimate of the length of wait time.
    • Note that survivors may have strong emotional reactions (i.e. everything from excessive crying and difficulties communicating to irritability or anger) that might be related to a sense of fear or dread while waiting or simply being triggered by returning to a medical office if they have had traumatizing medical encounters in the past.
  • When escorting a survivor back to the exam room, ask if they prefer the door open, closed, or ajar while they are waiting and allow them to choose the seating that is most comfortable for them (i.e. some survivors may not want to have their backs to the door or feel there are obstacles in the way of them getting to the door should they need to leave).
  • Screen for trauma. This may be done on initial paperwork of by asking the survivor in the exam room. Most trauma survivors indicate that it is okay to be asked about their history.
    • If a survivor has someone accompanying them, the provider may want to find a moment to talk to the survivor alone, this is particularly important if the provider might see indications of interpersonal violence (IPV).
    • Not all survivors are able to disclose trauma when asked whether because they do not identify that they are survivors, they may see disclosing as indicating weakness, or they come from a culture that discourages them from sharing or seeking help. Even if they do not outright identify as survivors, they may give clues during the exam or they may disclose later after trust is established.
    • For individuals who may object to this question, providers should indicate that this is a routine question that you ask all patients.
  • If a survivor needs a translator, it can be important for them to have a specially trained interpreter rather than relying on family or friends. Though it is important to note that some individuals may not feel comfortable with a stranger in the room and may prefer a different arrangement. Ask the survivor what is most comfortable for them.
  • Meet the survivor when they are fully clothed and sit eye to eye with them to discuss the plan of care before any exam begins.
  • 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.
    • Unhurried attention is of the utmost important if a suvivor is disclosing their trauma to the provider. Providers should not press for details of any trauma but if a survivor decides to describe incidences in their past, the provider should slow down the exam and allow the survivor to say as much as they need to. In doing so, the survivor may present important information a provider needs to know for the survivor’s care and can help provide a healing and safe space for the survivor to be heard and believed. (See also Disclosures and Care Transitions)
      • Details of trauma may also be disclosed in various forms of communication. Some survivors may not be able to talk aloud about their experiences but may be more comfortable writing about their experiences and how it affects their care. Give survivors the option as to how they wish to disclose trauma and make sure to acknowledge any trauma disclosed assuring that the patient feels heard and that it is okay to talk about their experiences.
      • When survivors disclose trauma, ask consent before sharing that information with others – including other providers outside the office or staff and providers within the office. Ask what level of detail is okay to share with others.
  • Give the survivor as much control and choice as possible about what happens and when. This can include things like asking if the survivor wants to be weighed or told their weight and asking before trying to listen to a survivor’s heart and lungs. Just because an action seems normal and easy does not mean that it is normal or easy for the survivor. Do not assume that any action is okay without consent.
  • Do not make sudden movements or touch the survivor without consent. While some providers or staff may want to offer a kind pat on the back or even a hug to reassure a survivor and provide comfort, this may be triggering to a survivor.
  • 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. As above, this includes things like listening to heart and lungs or weighing a patient.
    • If the procedure involves instruments offer the survivor a chance to see and handle it if they would like (for example: a speculum or something that might be inserted into the mouth). 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.
    • Warn patients about any noises they may hear during the exam.
    • 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.
  • Be sensitive to how home treatments might be triggering and thus may lead to survivors’ reticence to follow instructions. This may include asking patients to use suppositories or inserting medications vaginally or anally, telling patients to take sitz baths, suggesting prolonged baths or showers that would require patients to be naked and exposed for long periods of time, etc. Do not label survivors as non-compliant or non-adherent but understand that the treatment prescribed may need to be amended to accommodate survivors’ needs.
  • 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.
  • Work with management to develop trauma-informed office policies. This may include allowing for flexibility in setting appointments, excusing missed appointments, accommodating late arrivals, waiving fees for paperwork that may be necessary for the survivor to receive services or public benefits, working on alternative communication plans (as described above), and committing to strategizing and working with the survivor when obstacles in care arise including obstacles in negative interactions with providers or staff (for example, having a phone meeting to discuss an adverse event, recognizing power differentials and how that trauma might impact relationships, helping the survivor feel safe and supported in those discussion so care can continue).
  • 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.

Providers should also be mindful of co-regulation of emotions. The way a provider reacts can have a positive or negative effect on the survivor. In the face of a survivor who is dysregulated and showing intense emotion, reactions by a provider that are elevated may further dysregulate the survivor and make them feel unsafe. However, if a provider takes stock of their own emotional state and can remain calm (i.e. not react with hostile tones, threats, a louder tone, dismissiveness, or other emotional response), the provider’s emotional state can help regulate the patient and bring the survivor back to a sense of safety.

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,
  • becoming irritable,
  • seeming uncooperative or defensive,
  • changes in tone or pace of communication, i.e., talking louder or softer; talking more quickly or ceasing to talk.

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

There are many reactions one may experience in response to trauma. It is important for providers to learn to recognize emotional, physical, cognitive, behavioral, and existential reactions (seen in the table below) to be able to help survivors. Some providers say that these reactions can happen in the absence of trauma and are not specific to trauma, but they must consider the context. Moreover, there is no harm in acknowledging these responses in the context of trauma or not and implementing the same compassion of trauma informed care for all (a concept known as “universal precautions” – or the idea of practicing something across the board regardless of circumstance).

 

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:

Additional resources for Trauma Informed Care

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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.

This entry was posted on Monday, June 25th, 2018 at 5:48 pm and is filed under Doctors, Health Care Providers, Mental Health, Nursing, Patients, Trauma Informed Care. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

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