Candice Schachter, P.T., Ph.D.

April 23, 2015

Integrating trauma-informed care into healthcare practice

Sensitive Practice Project Researchers

Candice L. Schachter, PT, PhD

School of PT, College of Medicine, U of Saskatchewan

Carol A. Stalker, RSW, PhD Eli Teram, PhD

Faculty of Social Work Wilfrid Laurier University

Gerri Lasiuk, RN, MN, PhD

Faculty of Nursing University of Alberta

Alanna Danilkewich, MD

College of Medicine U of Saskatchewan

http://images.google.ca/imgres?imgurl=http://3.bp.blogspot.com/_8_qdV9hPklg/S1VVZ4kYdFI/AAAAAAAAAAM/V8mgmGdmOww/s160/Shouldnt%2Bhurt%2Bto%2Bbe%2Ba%2Bchild.JPG&imgrefurl=http://www.notwithmychild.org/&usg=__EqA8Gy_mQObPMVuKiZh5EeyXN00=&h=122&w=160&sz=8&hl=en&start=117&itbs=1&tbnid=wBlNdaToJFQM0M:&tbnh=75&tbnw=98&prev=/images%3Fq%3Dit%2Bshouldnt%2Bhurt%2Bto%2Bbe%2Ba%2Bchild%26start%3D108%26hl%3Den%26sa%3DN%26gbv%3D2%26ndsp%3D18%26tbs%3Disch:1Session One has been designed to help participants to:

gain insight into ways adverse childhood experiences + abuse affect interactions of adult survivors with health care providers;

develop an understanding of the evidence for why all health care providers should ensure that their practice and office/organizational procedures are trauma-informed;

explore a conceptual framework for trauma-informed clinical practice;

develop questions for ongoing self-reflection about one’s own work to ensure that it is trauma-informed.

Objectives

Format of Presentation

Quotations from survivors of childhood sexual abuse to illustrate points;

Questions to facilitate self reflection;Discussion in dyads and triads to provide

time for reflection.

Difficult discussion for many of us

High prevalence rates of interpersonal violence suggest that: Some of us have experienced and or

witnessed violence and abuse in childhood.We may know someone who was abused.

Please take care of yourself during this presentation.

Trauma-informed care is an issue for all health care practitioners (HCP)Prevalence of childhood sexual abuse

As many as one third of women and 14% of men are survivor of childhood sexual abuse.

All health care providers – whether they know it or not – encounter survivors of interpersonal violence in their practices.

No Effects

to

Range of Difficultie

s

Effects of childhood sexual abuse carried into adulthoodEffects of past abuse in adulthood can be seen

on a continuum:

Difficulties may go unrecognized by the health care providers.

Long term effects on health Poorer physical health

Higher levels of dental fear

Mental health problems

Relationships: abusive vs therapeutic

Therapeutic RelationshipViolation of boundaries,

trustSurvivor perspective

unheardPower imbalance

powerlessnessReality = HCP’s values

Symptoms redefined by HCP

Abusive RelationshipsBetrayal, boundary

violationUnheard/denied/

invalidated victim voice Powerlessness

Abuser’s reality + interpretation dominate

Secret---knowledge, information, relationships

Developing the Handbook: Research method

I •Interviews with survivors about experiences with health care practitioners

II •Working groups of survivors and health care practitioners

III •Consultations with participants + additional health care practitioners to develop 2nd Edition of Handbook

2009

Specific behaviours and feelings arising during health care encounters• Distrust of authority figures;

• Fear and anxiety;

• Discomfort with persons who are the same gender as their abuser(s);

• Triggers and dissociation;

• Ambivalence about the body;

• Fear of judgment;

Specific behaviours and feelings arising during health care encounters Need to feel ‘in control’;

Feeling unworthy of care;

Body pain;

Conditioning to be passive;

Self harm.

These difficulties and discomforts contribute to ‘difficult situations’.

Understanding symptoms and behaviors using the trauma informed approach

Symptoms, (behaviors, feelings, needs during health care etc.) Can be seen as coping strategies adopted by

the survivor.Symptoms likely arose within the context of

trauma.

Understanding symptoms and behaviors using the trauma informed approach

Individuals with complex PTSD may experience these characteristics of complex trauma during health care encounters:Reexperiencing Avoidance Hyperarousal

Dysfunctional or distorted beliefs can develop out of an attempt to make sense of the abuse.

(Clark 2014)

Fear of Judgment

One man said:

…when they do my teeth they are going to say, “Oh you haven’t been taking care of them, you should have come in before.”

One man said:

I feel really trapped in the chair, in a very vulnerable position … where you have your mouth open, you’re laid back. For me, a lot of my trauma occurred when I was in a laid back position ... and [so having a health care provider] ... over the top of me, I find that very threatening.

Lack of Control

Conditioning to be passive or aggressive

One woman said:

[The health care practitioner did something and] I really freaked but ... I didn’t show her I was freaking, because our history is that you don’t let on if things are a problem for you. You just deal with it however you can ... by dissociating or what have you.

Gender More similarities than difference between ideas

of men and women. Men stressed:

Recognition of male survivorsFear of judgment of being

PerpetratorGay (for heterosexual men)

Struggles with society’s image of manly men versus the weak victim

Anger--Aggression

What’s the big deal? Your patient may find that she or he:

can’t be present-listen and take information in;is unable to tolerate certain care;has problems with adherence; can’t take responsibility for health care;And possibly, CAN’T RETURN FOR FURTHER

TREATMENT.

Interpersonal violence affects a health and health care.

Implications for health care provider One man said:

There’s a huge populous out there that just needs that extra gentle care. It’s because of that, maybe the whole populous needs to be treated the same way.

Given the pervasiveness of trauma, trauma-informed care (TIC) it is not only prudent but warranted!

Relationship between trauma- informed care and Sensitive Practice

Sensitive Practice is part of trauma-informed care

Key areas for health care providers

Clark et al 2014 suggest that:Areas most sensitive to disruption due to trauma:

safety, trust, esteem, intimacy/connection, power/control

Understanding survivors’ experiences of relationships can inform the provider about how to build relationships that are empowering rather than traumatizing.

Principles of Sensitive Practice

The primary goal of Sensitive Practice is to facilitate feelings of safety for the patient.

Safety: The crucial elementCreating relationships that are safe and empowering can be profoundly positive.

The umbrella of safety

Umbrella of safety

Principles of Sensitive Practice are the spokes that keep the umbrella of safety open;

When the umbrella of safety is open, the survivor can comfortably participate in health care.

One woman said:

...I now am beginning to understand that my physical wellness is really very connected to my emotional state, and if I'm not comfortable, if I'm feeling unsafe, then I'm not going to progress as quickly as a [health care provider] would want me to.

Umbrella of safety

Respect

One woman said:

I need to have ... the ability to connect with the practitioner ... so [that] I’m not ... a number ... that I feel like I’m being respected…

• What might get in the way of communicating my respect for my patients?

Questions for reflection: respect

One woman said:

...I was just another name on a [referral]...She had no warmth...I didn't experience being safe with her because I didn't think that this was somebody I could talk to at all, about anything! She just was NOT interested...

Rapport

• What is my own personal style of interacting with patients? Does it seem to foster rapport? Do I put effort into maintaining rapport with each patient over time?

Questions for reflection: rapport

One man said:

It’s the [health care practitioners] that…stop and give you a moment. And that’s one of the biggest healing things right there, that moment.

Taking time

• How do I balance the demands of my whole practice with the need to take adequate time with each patient?

• What can I do if my patient’s expectations of the time I should spend with that person are much greater than the time I can spend with them?

Questions for reflection: time

Sharing informationOne woman said:

I think they should spend the five minutes at the beginning saying, “This is what [I] need to do to figure out what will best work for you,” so that we’re prepared, you know. The element of surprise is just really really difficult to deal with…

• How do I ensure that patients have received what they feel is adequate information about examinations, treatment options, and treatment processes?

• In my practice, what do I do to help my patients retain information I share with them? What could I change?

Questions for reflection: information sharing

Sharing controlOne woman said:

[I’m learning that if I don’t have a sense of control ... I will walk away from [the situation].

Sharing controlOne woman said:

[When I told my dentist that I was having problems that day, he responded,] “Well, what do I need to do? Are you comfortable in the chair? Are we going to need more breaks today?” ... There’s just an unbelievable level of respect with this man. He’s fabulous.

• How willing am I to share control with my patients?

• What can I change in order to share control?

Questions for reflection: control

Respecting boundariesOne woman said:

As a survivor, I need to know that that person is not going to invade my space. Or do harm to me. Not necessarily physically, but emotionally.

• What are my own personal boundaries?• How do I know if they are being violated?• Could any of my actions be seen as

boundary violations by patients?

Questions for reflection: boundaries

One man said:

I often need the “permission” later in the examination, when my trust has built, to be able to speak or ask about those things as well.

Fostering a mutual learning process

• acknowledge and apologize • ask if treatment can continue• discuss difficulties

Fostering a mutual learning processIf the health care provider creates a problem

•How aware am I of nonverbal communication of discomfort? Do I follow up on these indicators with my patients?

•How do I get feedback from my patients about how I are doing in their eyes?•How often do I ask?

Questions for reflection: mutual learning

Understanding non linear healingOne woman said:

Parts of my body at different times might be untouchable. It's gonna change, depending on what I'm dealing with. So, you're not going to be able to make a list and count on that every time: it's gonna be a check-in every session.

Questions for reflection: non linear healing

My patient says she can’t tolerate a certain treatment today. What are the potential consequences of

proceeding with this treatment?

Demonstrating an understanding of sexual abuse and interpersonal violence

One woman said:

[The health care practitioner] had a book and a pamphlet on a table nearby where I was sitting that talked about sexual abuse, and so immediately that said to me, number one, she is open to this

Demonstrating an understanding of sexual abuse and interpersonal violence (cont’d)

and therefore if it comes up I know that I’m in good hands because [otherwise] this stuff would not be sitting here.

Questions for reflection: demonstrating an understanding

Am I aware of resources in my community to which I can refer survivors for care outside my scope of practice? Is this information readily available?

Guidelines

Practitioners’ self-careSelf care (e.g. sleep, exercise, food, relaxation,

et cetera) is crucial! In addition, practitioners may need to seek the

support of a colleague or counsellor to talk about their own reactions to disclosures of childhood sexual abuse or other difficult situations with patients.Can be done while maintaining patient

confidentiality.

Practitioners’ self-careFor health care providers who are also

survivors:It is recommended that individuals work through

and come to terms with their on history of childhood sexual abuse to avoid confusing their own difficulties with those of their patients.

The health care provider’s roles when working with survivors of childhood violenceHerman 1992: “No intervention that takes power

away from survivors can foster recovery no matter how much it appears to be in her best interest” (p 133)

What about SCOPE of PRACTICE?…I can’t fix all of their problems

True—but survivors are not asking you to, either!

The health care provider’s roles when working with survivors of childhood violence

Empowerment

Positive patient-clinician relationship that includes:Working collaboratively

Sharing control, information, responsibilityEmphasizing a sense of safety, trust, choice,

collaborationEncouraging active participation in health care and

providing information on some ways to do this.

The health care provider’s roles when working with survivors of childhood violence

Reconnection and Connection

Clinician can facilitate and encourage new and healthy connections between the survivor and her/his body;

Clinician can contribute to positive connection between the survivor and the clinician.

Questions for reflectionMight any of my current practices be interpreted

as insensitive by survivors? What needs to change?

In what ways might I adapt my own practice to incorporate specific guidelines?

Questions for reflectionDo any of these guidelines seem unrealistic or

unworkable in my practice? What are some alternative ways of following such guidelines?

How committed am I to incorporating these guidelines into my routine practice and into the routine practice of those who assist me in my work? What does this level of commitment mean to my patients?

• What might get in the way of communicating my respect for my patients?

Questions for reflection: respect

• What is my own personal style of interacting with patients? Does it seem to foster rapport? Do I put effort into maintaining rapport with each patient over time?

Questions for reflection: rapport

• How do I balance the demands of my whole practice with the need to take adequate time with each patient?

• What can I do if my patient’s expectations of the time I should spend with that person are much greater than the time I can spend with them?

Questions for reflection: time

• How do I ensure that patients have received what they feel is adequate information about examinations, treatment options, and treatment processes?

• In my practice, what do I do to help my patients retain information I share with them? What could I change?

Questions for reflection: information sharing

• How willing am I to share control with my patients?

• What can I change in order to share control?

Questions for reflection: control

• What are my own personal boundaries?• How do I know if they are being violated?• Could any of my actions be seen as

boundary violations by patients?

Questions for reflection: boundaries

•How aware am I of nonverbal communication of discomfort? Do I follow up on these indicators with my patients?

•How do I get feedback from my patients about how I are doing in their eyes?•How often do I ask?

Questions for reflection: mutual learning

Questions for reflection: non linear healing

My patient says she can’t tolerate a certain treatment today. What are the potential consequences of

proceeding with this treatment?

Questions for reflection: demonstrating an understanding

Am I aware of resources in my community to which I can refer survivors for care outside my scope of practice? Is this information readily available?

Questions for reflection: general Might any of my current practices be interpreted

as insensitive by survivors? What needs to change?

In what ways might I adapt my own practice to incorporate specific guidelines?

Questions for reflection: generalDo any of these guidelines seem unrealistic or

unworkable in my practice? What are some alternative ways of following such guidelines?

How committed am I to incorporating these guidelines into my routine practice and into the routine practice of those who assist me in my work? What does this level of commitment mean to my patients?

Summary Keep the umbrella of safety OPEN by using

trauma-informed care at all times with all patients;

Reflect on your practice to improve the care you provide.

Handbook on sensitive practice for health care practitioners: Lessons from adult survivors of childhood sexual abuse. Schachter, CL, Stalker, CA, Teram, E, Lasiuk, GA, Danilkewich, A. (2009). Public Health Agency of Canada: Ottawa ON.

Available free of charge online. See archived material on child sexual abuse, National Clearinghouse on Family Violence.

Treating the trauma survivor: An essential guide to trauma-informed care. Clark, C, Classen, C, Fourt, A, Maithili, S. Routledge. 2014.

Comments and Questions