Candice Schachter, P.T., Ph.D. April 23, 2015 Using trauma-informed care in health care practice to...

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

April 23, 2015

Using trauma-informed care in health care practice to

respond to difficult situation: triggers & disclosure

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 Saskatchewan2

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 Two has been designed to help participants to use trauma-informed

framework to:

explore practical responses to 'difficult situations' in clinical practice (e.g., triggers/flashbacks) when working with adult survivors of adverse childhood experiences and abuse;

explore practical strategies to help avoid such 'difficult situations';

consider responses to an adult patient's disclosure of childhood abuse;

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

Objectives

3

During this 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. Please do what you need to do to take

care of yourself.4

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.

5

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

6

2009 7

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;8

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’. 9

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.

10

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)

Key areas for health care providers

Clark 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.

12

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

14

Difficult situations• A patient might become very upset and angry,

fearful, anxious, or sad during treatment• The health care provider may not know why this

has happened.• Such emotionally charged, “difficult situations”

may leave the health care provider feeling unsure about how to respond.

15

Contributing to difficult situations...

TransferenceOccurs when an individual displaces thoughts, feelings, and/or beliefs about past situations onto a present experience.

TriggersA trigger is anything (e.g., a sight, sound, smell,touch, taste or thought) associated with a past negative event that activates a memory, flashback or strong emotion.

16

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

Transference

One woman said:

Too many things in my mouth at once...You’re making me hold my mouth open too long, because you have to do that when somebody’s forcing you to do oral sex, like when you’re a child...

18

One woman said:

During my first experience in physical therapy, they didn’t have any Kleenex, and the minute [the physiotherapist started] touching me I just started sobbing without having any idea of why.

Triggers

19

A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment” that may be sudden or gradual, transient or chronic;

Can be seen as a continuum from day dreaming → → highway hypnosis →

→ Dissociative Identity Disorder

Dissociation

20

Non verbal indicators of discomfort, distress, or dissociation

Physiological reactions resulting from extreme stress (sympathetic nervous system’s fight or flight response) Rapid heart rate and breathing (breath holding

or sudden change in breathing pattern may also be seen);

Pallor or flushing;

21

How might a patient appear?

Sweating;

Muscle stiffness, muscle tension, and inability to relax;

Startle response;

Sudden flooding of strong emotions (e.g., anger, sadness, fear, etc.);

22

Cringing, flinching, or pulling away;

Trembling or shaking;

• Decreased concentration level;

• POSSIBLY-no noticeable difference.

How might a patient appear?

23

Considering my type of practice:

List 3 actions that I might do that could be triggering to a survivor.

List 3 things about being a patient in my practice that might be triggering for a survivor (excluding my actual actions).

Questions for reflection: Triggers

24

List 5 actions that a health care provider might do that could be triggering to a survivor.

List 5 things about being a patient seeing a health care provider that might be triggering for a survivor (excluding the actions of a health care provider).

Questions for reflection: Triggers

25

Responding to Difficult Situations:

Stop

Appreciate

Validate

Explore26

The SAVE strategy

Stop treatment

27

Appreciate what is going on for the patient

Try to appreciate and understand the person’s situation by using empathy and immediacy.

Immediacy is verbalizing one’s observations and responses in the moment, using present tense language.

28

For example, ‘Your fists are clenched and you look angry. What is happening for you?’

‘You seem upset’ or ‘I doubt there is anything that I can say that will make this easier. Is it okay with you if I sit here with you for a few minutes?

Appreciate

29

If the patient is unable or unwilling to answer, the practitioner can shift the focus to determining possible ways to be helpful

e.g. “How can I help you?”

Appreciate

30

Orient patients to the present;

Encourage slow, rhythmic breathing;

Do not touch them;

Offer verbal reassurance in a calm voice;

Appreciate

31

Avoid asking complicated questions;

Offer a glass of water;

Normalize the experience;

Ask what the clients need right now.

Appreciate

32

Validate the patient’s experience

Such interactions can be difficult; Health care encounters are difficult for

many people. For example, “Given what you have just told

me, it makes sense that you feel angry.”

33

Explore the next step. For example…• “Who can I call to come and stay with you?” • “This has been difficult for both of us. I am not

sure where to go from here. Can I call you tomorrow to see how you are doing?”

Explore

34

ways to work together that would feel better for the patient Reassure the patient that you would like to find the best way to work together.Discuss implications for future treatment.

Explore

35

The appointment has been going well. Suddenly, the patient’s words and tears and other body language suggest great upset. How do I respond?

The appointment has been going well. Suddenly, the patient begins to shout at me and sounds very angry. I feel fearful. How do I respond?

Questions for reflection: SAVE

36

Asking about sensitivities and difficulties that may be part of an examination, treatment, or other care.

Task-specific inquiry

37

All clinicians should use task-specific inquiry with all patients during each and every visit.

Task-specific inquiry

38

Using task-specific inquiryA health care provider might ask… “Have you ever had difficulty with

examinations/procedures like this one?”If the individual answers ‘Yes’, follow-up using

an open-ended question such as:“What can I do to make it easier for you?”

39

Using task-specific inquiry

• Before beginning an exam, offer one additional opportunity to disclose something the patient thinks might be relevant:• Is there anything else you think I should

know before we begin the examination?

40

Task-specific inquiry• Task-specific inquiry should be used: • during an initial meeting• before any new exam or procedure • any time body language suggests

discomfort or difficulty

41

Why use task-specific inquiry?

Help alert you to potential difficulties;

Demonstrates to patients that you recognize they may be having difficulty and that you want to work with them to decrease their discomfort.

Provides the survivor an opportunity to disclose as much as comfort/trust allow.

42

If attention to these points is missing… 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.

43

Considering my type of practice:

Formulate three questions to use when asking about potential task-specific difficulties.

During an examination, a patient’s body language suggests increased discomfort. What task specific questions can I as?

Questions for reflection: Task specific inquiry

44

Inquiring about past abuse There is no one correct way to ask about a

history of childhood abuse. Direct approaches are a relief to some

survivors, but too intrusive for others.Explain why you are asking. For example:You ask everyone this question;Past abuse can affect the way that a

clinician and patient interact, and affect health…

45

Asking effectivelySpend time developing an initial rapport;

Ask in a non judgmental way;

Communicate empathy verbally and non verbally;

Develop comfort asking and talking about trauma;Be aware of your own feelings about trauma and violence;

Use behavioral language instead of general terms. E.g. “Has anyone ever forced you to engage in sexual

behavior when you did not want to?”

46

Responding effectively to disclosure Accept the information; Express empathy and caring; Clarify confidentiality; Normalize the experience by acknowledging

the prevalence of abuse; Validate the disclosure;

47

Responding effectively to disclosure

Address time limitations; Offer reassurance to counter feelings of

vulnerability; Collaborate with the survivor to develop an

immediate plan for self care; Recognize that action is not always required; Ask whether it is a first disclosure;

48

Responding effectively to disclosure

At the time of disclosure or soon after: Discuss the implications of the abuse history for

future health care and interactions with clinician; Inquire about social support around abuse

issues.

49

Responding effectively to disclosure

Let the person know that the child who is abused is not at fault for the abuse;

Link disclosure to the care you provide.

50

What do I say when inquiring about history of interpersonal violence?

A patient who has previously denied a history of childhood abuse, suddenly discloses such a history of childhood abuse in the middle of a physical examination. How do I respond?

Questions for reflection: Disclosure

51

• Does my environment foster a sense of safety for potential disclosure? • Are there any steps I could take to

increase their feelings of trust and safety?

52

Questions for reflection: Disclosure

• How do I want to integrate routine inquiry about trauma?

• How would I feel if a client disclosed a history of child sexual abuse or other trauma? How would I know whether my reactions are helpful for my patients?

53

Questions for reflection: Disclosure

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.

55

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)

56

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

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

57

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.58

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.

59

Questions for reflection: GeneralMight 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?

60

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?

61

Considering my type of practice:

List 3 actions that I might do that could be triggering to a survivor.

List 3 things about being a patient in my practice that might be triggering for a survivor (excluding my actual actions).

Questions for reflection: Triggers

62

List 5 actions that a health care provider might do that could be triggering to a survivor.

List 5 things about being a patient seeing a health care provider that might be triggering for a survivor (excluding the actions of a health care provider).

Questions for reflection: Triggers

63

Considering my type of practice:

Formulate three questions to use when asking about potential task-specific difficulties.

During an examination, a patient’s body language suggests increased discomfort. What task specific questions can I as?

Questions for reflection: Task specific inquiry

64

The appointment has been going well. Suddenly, the patient’s words and tears and other body language suggest great upset. How do I respond?

The appointment has been going well. Suddenly, the patient begins to shout at me and sounds very angry. I feel fearful. How do I respond?

Questions for reflection: SAVE

65

What do I say when inquiring about history of interpersonal violence?

A patient who has previously denied a history of childhood abuse, suddenly discloses such a history of childhood abuse in the middle of a physical examination. How do I respond?

Questions for reflection: Disclosure

66

• Does my environment foster a sense of safety for potential disclosure? • Are there any steps I could take to

increase their feelings of trust and safety?

Questions for reflection: Disclosure

67

• How do I want to integrate routine inquiry about trauma?

• How would I feel if a client disclosed a history of child sexual abuse or other trauma? How would I know whether my reactions are helpful for my patients?

Questions for reflection: Disclosure

68

Questions for reflection: GeneralMight 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?

69

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?

70

Summary Keep the umbrella of safety OPEN by using

trauma informed care at all times with all patients;

Apply the S A V E strategy to all difficult situations;

Use task-specific inquiry with all patients;

71

Summary Ask about a history of violence and be ready

to respond to disclosure;

Work WITH the patient to identify and evaluate alternatives that work for both the patient and health care provider;

Reflect on your practice to improve the care you provide.

72

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.

73

Comments and Questions

74