Using trauma-informed care
in health care practice to
respond to difficult situation:
triggers & disclosure
Candice Schachter, P.T., Ph.D.
April 23, 2015
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
2
Objectives
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 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.
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.
Creating relationships that are safe and
empowering can be profoundly positive.
The umbrella of safety
14
• 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...
Transference
Occurs when an individual displaces thoughts, feelings,
and/or beliefs about past situations onto a present
experience.
Triggers
A 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
Abusive Relationships Therapeutic Relationship
 Betrayal, boundary
 Violation of boundaries,
violation
trust
 Unheard/denied/invalidat  Survivor perspective
ed victim voice
unheard
 Power imbalance
 Powerlessness
powerlessness
 Abuser’s reality +
 Reality = HCP’s values
interpretation dominate
 Symptoms redefined by HCP
 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
Triggers
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.
19
Dissociation
 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
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
How might a patient appear?
 Cringing, flinching, or pulling away;
 Trembling or shaking;
• Decreased concentration level;
• POSSIBLY-no noticeable difference.
23
Questions for reflection: Triggers
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).
24
Questions for reflection: Triggers
 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).
25
Responding to Difficult Situations:
Stop
The SAVE strategy
Appreciate
Validate
Explore
26
S
top 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
A
ppreciate
 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?
29
A
ppreciate
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?”
30
Appreciate
 Orient patients to the present;
 Encourage slow, rhythmic breathing;
 Do not touch them;
 Offer verbal reassurance in a calm voice;
31
Appreciate
 Avoid asking complicated questions;
 Offer a glass of water;
 Normalize the experience;
 Ask what the clients need right now.
32
V
alidate 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
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?”
34
E
xplore
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.
35
Questions for reflection: SAVE
 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?
36
Task-specific inquiry
 Asking about sensitivities and difficulties that
may be part of an examination, treatment, or
other care.
37
Task-specific inquiry
All clinicians should use task-specific
inquiry with all patients during each and every
visit.
38
Using task-specific inquiry
A 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.
43
Questions for reflection:
Task specific inquiry
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?
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 effectively
 Spend 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
Questions for reflection: Disclosure
 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?
51
Questions for reflection: Disclosure
• 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
Practitioners’ self-care
 Self 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-care
 For 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
violence
 Herman 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, responsibility
 Emphasizing a sense of safety, trust, choice,
collaboration
 Encouraging 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: 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?
60
Questions for reflection: General
 Do 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
Questions for reflection: Triggers
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).
62
Questions for reflection: Triggers
 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).
63
Questions for reflection:
Task specific inquiry
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?
64
Questions for reflection: SAVE
 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?
65
Questions for reflection: Disclosure
 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?
66
Questions for reflection: Disclosure
• 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?
67
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?
68
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?
69
Questions for reflection: General
 Do 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.
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Comments
and
Questions
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