Transcript ISSUES FOR PHYSICAL THERAPISTS WORKING WITH …
Integrating trauma-informed care into healthcare practice 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
Objectives
Session One has been designed to help participants to: http://images.google.ca/imgres?imgurl=http://3.bp.blogspot.c om/_8_qdV9hPklg/S1VVZ4kYdFI/AAAAAAAAAAM /V8mg mGdmO ww/s 160/Shouldnt% 2Bhurt %2Bto%2Bbe%2Ba% 2Bch ild.JPG&imgrefurl=http://www.not withm ychild.org/&usg=__EqA8Gy_mQO bPMVuKiZh5EeyXN00=&h= 122&w=160&s z=8&hl =en&st art=117&itbs= 1&tbni d= wBl NdaToJ FQM0M:&tb nh=75&tbnw=98&prev=/i mages%3Fq%3Dit% 2Bshouldnt%2Bhurt% 2Bto% 2Bbe% 2Ba%2Bchild%26star t%3D108%26hl%3Den%26s a%3D N%26gbv%3D 2%26ndsp%3D18%26tbs %3Disch:1 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.
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.
Effects of childhood sexual abuse carried into adulthood
Effects of past abuse in adulthood can be seen on a continuum: No Effects to Range of Difficulties 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 Abusive Relationships
Betrayal, boundary violation Unheard/denied/invalidat ed victim voice Powerlessness Abuser’s reality + interpretation dominate Secret---knowledge, information, relationships
Therapeutic Relationship
Violation of boundaries, trust Survivor perspective unheard Power imbalance powerlessness Reality = HCP’s values Symptoms redefined by HCP
II I
Developing the Handbook:
Research method
• Interviews with survivors about experiences with health care practitioners • 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 come in before.
” ’ t been taking care of them, you should have
Lack of Control
One man said: I feel really trapped in the chair, in a very vulnerable position … where you have your mouth open, you threatening. ’ 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
Conditioning to be passive or aggressive
One woman said: [The health care practitioner did something and you ] I really freaked but ... I didn’t show don’t let on if things are a problem by dissociating or what have you.
her I was freaking, because our history is that for you. You just deal with it however you can ...
Gender
More similarities than difference between ideas of men and women.
Men stressed:
Recognition of male survivors Fear of judgment of being Perpetrator Gay (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; A nd possibly,
TREATMENT.
CAN
’
T RETURN FOR FURTHER
Implications for health care provider
One man said: There ’ s a huge populous out there that just needs that extra gentle care. It be treated the same way. ’ s because of that, maybe the whole populous needs to 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. Creating 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.
Umbrella of safety
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.
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…
Questions for reflection: respect
• What might get in the way of communicating my respect for my patients?
Rapport
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...
Questions for reflection: 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?
Taking time
One man said: It ’ s the [health care practitioners] that…stop and give you a moment. And that moment. ’ s one of the biggest healing things right there, that
• •
Questions for reflection: 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 them? ’ s expectations of the time I should spend with that person are much greater than the time I can spend with
Sharing information
One 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 deal with… ,” so that we’re prepared, you know. The element of surprise is just really really difficult to
• •
Questions for reflection: information sharing
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?
Sharing control
One woman said: [ I’m learning that if I don’t have a sense of control ... I will walk away from [the situation].
Sharing control
One 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 man. He’s fabulous.
?” ... There’s just an unbelievable level of respect with this
Questions for reflection: control
• • How willing am I to share control with my patients? What can I change in order to share control?
Respecting boundaries
One 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.
Questions for reflection: boundaries
• • • 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?
Fostering a mutual learning process
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 If the health care provider creates a problem
• • • acknowledge and apologize ask if treatment can continue discuss difficulties
Questions for reflection: mutual learning
•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?
Understanding non linear healing
One 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 v iolence (cont’d)
and therefore if it comes up I know that I’m in good hands sitting here.
because [otherwise] this stuff would not be
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 -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.
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)
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, responsibility Emphasizing a sense of safety, trust, choice, collaboration Encouraging 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 reflection
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
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?
Questions for reflection: respect
• What might get in the way of communicating my respect for my patients?
Questions for reflection: 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: 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 them? ’ s expectations of the time I should spend with that person are much greater than the time I can spend with
• •
Questions for reflection: information sharing
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: control
• • How willing am I to share control with my patients? What can I change in order to share control?
Questions for reflection: boundaries
• • • 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: mutual learning
•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: 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: 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?
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.