ARCHIVED: Chapter 4: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Principles of sensitive practice

Principles of Sensitive Practice

Overarching consideration: Fostering feelings of safety for the survivor

“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 [the health care practitioner] would want me to”. (Woman survivor)

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

The primary goal of Sensitive Practice is to facilitate feelings of safety for the client. The nine themes below were identified by virtually all participants as important to facilitating their sense of safety during interactions with health care practitioners. These themes are so critical to survivors' feelings of safety that we term them the principles of Sensitive Practice. Through the course of our research, we have come to conceptualize safety as a protective umbrella, with the principles of Sensitive Practice being the spokes that hold the umbrella open. When the umbrella is open, an individual feels safe, and can participate in the examination or treatment at hand. While most of the principles are components of patient-centred care (see Stewart¹⁶³), they take on even greater significance within the context of childhood sexual abuse and other interpersonal violence.

Since all health care practitioners work with individuals with histories of violence, the principles of Sensitive Practice represent a basic approach to care that should be extended to all clients.

Child sexual abuse is a betrayal of trust and the antithesis of safety. Survivor participants frequently described to us how perpetrators, while abusing them, assured them that they were safe when just the opposite was true. For some adult survivors, the experience of being told that they are safe can trigger fear and anxiety. Thus it is clearly not enough for health care practitioners to simply assure their patients that they are safe. To facilitate survivors' feelings of safety, practitioners need to make every effort to follow the principles of Sensitive Practice. To paraphrase one of the health care practitioner participants, the principles of Sensitive Practice articulate a standard of practice and provide a concrete and specific "how to" guide for doing this.

Since all health care practitioners - knowingly and unknowingly - work with individuals with histories of sexual, physical, and emotional abuse and other forms of violence, these principles represent a basic approach to care that should be extended to all clients. The principles of Sensitive Practice are analogous to the infection control guidelines (commonly termed "routine practice" or "universal procedures") that have become part of everyday practice in all health care settings. Just as clinicians may not know an individual's history of past infection, they may not know an individual's abuse history. By adopting the principles of Sensitive Practice as the standard of care, health care practitioners make it less likely that they will inadvertently harm their patients or clients.

The nine principles of Sensitive Practice

First Principle: Respect

“[Feeling respected], to the person who has been abused, it certainly means a great deal”. (Man survivor)

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The Oxford English Dictionary 118 defines respect as to give heed, attention, or consideration to something; to have regard to; to take into account. Conveying respect for another involves seeing the "other" as a particular and situated individual, with unique beliefs, values, needs, and history. It means acknowledging the inherent value of each individual, upholding basic human rights with conviction and compassion, and suspending critical judgement.46

Conveying respect for another involves seeing the "other" as a particular and situated individual, with unique beliefs, values, needs, and history.

Because abuse undermines an individual's personal boundaries and autonomy, survivors often feel diminished as human beings and may be sensitive to any hint of disrespect. Many survivors said that being accepted and heard by a health care practitioner helped them to feel respected:

“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 ... [and] that I have information about myself that's valuable for them to have [I need to know that I will] be allowed to be confused in their office, that's it okay for me to be upset and afraid in front of them. Not that I want to be ... but sometimes that happens when you're dealing with illness. And [I need] not to be put down for it or ... judged for it”. (Woman survivor)

Second Principle: Taking time

Time pressures - a reality in today's health care system - constantly challenge clinicians to balance efficiency with good care. Sadly, this often leaves individuals feeling like one of many objects in a never-ending assembly line, and compounds survivors' feelings of being depersonalized and devalued. For some, being rushed or treated like an object diminishes their sense of safety and undermines any care that follows.

Feeling genuinely heard and therefore valued is healing in itself, and in some cases may be the most effective intervention a clinician has to offer.

Escalating patient-clinician ratios may lead many practitioners to become exclusively task-oriented, questioning whether they can afford the time to really listen to their patients. It is important to remember that feeling genuinely heard and therefore valued is healing in itself, and in some cases may be the most effective intervention a clinician has to offer:

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. (Man survivor)¹⁵⁹

Third Principle: Rapport

“Showing some empathy, some caring, some concern ... make me feel that I'm a person as opposed to another client file going through”. (Man survivor)

Developing a tone that is professional and yet conveys genuine caring promote a sense of safety and helps to establish and maintain appropriate boundaries.

While rapport is essential to every therapeutic relationship, it is an absolute necessity to facilitate safety for survivors. Practitioners who are warm and compassionate facilitate good rapport and subsequent feelings of safety:

[For the health care practitioner I saw, this was] just a job like any other job. She could be answering phones. And I was just another name on a [referral] ... She wasn't interested. 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. (Woman survivor)^143p.252

Good rapport not only increases individuals' sense of safety, but also facilitates clear communication and engenders cooperation. Survivor and clinician participants agreed that rapport is strengthened when clinicians are fully present and patient-centred.

The balance of professionalism and friendliness that contributes to positive rapport is partly a function of interpersonal style, but it can be developed with practice. Clinicians who are distant and cold in their professionalism are unlikely to facilitate a positive connection with clients. Conversely, an overly familiar style may be perceived as invasive and even disrespectful. Developing a tone that is professional and yet conveys genuine caring promotes a sense of safety and helps to establish and maintain appropriate boundaries.

Fourth Principle: Sharing Information

“[He always gave] a reason why he was doing something, which was great ... It wasn't just doing things and then leaving you in the dark. Or if he was asking questions, you don't have to second guess, Why did he ask that question? Because my favourite sport is jumping to conclusions, right? ... If the person took ten seconds to tell me, This is why I'm going to do it, it will stop the mind from running”. (Man survivor)

While knowing what to expect decreases anxiety for most people, it is particularly important for survivors. Survivor participants emphasized that they do not know what many health care practitioners do and therefore do not know what to expect. Being told what to expect on an ongoing basis helped to allay their fear and anxiety and often prevented them from being triggered by unanticipated events:

“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 ... and if there's a preparation and there's not that fear of the unknown, and not the likelihood then that I will be triggered by something that is done, you know, into remembering something that is abusive for me”. (Woman survivor)^143p.255

“The surprises are the worst thing”. (Man survivor)

In many cases, clinicians can begin the information sharing process before seeing the new patient by providing written information about what is involved in a patient appointment. Some clinicians share information by offering a running commentary on what they are doing as they are doing it. This does not require additional time, can be a tool for patient education, and is tremendously reassuring.

As the term sharing information implies, it is a mutual process of information exchange in which both parties feel heard and understood.

As the term sharing information implies, it is a mutual process of information exchange in which both parties feel heard and understood. A place to begin is to ask patients what information they want or need and to invite questions:

“[The clinician] brings definite knowledge and expertise [into treatment] ... So together with what I know and what I can tell her, I would hope that she would be able to ... assess the situation and offer alternatives ... So instead of her being the expert and me being the patient, us being co-communicators about my body. That's what I'd like to see”. (Woman survivor)^144p.82

Sharing control of what happens in the clinician-patient interaction enables individuals to be active participants in their own care, rather than passive recipients of treatment.

Health care practitioners must also seek ongoing feedback about the patient's reactions to the exam, treatment, or intervention throughout every encounter and prior to the next encounter. This invitation to articulate one's reactions is particularly important for individuals who may indeed experience adverse reactions - such as flashbacks or nightmares - after an encounter (one man who had experienced oral abuse, for example, spoke about having nightmares for many successive nights after getting braces put on his teeth).

Fifth Principle: Sharing control

A central aspect of sexual victimization is the loss of control over one's body. It is understandable, then, that having a sense of personal control in interactions with health care providers who are more powerful is crucial to establishing and maintaining safety.

“I'm learning that if I don't have a sense of control ... I will walk away from [the situation]”. (Woman survivor)^143p.255

Although both parties contribute to the dynamics of the helping relationship, the health care practitioner, by virtue of having greater social power and specialized training, has a greater responsibility in this area. Contracts for care, practitioner services contracts, and therapeutic contracts (either written or verbal) are all tools for articulating goals, clarifying roles and responsibilities, and defining the parameters of the helping relationship. A frank, matter-of-fact discussion of these issues should be part of the treatment plan, as it serves to minimize miscommunication and misunderstanding and contributes to increased trust on the part of patient and health care practitioner alike. To proceed without such discussion assumes that clients and clinicians are all mind readers who, without deliberate effort, can clearly understand others' words, motives, and intents.

Sharing control of what happens in the clinician-patient interaction enables individuals to be active participants in their own care, rather than passive recipients of treatment. In this way, the clinician works with, rather than on, the client:

“[A health care practitioner should say,] If you are not comfortable with doing it that way, maybe we can make adjustments and do it some other way that you feel more comfortable - help us, help us so that we can help you out. Let's communicate here, let's talk about things. I can't read your mind ... I care enough about you to consult with you. To make you part of the healing process rather than a recipient. You know? You need to be part of it.” (Man survivor)

The process of ascertaining informed consent is a vital part of sharing control, as well as a legal responsibility. Informing, consulting, and offering choices are all part of seeking consent:

“It's the approach for me. That immediate taking over, taking over for me without consulting me or giving me a choice ... For me that's the first thing that raises my anxiety level ... for instance if you lay on a table, [the health care practitioner could say], Are you okay to lay sideways or are you okay to lay on your back? , instead of telling me, You lay on your back. ... It goes back to education in a sense: This is the procedure that we'll be doing and this is what is expected of you. ... So information and then choice”. (Woman survivor)¹⁵⁹

By demonstrating respect for and sensitivity to personal boundaries, clinicians model healthy boundaries and reinforce patients' worth and right to personal autonomy.

The health care practitioner must directly address all clients - even those who are minors, speaking through an interpreter, or cognitively impaired - and negotiate care with them.

Sixth Principle: Respecting boundaries

“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”. (Woman survivor)^164p.95

Because respect for boundaries is crucial to a sense of safety for most survivors, it is a principle in its own right, separate from the first principle of Sensitive Practice, "respect." The provision of health care often requires clinicians to work in close physical proximity to patients and to seek information of an intimate nature. Survivors said that health care practitioners' questions and actions when initiated either without explanation or without permission left them feeling violated.

Violation of a client's personal boundaries may occur unintentionally. For example, a practitioner, when rushed for time, may neglect to ask for consent before beginning a procedure. Although this action may meet the health care practitioner's need for expedience, it does so at the expense of the client's need for control and autonomy. Similarly, asking a very personal question before establishing rapport can be perceived as a psychological breach:

“[My concerns when seeing a health care practitioner] are related to the problems that I experienced as a child, and I'm still affected by them, and when somebody's going to cross my what I call my personal boundaries, the space that's around me, that I call my own ... and if anyone else is coming into that space, I prefer that they tell me exactly what they're doing there. When it comes to doctors, more so than anybody else, because they have a tendency to approach you ... with their hands out to go to work. I just can't accept that because of the feelings and the stress and the emotions that are created in me are just too hard on me”. (Man survivor)

Learning about boundaries and boundary maintenance is a lifelong process. The blatant disregard of personal boundaries during abuse teaches children that their wants and needs are of little consequence. For many survivors, healing from abuse involves establishing or reestablishing personal boundaries and learning healthy and effective boundary maintenance strategies. By demonstrating respect for and sensitivity to personal boundaries, clinicians model healthy boundaries and reinforce patients' worth and right to personal autonomy.

As health care practitioners learn about the health effects of interpersonal violence and about working effectively with survivors, their best teachers will be survivors themselves.

It is also possible that a clinician's boundaries may be violated. For example, the patient who persistently asks for longer appointments or attempts to contact the health care practitioner outside of work hours may be testing the firmness of the clinician's professional boundaries.

Talking calmly with the patient about the need to respect the health care practitioner's need for time limits and personal privacy can provide useful modelling for patients who have difficulties maintaining their own boundaries with others. Boundaries may also be violated by survivors who sexualize their relationship with a health care practitioner, having learned as children to relate to their more powerful abusers in a sexual way. This can be a difficult situation for any health care practitioner, but a calm stance that avoids blame is likely to be most helpful.

Boundary maintenance is a fiduciary responsibility clearly spelled out in professional codes of ethics, and violations carry serious sanctions. Addressing boundary problems in a direct, matter-of-fact way helps ensure patient safety and helps health care practitioners avoid potentially dangerous or compromising situations. While effective boundary maintenance may seem simple at first glance, it can be just the opposite and so requires the ongoing, lifelong attention of every health care provider. Practitioners who encounter specific difficulties are encouraged to consult with a respected peer or supervisor or seek advice from their professional body.

The degree to which a survivor is able to tolerate or participate in treatment may vary from one health care encounter to the next.

Seventh Principle: Fostering mutual learning

The principles of Sensitive Practice are intended to increase clients' sense of interpersonal safety. Because many of them have not experienced that sense of safety as children, abuse survivors may be learning about it only in adulthood. Thus, they may need encouragement to become full, active participants in their own health care. Many of the survivors in our studies talked about the importance of even small encouragements from health care practitioners and of how they carry these encouragements into other life situations:

“That assertiveness of [saying] no takes a long time to get ... it was somebody else giving me permission that allowed me to say no until I could learn to give myself permission [to do so]”. (Woman survivor)^143p.254

“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”. (Man survivor)

As health care practitioners learn about the health effects of interpersonal violence and about working effectively with survivors, their best teachers will be survivors themselves. Most survivors are interested in helping clinicians who demonstrate genuine compassion and interest to learn about the health effects of interpersonal violence and about their particular needs. In the context of a caring relationship, most survivors are even willing to tolerate missteps and the inevitable discomfort that comes with addressing a difficult topic.

Eighth Principle: Understanding nonlinear healing

Survivor participants reminded us repeatedly that healing/recovery from childhood sexual abuse is not a linear process. As a result, the degree to which a survivor is able to tolerate or participate in treatment may vary from one health care encounter to the next. This variability may occur over the short term (day to day) or over longer periods of time. In recognition of this reality, health care practitioners must check in with their clients throughout each encounter and adjust their behaviour accordingly. The practitioner who responds with under-standing and compassion in these circumstances contributes to the survivor's feeling of safety and to a stronger therapeutic alliance:

“Parts of my body at different times might be untouchable. It's going to 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 going to be a check-in every session”. (Woman survivor)^143p.255

Ninth Principle: Demonstrating awareness and knowledge of interpersonal violence

“[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 and therefore if it comes up I know that I'm in good hands because [otherwise] this stuff would not be sitting here”. (Woman survivor)

Many survivors look for indicators of a clinician's awareness of issues of interpersonal violence. Evidence of this awareness can take a variety of forms. Posters and pamphlets from local organizations that serve those who have experienced violence may help a survivor overcome hesitancy in raising the issue with a health care practitioner. In addition to an indication that their health care practitioners have an understanding of interpersonal violence, male survivors may also be looking for an indication that they are aware that men may be survivors:

Posters and pamphlets from local organizations that serve those who have experienced violence may help a survivor overcome hesitancy in raising the issue with a health care practitioner.

“A poster in all the examining rooms. You know victims of child abuse are welcome. That's easy. Male victims of child abuse validated here. We care about the victimization of children, help prevent victimization of male children. Those are messages that you can put on posters. Let's protect little boys and girls see, inclusive. Boys and girls who have been victimized as children are welcome. Boys and girls ... [and] have the picture boy and girl”. (Man survivor)^{167 p.512}

Incorporating the principles of Sensitive Practice into daily practice also indicates a health care practitioner's awareness of issues related to interpersonal violence.

Using the principles to avoid retraumatization

The nature and quality of the relationship between a clinician and a survivor has implications for the safety and effectiveness of health care. A good helping relationship not only contributes to an open exchange of information, but also creates the "human- to- human" environment that is essential for the establishment of trust. Effective helping relationships are not ethereal, mystical connections that "just happen," nor are they a naturally occurring byproduct of a charismatic personality. Effective helping relationships are intentional and skill-based interactions that exist to serve the needs of the patient. Effective helpers are genuine, empathic, and warm. They are also open-minded, knowledgeable, attentive to verbal and nonverbal communication, self-aware, and reflective.

Consciously applying the principles of Sensitive Practice can not only enhance the therapeutic relationship with the survivor but also assist the practitioner to avoid retraumatizing the patient. Many survivors spoke about how interactions with health care practitioners had left them feeling violated and retraumatized:

“It's critical that they understand that we can be retraumatized as a result of how we are treated by them ... Not that they're meaning to go there, but by not treating us respectfully giving us what we need to feel safe, and being allowed to be seen as co-partnering and not as having no power at all [they are making it] possible for us to be retraumatized. And I would like them to get the information”. (Woman survivor)¹⁵⁹

Without attention to these principles, survivors' umbrellas of safety can collapse, interfering with their ability to benefit from or perhaps even tolerate health care interventions.

Without attention to these principles, survivors' umbrellas of safety can collapse, interfering with their ability to benefit from or perhaps even tolerate health care interventions. Survivors told us repeatedly that this applies in all health care settings, including offices (physicians, dentists, chiropractors, massage therapists, naturopathic doctors, physical and occupational therapists, etc.), acute care hospitals, community-based care, long-term care, and rehabilitation settings.

Questions for reflection

• How willing am I to share control with my clients?
• How do I ensure that patients have received what they feel is adequate information about examinations, treatment options, and treatment processes?
• 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 clients?
• How do I balance the demands of my whole practice with the need to take adequate time with each client?
• What might get in the way of communicating my respect for my patients?
• What is my own personal style of interacting with clients? Does it seem to foster rapport? Do I put effort into maintaining rapport with each patient over time?