ARCHIVED: Chapter 5: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Guidelines: context of encounters
The quality of interactions with administrative staff and assistants who work in health care environments can affect survivors' feeling of safety. Participants overwhelmingly agreed that, in an office environment, their interactions with administrative staff and assistants set the tone for the practitioner-patient relationship. For these reasons, staff need to have some understanding of the dynamics and long-term effects of interpersonal violence and require coaching in applying the principles of Sensitive Practice in ways that will work in their specific environments.
In both hospitals and community-based settings, routines and procedures have evolved to be cost- efficient and to maximize the clinician's time. They may, however, be experienced as more clinician-centred and less patient-centred. In many offices, for example, it is common practice for the receptionist to ask about the nature of the problem in order to book the appropriate type and time of visit. Many survivors said they experienced this as an invasion of privacy, especially when they are seeking assistance with psychosocial or mental health problems. The clinician participants in our working groups suggested that a preferable approach would be for receptionists to ask whether the appointment was for a discussion or an exam. Office personnel who usher individuals to examination areas and carry out preliminary procedures could also demonstrate respect for privacy by using this kind of question. Health care practitioner participants also reminded us that assistants and technicians (such as physical therapy assistants or x-ray technicians) who work directly with patient evaluation and treatment should use Sensitive Practice in the same ways that the clinician does.
One survivor emphasized the need for receptionists to learn about Sensitive Practice when she described her attempt to make an appointment with her family physician, who had previously agreed to see her if she was feeling suicidal:
“What do I have to do, stand up on a chair and say, Yes, I look fine but at this moment I am thinking of a thousand and one ways to kill myself ? [When the receptionist refuses to give me an appointment] the shame and guilt kick in and I blame myself and I do go home and I OD or I slash my wrists”. (Woman survivor)
Survivor participants spoke at length about the extreme anxiety that they experience while waiting for health care appointments because it takes them back to past abuse experiences. Because of their naiveté, children never anticipate the first episode of abuse; it catches them unaware and defenceless. The sexual acts seem strange and may be painful; the secrecy is confusing; and the coercion or threat of harm is frightening. Children have no prior reference from which to understand why someone, especially someone they love and trust, would do these things to them. After the abuse has happened once, many children are haunted by the fear that it could happen again. They become hypervigilant and watchful, and wait in dread for the abuse to reoccur.
Although waiting for appointments is a fact of life, the experience may be particularly trying for survivors who have never completely shed the apprehension associated with waiting. Therefore, participants urged practitioners to:
- Create waiting areas that are warm and welcoming;
- Provide and clearly identify washrooms;
- Provide printed materials related to interpersonal violence;
- Provide a realistic estimate of the length of wait time.
Privacy is another important environmental aspect of survivors' feelings of safety. The balance between safety and privacy is not the same for all survivors: some will be most comfortable in a private room; others may choose this option as long as they can be accompanied by a support person; and still others feel safer in public spaces. Many survivor participants ask that health care providers approaching a waiting client knock or announce themselves and await permission before entering.
Specifically, clinicians should consider the privacy (or lack thereof) that their practice environment affords, by reflecting upon the following questions:
- What can be heard and seen in the reception area?
- Are patients required to respond to personal questions in a public reception area where others may overhear the exchange of information?
- What can be heard and seen from the hallway?
- What can be heard between examination rooms or cubicles?
If your facility cannot provide an environment in which a particular client feels safe, discuss the option of a referral to another clinician or facility.
Practitioners are further urged to have at least one soundproof examination or interview area available for use. While privacy is even more difficult (and sometimes impossible) to achieve in hospital settings, clinicians are urged to be creative and to consider the possibility of using areas that are not soundproof when others are not present, such as during mealtimes and outside of peak hours.
Having had so little control over what happened to them in childhood, many survivors seek ways to control the current physical environment in order to feel safe. They offer the following comments and suggestions:
- Designate separate washrooms for men and women;
- Take the time to familiarize the client with the physical environment (e.g., waiting area, washrooms, patient care areas, equipment, and emergency exits);
- Whenever possible, offer clients a choice of where they may sit in examination, treatment and waiting rooms (e.g., some survivors prefer to sit near or be able to see the door);
- Because some survivors are strongly affected by lighting and views of floors and ceilings, ask clients about their comfort level with the lighting. This is particularly important if treatment requires the patient to assume a position facing the floor or ceiling;
- For practitioners who use music, candles, or scent during treatment, check with the patient regarding their preference to avoid triggering negative responses.
The importance of sharing information about health care procedures prior to beginning any exam, treatment, or hospital admission cannot be overstated. Since advance preparation can help significantly to reduce an individual's anxiety even before the clinician and client meet, practitioners should consider the following possibilities:
- Send printed information to clients before their first appointment or give it to them while they wait for their first appointment. Also consider displaying it in waiting rooms or treatment areas. These materials should be written in clear, plain language that avoids jargon or medical terminology. As well as providing information about the organization and service, these materials can also cue survivors to think about what they can do to facilitate their own safety (e.g., bringing a support person or a small familiar object that symbolizes safety and security with them to appointments).
- Because not all clients are able to read written material or understand English, alternate strategies can be used to inform them about what they can expect in the health care encounter (e.g., consider using drawings, photographs, or videos that answer frequent questions and explain what will happen from the beginning to the end of the interaction).
- Helping any client prepare for hospitalization or outpatient procedures begins by assessing what they know and identifying any knowledge gaps. Responding to those gaps may involve brainstorming and negotiation as well as information sharing. For example, when working with abuse survivors it is important to discuss: (a) ways that the survivor can get through the experience in the least traumatic way; (b) ways to avoid identifiable triggers; and (c) plans to ensure sufficient ongoing support.
The presence of a support person requires balancing competing demands for confidentiality, support, and protection of both patients and practitioners.
Collaborating with clients to develop a written plan of care ensures that everyone who works with them is aware of their particular needs.
“[The presence of the assistant] would make me feel more comfortable if the door had to be closed ... it wouldn't be that one-on-one”. (Man survivor)
A third party observer (either a patient- nominated support person or clinician-nominated "chaperone") is commonly used for some examinations and procedures. Survivors explained that having a support person with them often helps to decrease their fears. The support person can also serve as another set of ears to hear any information offered by the clinician:
“If you're being given a lot of information and you can't necessarily hold it or get it all straight or if you're anxious ... and there's a lot of new information coming at you, it's nice to have somebody in the room that can help you remember what's being said”. (Woman survivor)
The presence of a support person requires balancing competing demands for confidentiality, support, and protection of both patients and practitioners. To facilitate both the patients' abilities to take advantage of the option of having a support person present and the integrity of their practices, health care providers are encouraged to:
- Inform patients verbally as well as via brochures and signs in the waiting areas about the option of having a third party observer with them;
- Remain aware that the presence of a support person may not always be in the client's best interests (e.g., a violent partner who seeks to control the client's interactions with others);
- Speak privately with the client at the beginning of the appointment to ensure that the individual actually wants to have the support person present, to ascertain the role that the client wants the support person to play, and to discuss issues of confidentiality (keeping in mind that individuals may want to speak privately with the practitioner but may not know how to say so);
- Establish the role of the support person at the beginning of the appointment when all are present, so that the patient, support person, and clinician are in clear agreement;
- Ensure that, when a third party must be in the examining room for medical or legal reasons, patients both understand and consent to this witness, and then offer them the choice between having a personal support or staff person present.
Because Canadian society is composed of individuals from many racial, ethnic, and cultural groups, it is imperative that health care be culturally sensitive. Although much has been written about cultural awareness, cultural sensitivity, and cultural competence in health care, ideas about how to address the topic of culture are continuing to evolve. Early work in the area (for example,37,38,19,20,21) offered models of cultural competence as a framework for delivering responsive health care services to individuals from culturally and ethnically diverse backgrounds. More recently, proponents of the critical cultural perspective (e.g.,34,74,75) have encouraged practitioners to broaden their thinking about culture beyond that described in these early models and to recognize culture as a complex, dynamic, and relational process that is shaped by historical, social, economic, and political forces. As University of British Columbia nursing professors Annette Browne and Colleen Varcoe explain,
Health care practitioners and health care organizations are encouraged to examine current practice with diverse groups on an ongoing basis.
“A critical cultural perspective, and understanding culture as relational, shifts the gaze away from cultural Others onto the self, and requires examination of how each individual is enmeshed within historical, social, economic, and political relationships and processes. This then leads to questions such as: How am I reinforcing certain norms (for example, Eurocentric norms perhaps) within the culture of health care? How am I seeing certain behaviours, beliefs, and practices as normal and others as cultural ? How am I serving certain economic and political interests through my daily practices? ”34p.163
These ideas are also reflected in Irihapeti Ramsden's work on cultural safety.124,125 Ramsden, a Maori nurse leader in New Zealand, developed the concept of cultural safety to bring attention to the negative impact of colonization on the health of Maori people and the ways in which colonization privileged Eurocentric health/illness beliefs and many current practices perpetuated inequalities. A full discussion of this topic is beyond the scope of this handbook; however, health care practitioners and health care organizations are encouraged to examine current practice with diverse groups on an ongoing basis.
While interpersonal violence is present in all cultural and ethnic groups, we pay special attention to Aboriginal Peoples in this Handbook because they represent a significant and growing portion of the Canadian population, they continue to experience the long-term effects of widespread abuse in residential schools, and, in our view, are likely to benefit from the universal application of the principles of Sensitive Practice. It is our hope that even a basic understanding of the abuses (many of them systemic) that large numbers of Aboriginal people experience will help health care practitioners be more sensitive and therefore more effective in health care interactions with Aboriginal peoples.
Survivors spoke about instances in which they did not feel comfortable or safe working with health care providers to whom they had been referred. While options may be limited, all patients have the right to referral to another clinician or facility. Clinicians may also find themselves in a position in which they cannot meet survivors' expectations or needs for care. Broaching such discussions may not be easy, but practitioners are encouraged to respond to requests for referral and to be supportive in discussing situations in which they believe they cannot meet patients' needs.
For permanent transfer of care, the "outgoing practitioner" should ensure that the new colleague is knowledgeable about interpersonal violence and the sensitive care of survivors.
The transfer of care from one practitioner to another without prior notice can evoke feelings of abandonment and erode trust. Whenever possible, individuals should be offered a choice of alternate caregivers. Announcing planned absences well in advance provides clients with the option of making alternative arrangements. In the best possible scenario, clinicians are able to introduce their clients to the practitioner who is taking over. Discussion about what information regarding past abuse the individual consents to be given to the temporary caregiver is essential. For permanent transfer of care, the "outgoing" practitioner should ensure that the new colleague is knowledgeable about interpersonal violence and the sensitive care of survivors.
Most survivors agreed that they did not expect any one person - including a health care practitioner - to fix all of their problems.
Survivors urged health care providers to consider making (with permission) informal links with other practitioners with whom they were working to address health problems more fully.
Sadly, some survivors reported that their encounters with the health care system actually detracted from recovery from childhood sexual abuse:
As a survivor of abuse, [I feel that today's health care system] is reobjectifying ... to the point where I scarcely exist ... as a whole being because society [has] modeled a dissociative process that took my emotions to a psychiatrist, and my body to a GP, and my teeth to a dentist. They didn't show me any model that would pull me back out of dissociation. (Man survivor)
Survivors agreed that they did not expect any one person - including a health care practitioner - to fix all of their problems. Some suggested that access to a range of practitioners from different health care disciplines would be an asset to their healing and those who had experience with primary health care teams were very positive about that experience.
Many participants were aware of the connections between mind, body, and spiritual wellbeing and wished that health services were more holistic in their approach:
“I think that the connection between mental health and physical health can't be separated ... The [practitioner] would be able to help a client deal with their health issues significantly more if they understood what the underlying emotional stuff was as opposed to never, ever asking the question and possibly figuring this out ... I think that the role of the [practitioner] in health should [include] a larger component of emotional health ... I think that I ... could have got to the place of dealing with the emotional place and impacts of sexual abuse an awful lot sooner if there had been some help to sort of draw that out.” (Man survivor)
Survivors urged health care providers to consider making (with permission) informal links with other practitioners with whom they were working to address health problems more fully. For example, a conversation between a counsellor and a practitioner about a treatment that a survivor experiences as triggering intense negative emotion might lead the counsellor to work with the survivor on grounding techniques and to offer the practitioner additional suggestions to minimize these reactions:
“I was quite amazed and thrilled that I could go in to see my [psycho]therapist and ... during the week she and the medical doctor and the psychiatrist had talked about my case and, you know, they were all concerned on a certain level about a certain thing.” (Man survivor)
The basic tenet of self-care for practitioners is the need to extend to themselves the understanding and compassion that they demonstrate to their patients.
Taking care of oneself - eating well, getting enough rest, engaging in regular physical activity, taking time to relax, and so on - can be a challenge for most people. For survivors who learned as children that their needs are not important, self-care may be even more difficult:
“This is the first time in my life for the past three years that I've given a damn about my physical well-being. I never gave a damn before. That's due to living with very poor self-esteem.” (Man survivor)
An important aspect of health teaching is the modelling of self-awareness and self-care. Patients who have difficulty in these areas may learn from seeing their health care practitioners modelling self-care and appropriate boundary setting.
The basic tenet of self-care for practitioners is the need to extend to themselves the understanding and compassion that they demonstrate to their patients. Every clinician needs to develop and use a repertoire of strategies that promote and maintain health, particularly during stressful or emotionally intense encounters with patients. It is also crucial to remember that the capacity to work through difficult situations is never constant, even for experienced practitioners.
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. Obtaining this support can and must be done without breaching confidentiality. Seeking support is not a sign of weakness; rather, it is indicative of taking professional responsibilities seriously. Ignoring one's distress or discomfort increases the risk for Secondary Traumatic Stress Disorder (STSD), also known as Vicarious Traumatization (VT), or Compassion Fatigue (CF).109 Charles Figley, director of the Traumatology Institute at Florida State University, described the symptoms of STSD as being similar to those of Post-Traumatic Stress Disorder (PTSD) "except that exposure to a traumatizing event experienced by one person becomes as traumatizing even for the second person."66p.11 Individuals with PTSD or STSD may experience depression, anxiety, lethargy, overinvolvement with abused patients, and undue fear of personal and familial abuse. If these symptoms go unrecognized and untreated, practitioners may react by avoiding abused clients or inadvertently conveying to them that they have done something wrong.
For health care practitioners who are also survivors. It is also important to keep in mind that childhood sexual abuse survivors and health care providers are not categorically discrete groups. A proportion of clinicians are themselves survivors of childhood sexual abuse.94 Practitioners who have personal histories of childhood sexual abuse may be especially empathic towards other survivors, particularly if they have worked through and resolved their own wounds. However, practitioners who have unresolved abuse issues may face great challenges when working with other survivors.24,109 They may be at risk for being triggered, developing boundary problems, and counter-transferring harmful responses to patients. It is recommended that individuals work through and come to terms with their own history of childhood sexual abuse to avoid confusing their own difficulties with those of their patients.
Survivors clearly do not expect health care practitioners to be all things to all people. At the same time, practitioners can play a vital role in helping their patients locate and access appropriate services and resources. Organizations such as sexual assault centres, women's centres, community mental health agencies, and residential addiction treatment facilities may provide information for survivors and practitioners. Organizations serving male survivors have emerged in some communities in recognition that many organizations established earlier were serving only women. Many sexual assault centres can offer specialized training or support for clinicians in their work with childhood sexual abuse survivors. Practitioners in the community who have expertise in working with survivors may be available, and they may be willing to consult or mentor other health care providers. Professional associations and regulatory/licensing bodies may be able to suggest other available resources.
Practitioners can play a vital role in helping their patients locate and access appropriate services and resources.
Prominently displaying posters and brochures for programs and agencies that serve abuse survivors offers patients the message that the practitioner is aware of the prevalence and potential long-term problems associated with sexual, physical, and emotional abuse.
Gathering information on the following questions will help practitioners determine whether an organization is appropriate for counselling referrals:
- The agency's mandate and the nature of services offered (e.g., crisis intervention, individual counselling, group therapy, support groups).
- The agency's policy on fees for service (e.g., what the fees are, whether the agency offers a sliding scale, whether it accepts payment from second parties such as employee health plans).
- How soon a prospective client can expect to receive service and whether there is a wait list.
Prominently displaying posters and brochures for programs and agencies that serve survivors of interpersonal violence offers patients the message that the practitioner is aware of the prevalence and potential long-term problems associated with sexual, physical, and emotional abuse. Materials should provide information on:
- Sexual assault centres, women's centres, community mental health agencies, and residential addiction treatment facilities;
- Telephone help lines and suicide hotlines;
- Battered women's shelters;
- Mobile crisis units.
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