ARCHIVED: Chapter 7: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Guidelines: problems in encounters

Guidelines for Sensitive Practice: Problems in Encounters

Pain

Pain is a complex issue involving the dynamic interaction of biological, psychological, and social factors that is only partially understood. Research has repeatedly found an association between childhood sexual and physical abuse and increased risk of chronic pain syndromes. An individual may experience pain associated with body (somatic) memories of past abuse in addition to the pain of the disease, illness, or injury for which they seek treatment.

Research has repeatedly found an association between childhood sexual and physical abuse and increased risk of chronic pain syndromes.

In keeping with the responses learned in childhood, some survivors cope with their memories by ignoring pain, dismissing its significance, or dissociating from it:

“The experience as a child is to discount the pain, [the abuser will] threaten [the child], say Don't tell anyone about this, [and so the child will] hide the pain, to begin to dissociate from the pain.” (Woman survivor)

These responses may make it more difficult for health care practitioners to assess patients' level of pain, factors that may aggravate the pain or change their experience of pain during the course of treatment.

To complicate matters further, some survivors come to health care encounters having had negative experiences with other practitioners who have either discredited the patient's pain because it was inconsistent with objective evidence or questioned the client's rating of pain severity:

“While I was lying there I did hear some of the [clinicians] saying things like Why doesn't she suck it up and What's she doing back here again? She was here all day ... I thought they were derogatory things because they didn't know my history ... My history was all there but obviously they hadn't looked at it.” (Woman survivor)

Because an individual's experience of pain is real, whether or not the pain is consistent with objective findings, it is the clinician's responsibility to assess the client's pain in a systematic, thorough, and nonjudgmental manner. The clinician can also:

• Include other practitioners on the treatment team (e.g., mental health practitioners, pain specialists, or pharmacists) to ensure a comprehensive treatment regime;
• Initiate a discussion of other options, including referral to other practitioners who specialize in the management of chronic pain (considering both traditional and complementary practitioners) if an individual's experience of pain does not remit despite the practitioner's best efforts;
• Offer a referral, where appropriate, for psychotherapy, clearly explaining the reasons for the suggestion and carefully documenting the details of the discussion;
• Follow up on any referral in future interactions with the client.

Disconnection from the body

Judith Herman⁸¹ emphasizes the importance of reconnecting with the body in healing from trauma. Being out of touch with one's body can make looking after one's body difficult for a survivor. Indeed, for many survivors, the body becomes nothing more than "a vehicle to get around [in]" (Woman survivor). Such individuals often remain unaware of the messages that their bodies are sending and fail to recognize or attend to signs and symptoms of things such as stress, anxiety, fatigue, or overexertion. These individuals may require specific guidance about activities of daily living and leisure time, physical activity (from doing laundry to gardening), or exercise (either therapeutic or physical fitness training).

Feeling out of touch with their bodies can make self-care difficult for childhood sexual abuse survivors.

For many survivors, assistance from a health care provider to help them become more aware of their bodies may be a critical step in their process of recovery:

“[One part of treatment] has been for me to start to get in touch with my body ... I think that a physiotherapist can really affect that [by giving] that supportive invitation to ... come back into [one's] own body.” (Woman survivor)^143p.256

The inability or apparent unwillingness of clients to adhere to treatment may be related to childhood sexual abuse.

“I needed ... my [massage therapist to] introduce me to my body ... [to] talk to me about my body because I'm not in touch with it.” (Man survivor)

Accordingly, health care providers who encounter patients who seem out of touch with their bodies should:

• Repeatedly invite those individuals to focus on their bodies.
• Offer ongoing health teaching about the importance of paying attention to somatic signs and symptoms.
• Provide detailed verbal and written specific instructions for activities of daily living that are problematic as well as for leisure time physical activity. These instructions should include a description of what the activity should feel like and give upper and lower limits for the performance of the activity (e.g., "If your pain increases after making one bed, rest before continuing" or "If you are out of breath, you are doing it too vigorously").
• Monitor performance and progress.
• Help clients set small, achievable goals to develop neuromuscular skills and understand how to perform the activities correctly.
• Provide careful instructions to facilitate adherence to the treatment program.
• Teach the signs and symptoms of overuse so that survivors can learn how to monitor activity both during treatment and, later, independently of the clinician.
• Suggest a range of strategies to aid self- awareness and connection to the body including: (a) physical activity; (b) somatic- based re-education strategies (e.g., guided visualizations, relaxation exercises, breathing exercises, or yoga); or (c) referrals to other health care providers including complementary health care practitioners.

Non-adherence to treatment

As stated previously, the inability or apparent unwillingness of clients to adhere to treatment may be related to childhood sexual abuse. Factors such as depression and negative self-perception can lead to unsuccessful courses of treatment for patients and frustration for practitioners. In some instances, the difficulties which survivors experience are directly related to the specifics of past abuse:

“There [were] some of the exercises ... that they wanted me to do [after a total hip replacement] ... and one of them that I still today cannot do ... You lie on your side ... it's a scissor ... [Even when the practitioner] had the sling ... around my ankle and it had a handle and I could pull it and my leg would go up, I couldn't even do that. I'd get it so far, but I wouldn't go any further because I had to keep [my legs] so tight ... [and the practitioner] got frustrated, she really did ... she thought I wasn't trying, and that wasn't true at all because I was doing the other [exercises] very well.” (Woman survivor)^143p.257

In other instances, fear and anxiety decrease survivors' ability to hear and retain information. If they are in a dissociative state while information or instructions are given, they may be unable to recall them or to decipher cryptic written instructions.

The following suggestions may help practitioners elicit survivors' participation in their health care:

• Always explain the rationale for the recommendations being offered.
• Avoid using words such as must and should .
• Provide detailed written as well as verbal instructions.
• Ask clients whether they feel able and willing to follow the recommendations.
• Explore barriers to treatment adherence (e.g., values, social factors, finances, or past abuse) and make adaptations where possible.
• Adapt at-home treatment to fit the client's lifestyle and abilities, particularly for individuals whose low self-esteem undermines their motivation and sense of agency.
• Where adherence to treatment is particularly important (e.g., for postoperative mobilization), work with individuals to achieve small and reasonable goals (e.g., by ensuring adequate analgesia, teaching splinting techniques, etc.), and acknowledge all successes.
• Remember that blame and guilt are more likely to lead to withdrawal than adherence.
• At the beginning of the meeting, check with clients about reactions during or after the previous meetings, address any problems that have occurred, and answer questions.
• Encourage the view that actively taking care of oneself fosters autonomy and independence.

It is helpful for service providers to understand why survivors may cancel appointments and, wherever possible, to make changes in their practice environment to facilitate feelings of safety.

Appointment cancellations

For many survivors, "walking through the door [for a health care appointment] is a big deal," (Man survivor) and they cancel appointments as a means of avoidance:

“My wife had been bugging me for a while now, The dentist has been calling you. You've got to go. Okay I'll call her back, and I don't call her back. But then eventually ... the adult part of me says, okay you need to go to the dentist ... but the emotional side of me [says] no way I'm going there at all.” (Man survivor)

Certainly, cancellations are problematic in that they waste valuable health care resources and are a liability to fee-for-service practitioners and organizations. Nonetheless, it is helpful for service providers to understand why survivors may cancel appointments and, wherever possible, to make changes in their practice environment to facilitate feelings of safety.

To help minimize cancellations, practitioners could:

• Offer "same-day" appointments that would allow survivors to book appointments on days when they feel able to cope. (This can be particularly helpful for oral health practitioners.)
• Work with clients who have identified their apprehension and tendency to cancel appointments to develop a strategy that will assist them.

"Save the Situation": a general approach for responding to difficult interactions with patients

All health care practitioners encounter difficult situations in the course of their day-to-day practice (e.g., informing a family of the death of a loved one, diagnosing a life-threatening disease or condition, or encountering someone who is angry, anxious, or extremely distressed). These emotionally charged situations may leave practitioners feeling unsure about how to respond. In such instances, reference to the "SAVE the Situation" model may be helpful. The model uses "SAVE" as an acronym for the following four steps: Stop, Appreciate, Validate and Explore. A particular benefit of the "SAVE the Situation" approach is that it can be effective in any difficult situation and is not reserved exclusively for work with survivors.

TABLE 3 - S A V E the situation

The acronym SAVE is a guide for responding effectively and compassionately in a variety of emotionally charged situations.

STOP

Stop what you are doing and focus your full attention to the present situation.

APPRECIATE

Try to appreciate and understand the person's situation by using the helping skills of empathy and immediacy. Empathy involves imagining the other person's experience (thoughts, feelings, body sensations) and communicating an understanding of that experience. Immediacy is verbalizing one's observations and responses in the moment, using present tense language. For example, 'Your fists are clenched and you look angry. What is happening for you?' or '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? 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?").

VALIDATE

Validate the other person's experience. For example, "Given what you have just told me, it makes sense that you feel angry."

EXPLORE

Explore the next step. For example, "Who can I call to come and stay with you?" or '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?"

Triggers and dissociation

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. While the focus of this section is on triggers related to abuse, it is not the only cause of this type of adverse reaction to examination and treatment. The suggestions in this section can be used regardless of the origin of the trigger.

“[After] surgery on my arm ... the [clinician] would put my arm in water ... [That was something] that my perpetrators had done, had victimized me ... [in] bathrooms. Being in the tub area ... had quite an effect.” (Man survivor)

Because triggers are directly associated with a particular event or events, they are unique to each individual. This explains why different stimuli will trigger different people and why a practitioner can never remove or avoid every potential trigger in a practice setting. At the same time, common themes in triggers (see Table 4) are apparent and practitioners are encouraged to consider whether some of these potentially triggering situations can be anticipated. If a patient is able to identify a trigger, the clinician and patient can problem-solve together to either avoid or minimize that trigger during future interactions.

Different stimuli will trigger different people and a practitioner can never remove or avoid every potential trigger in a practice setting.

Clinical practice incorporates many experiences in addition to touch that may trigger a negative response in a survivor even though they seem innocuous to the clinician. Survivors described triggers such as the use of water, ice, traction, or ultrasound gel. They also spoke about medical procedures and treatments during which they had to remain immobile or silent or heard others crying out with pain or anxiety, reminding them of abuse experiences. Other participants told us that a practitioner's body language or reprimands for behaviours interpreted as deliberate non-adherence to recommendations could also trigger intensely negative experiences.

Survivors may or may not be aware of their triggers and may realize that they have been triggered only after they have had this experience. Individuals may also be triggered whether or not they have conscious memory of past abuse or have disclosed to anyone:

“[During] my first experience [with this type of practitioner], they didn't have any Kleenex, and the minute [the clinicians started] touching me I just started sobbing, without having any idea of ... why.” (Woman survivor)^143p.258

“When he did the physical examination I just basically dissociated myself from my body and I never had any idea why ... or how I did it. But looking back now, I used to do that quite a bit. After the examination was over I had no idea what he said to me. The only thing I wanted to do was get out of there. I felt extremely violated.” (Man survivor)

Survivors stressed that it is important that all clinicians have a general understanding about triggers and how to respond to an individual who is triggered:

“The flashbacks that could happen while you're having an exam. The not being present in the moment ... It would be helpful for a [clinician] to be able to help bring a patient back into the present moment and give them the time to sort through what's going on in their head.” (Woman survivor)¹⁵⁹

“If you have a guy crying in front of you and especially if he's a victim, [if you understand triggers], at least you can have some type of understanding of where this person's coming from.” (Man survivor)

Health care practitioners should be attuned to the following behaviours, which may be nonverbal indicators of discomfort, distress, or dissociation:

• Rapid heart rate and breathing (breath holding or sudden change in breathing pattern may also be seen);
• Sudden flooding of strong emotions (e.g., anger, sadness, fear, etc.);
• Pallor or flushing;
• Sweating;
• Muscle stiffness, muscle tension, and inability to relax;
• Cringing, flinching, or pulling away;
• Trembling or shaking;
• Startle response.

These behaviours are probably best understood as "freeze-fight-or-flight" responses to the perception of a threat (i.e., sympathetic nervous system arousal).

The following responses may be clearer indications of dissociation:

• Staring vacantly into the distance;
• Spacing out or being uninvolved in the present;
• Being unable to focus, concentrate, or respond to instructions;
• Being unable to speak.

After being triggered into a dissociative state, an individual may seem confused or vague and ask questions such as "Where was I?", "What did I just say?", or "What just happened?" However, it is possible that the clinician and even the clients themselves may not know that they have dissociated. Indeed, some survivors only discover as adults that they dissociate under stressful circumstances:

“The health care practitioner would come into my personal space and.... I would just dissociate. She'd touch me and then I'd just be gone. She worked with a lot of women who were survivors and she knew it. She'd just stop and say, Where did you go? And I didn't have a clue what she was talking about. But over the years I started getting a clue.” (Man survivor)

“Now, [clinicians] don't have to handle the [whole] crisis, but they do need to know how to recognize [it]. And how to make a referral in a nice way [by saying, for example,] Do you see your counsellor tomorrow? or Is there someone you can talk to? . . . They wouldn't need to go beyond [their scope of practice], but [it is helpful] if they can recognize what can happen when a woman is going through a flashback ... [and know] how to ground a person. It's not hard; ... [it's] just basic humanity and reassurance. You know, You're okay, it's safe here, or [validating] the energy and the courage that it takes to go through [the specific intervention] ... And [they can say,] Yes, [this treatment] can trigger memories, and it can be really disturbing and distressful, and what you're feeling is normal. ” (Woman survivor)^143p.258

To support clients who have been triggered and ensure that they do not leave the encounter feeling disoriented or embarrassed about their reactions to treatment, practitioners should:

• Follow the SAVE protocol;
• Orient clients to the present by reminding them where they are and what was happening when they began to have trouble staying present;
• Encourage slow, rhythmic "4-6 breathing" (inhale to the count of four and exhale to the count of six) and (if possible) sitting up and placing their feet on the floor;
• Remind individuals to keep their eyes open and to look around the room;
• Encourage patients to notice physical sensations (e.g., the feeling of their back on the chair and their feet touching the floor, or the sensation of the air on their face).

As clients become more oriented and responsive:

• Do not touch them;
• Offer verbal reassurance in a calm voice;
• Avoid asking complicated questions or giving complex instructions; instead, ask simple questions to try to connect with the person (e.g., "Are you with me?", "Are you following me?", "Do you have ways of staying present?");
• Offer them a glass of water;
• Allow them the necessary time and space to regain their equilibrium (a quiet room may be helpful);
• Normalize the experience. If the patient has disclosed abuse prior to this incident, let her or him know that health care interventions commonly trigger flashbacks or emotional responses, but do not ask for details of past abuse that may have contributed to being triggered. If the patient has not disclosed abuse, frame the normalizing comments in terms of anxiety that many people feel when seeing health care practitioners;
• Ask what the clients need right now (e.g., do they want your company, or would they rather be left alone);
• Offer continuity of care (i.e., if time constraints prevent you from staying with upset clients as long as you would like, explain this and ask if someone else can help, such as another staff member or a friend whom you could call).

Being triggered can be a frightening or be- wildering experience. Some clients may benefit from talking about the experience with someone. Thus clinicians should:

• Inquire about whether the patient has someone to offer support and whether they would like to contact that person now (e.g., "A new exam like the one we were doing today can be scary for many people and can bring about very strong emotions, as you just experienced. Sometimes it helps to talk about what happened. Do you have anyone you can process this with? Would you like to call this person to be with you now?").
• Find out whether patients would like to explore what has happened; if they have no one to talk with, ask them whether they want a referral to a counsellor or other community resource and whether they know about telephone help lines that exist in your community.
• Ask whether the client feels able to continue the examination or treatment.

Being triggered can be a frightening or bewil-dering experience.

A person who has been triggered or has dissociated may not retain or recall important information shared by the clinician. Thus, it is helpful for practitioners to:

• Repeat all instructions;
• Write down instructions and recommendations in clear language.

For individuals who have repeated experiences of dissociation during their interactions with clinicians:

• Suggest that they use a notebook to write information, instructions, and suggestions;
• Share with clients the responsibility for ensuring that essential information is recorded before the end of the interaction.

The next time the practitioner sees the client who has been triggered or dissociated:

• Discuss the experience with clients to ensure that they are feeling better and to reaffirm the message that the event does not alter the esteem in which they are held;
• Problem-solve with clients to identify what to avoid or modify in the future to prevent further triggering, keeping in mind that they may or may not be able to identify the trigger of a particular incident;
• Learn from the individuals what techniques they use to stay present and grounded, including any reminders or instructions that you can give them;
• Suggest - if the severity of the client's reactions and subsequent difficulty so indicates - a consultation with a mental health practitioner to develop additional strategies for coping with triggers.

A person who has been triggered or has dissociated may not retain or recall important information.

Some survivor participants suggested that practitioners offer general cautionary messages to clients about adverse reactions to procedures or treatment that are invasive or uncomfortable (e.g., pelvic and rectal exams and dental work):

“Something that my orthodontist may have never realized, for me with that history of abuse, [is that] when I got the braces on, for three nights in a row I just had horrible nightmares. I was phoning my counsellor and saying, Can I book an appointment, get in right away? Because I didn't have a clue what was going on ... All of a sudden I'm having nightmares being that little kid again because of all this prodding and pulling going on in my mouth. I would want an orthodontist handing out a leaflet going, if you've had sexual abuse, keep in mind this could give you nightmares or this could trigger you.” (Man survivor)

If health care providers are shaken or upset by the triggering or dissociation of a client, they should talk with a colleague, a supervisor, or someone within their support system. This can be done without breaching confidentiality.

Anger or agitation

“[Anger is] my initial response to almost everything ... I try to hold on to myself, which I do much better than before I was 40. But initially my reaction is to get angry.” (Man survivor)

Many men survivors and a few women survivors talked about responding with anger when they are anxious or fearful or have been triggered:

“Anger shows up often when you are triggered like [when] somebody touches you in the wrong place.” (Man survivor)

Anger often elicits responses of defensiveness, irritation, or withdrawal.

While it is generally easy to respond compassionately to someone who is sad or afraid, anger often elicits the opposite response - defensiveness, irritation, or withdrawal. This type of response, however, can leave survivors in an even more difficult situation:

“You are frightened and everybody is frightened of you.” (Man survivor)

Health care providers will benefit from recognizing the connection between anger and past abuse for some survivors as well as from realizing that anger (an emotion) and violence (a behaviour) are distinct entities, not to be confused or seen as one response. Participants recommended that practitioners use the SAVE guidelines to understand the cause of the anger. They advised against trying to control agitated patients' behaviours; rather, they suggested that the clinician: (a) allow clients time to cool down; (b) reflect their observations back to the clients; and (c) work with them in seeking a solution to the problem (i.e., "Don't dictate, negotiate!" (Man survivor)).

A situation can quickly escalate if a practitioner responds to an angry or agitated client with defensiveness or anger. Managing one's own anger is critical to interpersonal effectiveness. Although many institutions and organizations have established policies to deal with angry and violent patients, it remains crucial that health care providers:

• Manage their own feelings of anger;
• Pay attention to personal safety (e.g., do not stand too close, do not make quick or sudden movements, identify an escape route);
• Adopt non threatening body language (e.g., stand with arms uncrossed, at a slight angle to the person to avoid the experience of face-to-face confrontation);
• Speak slowly in a low voice, breathe slowly and rhythmically.
• Encourage agitated individuals to relax and assure them that you are interested both in listening to their concerns and in helping them find solutions to their problems.