Trauma Informed Care

I was nervous for my first patient as a pelvic health therapist. I had gone through the required training, so i had the technical knowledge. I had also been an inpatient therapist for 4 years, so I had lots of experience in tricky situations. But still, this patient would be seeking my help in a specialty area, and I hoped I would be up to the task. The receptionist brought in the patient’s intake paperwork, and I grimaced at the sight of giant question marks drawn next to about half the questions on the outcomes measures and medical intake forms. I took a deep breath and knocked on the door to the examination room. The patient was fidgeting nervously in her chair. I pulled my stool next to her chair, looked down at the incomplete paperwork again, and decided to put it away.

I thanked her for coming in and asked her to just tell me the whole story of what led her to this first visit. She reported some vague symptoms with very little detail - something about having pain “down there” and that she might be leaking urine but wasn’t sure. When I tried to ask more specific questions about the location and qualities of her pain, she said she didn’t know. I felt completely unprepared. To buy time to think and create some rapport, I decided to start with patient education. I pulled out my model pelvis and said, “Ok. I’m glad you’re here, and I think I can definitely help you. Let’s talk about pelvises for a minute.” The patient burst into tears. Actually, she cried every time I said the word pelvis for her first 3 sessions.

As it turns out, she was unable to fill out her paperwork because she didn’t know the words to describe her anatomy. She could read the anatomical names for different parts of the female pelvis on her paperwork, but, without knowing what those words meant, she felt confusion, shame, and fear. Not only was she uncomfortable physically, and experiencing distressing/embarrassing symptoms, but she did not have the language to communicate clearly, which exacerbated her fear and pain. She had been traumatized by the medical system during previous attempts to address her symptoms with medical providers, and her nervous system was ramped up to prepare for fight or flight. She was terrified that this visit would end with a painful internal pelvic exam, followed by the statement that “everything looks fine!”, which is what she experienced in the gynecologist office on multiple occasions.

To establish a relationship with this patient, acknowledge her suffering, and attempt to help her, while believing that she is the expert on her own situation (implementing the beliefs for compassion and empathy), the best course of action for this evaluation was to NOT perform a physical examination on this patient, pelvic or otherwise. By sobbing in the office and demonstrating a flooding emotional response, along with general confusion about her body, it was clear that I needed to de-escalate the situation before I could even give her more information. I put away my pelvis model, which was clearly triggering, and for the rest of the session, I got to know her better. I asked some neutral questions about her job and hobbies. She told me about her personal relationships and how they are sometimes affected by her symptoms. I spoke in general terms about muscles, and about how they tense up in response to discomfort, fear, or fear of discomfort. I talked about how some people carry tension in their neck and shoulders, but other people carry tension in their hips and pelvic muscles. We talked about some simple stress management strategies, like diaphragmatic breathing and unclenching her jaw. I told her that powering through physically painful situations can trigger future pain in those same situations. We didn’t do much that I could put into an evaluation write up, or that I could bill to insurance, but the patient did calm down and laugh some, and we did create a trusting rapport that we could build on next session.

I told her that, in future sessions, we could move at her pace. I explained that in our next session, I would like to show her pelvis diagrams from my anatomy book so that we could talk about body part names and gain confidence with acknowledging anatomy. I told her that I would like to assess the strength and flexibility of her hip, abdominal, and glut muscles. I explained that, perhaps way down the line, it might be beneficial to do an internal pelvic floor assessment, but that we could make a lot of progress before getting to that stage of things. She did not leave her initial visit scared or re-traumatized. This patient chose to come back for her follow up visit, and although she did become emotional in several later sessions, she was empowered with knowledge of her own body and the knowledge that I would not perform any treatments without her explicit consent.

In this office, pelvic floor therapists were given mostly free reign because management had some embarrassment in talking about pelvic floor related subjects. This afforded me the freedom to take things slow with my first patient. It is generally frowned upon to write “deferred” under every single section of the physical exam in an initial evaluation. There is no billing code for rapport building. My pelvic floor course work did not prepare me for this situation. But, relating human to human, it was clear that doing anything hands on during that first visit would further traumatize her and would jeopardize her ability to trust me in the future. I was fortunate to have so much autonomy in this situation, and I recognize that, in a busy outpatient clinic, or in a clinic with more managerial oversight, I would not have been able to engage with this patient in the same manner.

There is a movement in the medical community called trauma informed care, which is defined as “practices that promote a culture of safety, empowerment, and healing”[1] . The trauma informed care movement attempts to acknowledge that patients come to providers with undisclosed traumas all the time, and that health care providers should treat patients as individuals, seeking to alleviate distress and meet patients where they are instead of actively causing or contributing to further trauma. It attempts to minimize the power differential that exists between patient and provider by asking the provider to keep the patient informed about rationale for sensitive questions and/or examinations, and by keeping the patient at the center of her own care. I believe that trauma informed care is a specific type of compassionate care, and that a provider acting from either frame of reference would have similar actions toward the patient in this case. An older philosophy of medical care would dictate that the provider is the ultimate authority and information gate keeper – an all knowing decider of the most appropriate next step. By placing compassion at the forefront, we can provide patients with information about their own bodies, and, by creating a trustful relationship, recruit patients as active participants in their own healing instead.

This patient did experience symptom resolution. She worked on her physical symptoms with me and on her emotional symptoms with a licensed counselor. By learning how to manage her symptoms independently, she gained agency, knowledge, and confidence that if she experiences similar symptoms in the future, it’s not a catastrophe, and she will know what to do. Working with this patient helped me solidify my values as a health care provider. I had to get creative with my interventions, especially in the beginning, and I had to get creative with my billing in order to justify why my time with the patient was valuable and billable, albeit nontraditional. By engaging with her, rather than steamrolling her, I gained valuable insights about myself that I have been able to carry through to other settings and other patients. If we, as a health care community, really take the Hippocratic Oath seriously to “do no harm”, then trauma informed, compassionate, care is the most appropriate approach in all situations.

[1] https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562