Trauma-Informed Care Training: Building Empathy in Physical Therapy
Physical therapists commonly encounter the aftereffects of physical trauma when working with patients recovering from injuries, whether they’re from industrial accidents, motor vehicle collisions, or daily life. Less visible, however, are prior emotional, social, or spiritual traumas—traumas that don’t leave obvious physical scars or deformities.
When we consider the prevalence of trauma in North America, evidence indicates that it’s more likely than not that the person seeking your care has experienced prior trauma. In both the United States and Canada, an estimated 60 percent of adults will have experienced at least one childhood trauma before age 18, and in both countries approximately one in three women and one in six to ten men report experiencing domestic or interpersonal violence in adulthood.1 On top of that, instances of trauma are likely underreported.
Notably, a large and growing body of evidence supports a strong link between these prior traumatic experiences and current health status, including chronic pain, headache, frailty, concussion, cardiovascular disease, and recovery from injury. For this reason, we endorse trauma-informed care (TIC) and trauma-assumed care (TAC) as important approaches to physical therapy.
What Is Trauma?
‘Trauma’ is a difficult word to define, yet it seems to be heard with increasing frequency in recent years, with a variety of definitions. Traditional views of trauma tend to suppose that trauma is the result of a single major event that is visible and can be observed by a third person. However, we prefer a more contemporary definition of trauma, such as that provided by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA): “An event, series of events, or set of circumstances that is experienced as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”2
Per the SAMHSA definition, and other contemporary theories of trauma, the experience of such events can lead to a sense of vulnerability that manifests as any number of behaviors such as hypervigilance, avoidance, increased sensitivity, tonic immobility, emergence delirium (an abnormal mental state during the transition from unconsciousness to complete wakefulness post-surgery), reactivity to environmental stimuli, and difficulty admitting others into one’s personal space.
Many aspects of a typical PT visit that are often taken for granted might be experienced as traumatic and triggering for some patients, including being observed by another person; asked to perform maneuvers for them; being touched; or being judged or evaluated.
Through this lens, if the person sitting in front of you has experienced events that have threatened their sense of safety, self, or of the world as a fair and just place, then that’s their trauma, regardless of how those events might be viewed or experienced by others.
Trauma-Informed Care Training: Helping Clinicians Recognize and Respond
The current standards for TIC from the U.S. Centers for Disease Control require that all members of an entity (a clinic in the case of most PTs) are aware of the effects of trauma on people (other clinical staff members included), recognize the signs of retriggering, and respond appropriately. Successfully implementing TIC goes beyond brief trauma-informed care training and extends to integrating the principles in all aspects of clinic operations, including reception on walking into the clinic and administrative and hiring practices. It requires ongoing reflexivity and actively seeking opportunities for feedback and improvement.
Awareness starts with acknowledging that no one person walks into a PT clinic having lived life in a vacuum, but rather brings all prior experiences, both positive and negative, with them to that encounter. Staff members can learn to recognize the signs of retriggering, many of which would at one time have been interpreted as ‘malingering’ or exaggeration. These can include any or all of the following:
- Exaggerated reactions to clinical tests
- Avoiding answering certain questions
- Inability to recall certain details of an event
- Pulling away or flinching at touch
- Early discontinuation of a visit or a sudden desire to leave (escape) the clinic
- Non-anatomical descriptions of symptoms or atypical resistance to movement
- Teariness
- General aloofness or stand-off posturing during the encounter
Responses in the moment can range from giving the person space to feel safe and collect themselves, directly acknowledging the reactions and asking what the person needs at this time, to discontinuing the session early. While we need not assume such reactions are the direct result of prior trauma, adopting a TIC approach to care ensures that, even when wrong, the worst thing you’ve done is treat the person in accordance with principles that ensure safety and respect for all people in your clinic.
Trauma-Assumed Care Training: Taking a Preventive Approach
While recognizing and responding are important competencies for the TIC practitioner, ideally a preventative approach frequently referred to as trauma-assumed care (TAC) aims to prevent traumatic retriggering in the first place. According to SAMHSA, there are six such principles:
1. Safety: Creating a space in which people feel safe.
2. Trustworthiness and transparency: Explaining the purpose of every test and interaction, and owning unintentional mistakes.
3. Peer support: Actively seeking opportunities for patients to interact with and be mentored by, or mentor, others like them.
4. Collaboration and mutuality: Actively seeking opportunities for sharing information and making collaborative decisions.
5. Empowerment, voice, and choice: Creating space for patients to have options in their care, and empowering them with the information needed to advocate for themselves.
6. Cultural, historical, and gender issues: Acknowledging that your way of thinking about health and well-being is only one way of thinking about those things, and that other ways of thinking can be equally valid.
Viewing your routine clinical practices through the lens of TAC, you will find yourself reflecting on where and how power is enacted, who holds that power, and how it can be shared. This might involve the physical aspects of your clinic space, considering how patients with prior histories of trauma may experience things like beds, treatment tables, belts, straps, needles, rubber gloves, electrodes, private versus open treatment spaces, and even exercise itself.
This might also involve personal and group-based reflection, thinking about the ways in which patients are seen: as collections of moving parts first or as humans first. Even the words commonly used in PT practice (for example, ‘loose,’ ‘abnormal,’ ‘stiff,’ ‘degenerative,’ or ‘fear-avoidant’) can hold very different meanings outside of our professional sphere.
In addition, if more than half of adults have had significant prior traumatic experiences, there’s no reason to believe that clinical staff are immune to those. Creating an environment in which patients, therapists, and staff can feel safe should be equally important during this process.
Integrating Trauma-Informed and Trauma-Assumed Care
Reflecting on power and adopting a TIC/TAC approach to care can be uncomfortable and require dedication and support from all levels of the clinic to ensure success. However, we encourage adoption of this type of approach as the default way of being in physical therapy practice.
In our MedBridge courses, we scaffold the discussion of TIC/TAC by wrapping it around the context of treatment for neck pain specifically, as the neck is a particularly vulnerable body region often targeted during interpersonal violence.
While not all people with a prior history of trauma are broken, frail, or vulnerable, adopting an ethic and approach to care that centers the principles as described above means you’ll be right more often than you’re wrong, and even when wrong the worst thing you’ve done is created a clinical environment that puts safety, trustworthiness, support, collaboration, empowerment, and respect for individuality at the center of practice. There are few win-wins in healthcare, but this very much seems like one of them.
References
- Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatr. 2018 Nov 1;172(11):1038-1044. doi: 10.1001/jamapediatrics.2018.2537.
- https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf
