My husband, a cardiologist, and I recently spoke to a group of physicians about how heart disease is caused by traumatic stress and also causes it. Afterwards, one family practice doc asked me, “I never know what to say when patients tell me their traumas.”
I realized that many doctors and therapists, for that matter, were trained in an era before abuse was acknowledged, before trauma and PTSD were common household words (in some places they still are not).
So I’ve compiled a short list of do’s and don’t’s when answering a client that discloses a disturbing history of trauma or a traumatic event.
~ Routinely administer a screening questionnaire for abuse in your intake forms. You can use the ACE questionnaire or website or come up with your own boxes to check off (e.g. history of physical abuse, sexual abuse, domestic violence, neglect, veteran etc.) Clients with a very high ACEs score will have more health problems as they age.
~ Answer with a sympathetic and simple affirming response such as:
“I’m sorry that happened to you.”
“ That is a terrible thing to have to go through.”
“You must really be suffering a lot (if the event is currently affecting the client).”
If your client’s disclosure is met with a stony or panicked silence they will leave feeling very guilty, damaged, enraged or all three. Abuse has a lot of shame associated with it. Please do not reinforce this by failing to respond appropriately.
~ Maintain eye contact with a soft gaze. Our clients often do not feel seen or like others really want to see them and their suffering. Eyes are “the windows of the soul” and the client really needs to see that you are with them in taking this great risk of disclosure. We know that people are present to us and with us when they look into our eyes.
~ Get yourself grounded in that moment. Take a deep breath and take a moment to really absorb what your client just said to you.
Some of us providers have our own trauma histories and the older we are the more likely that is. If we dissociate or ‘check out’ our client will definitely notice and probably assign the worst possible meaning to our behavior such as: “they don’t really care about me”; “they are just collecting their paycheck”; “they think I’m crazy”. Our traumatized clients already have those feelings, and they respond to any perceived confirmation of those thoughts with panic and/or rage. This panic/rage can be expressed outwardly in your office as difficult behavior or as self-harm when they go home.
~ Ask for more details – especially about how this is affecting the patient in their body right now. It is a universal truth that our clients will only tell us what we are ready to hear. They do not want to ‘injure’ us with sordid details and will often leave out important aspects of their traumas. Occasionally a client will disclose too much in a kind of verbal diarrhea manner; in those cases it is OK to gently contain the discussion and take the necessary action for that client to get help.
~ Assess for current safety and contact the correct agencies as a mandated reporter. You can never overreport elder abuse or child abuse. As a medical social work supervisor I am always surprised about how conflicted medical staff are about filing reports and how little the laws are understood and followed. The state is responsible for determining whether abuse is happening or not. Most medical providers are not trained to make those screening decisions. Hence the law that says you are a mandated reporter to file if abuse is suspected. And, yes, that means everyone on your team who has a contact with the patient. It is extremely common for abuse victims to divide up what they tell to different people. There is no way for agencies to file as a single entity. If a doctor, a nurse and a social worker talk to this person and get any kind of disclosure they ALL are legally obligated to file a report. Our clients almost never call disclosure hotlines themselves. Sometimes they don’t understand that what is happening is reportable. Child and adult lives depend on us doing our jobs. The states do a very good job of maintaining confidentiality about who said what.
~ Refer! to the appropriate provider. Have a list of trusted mental health providers in your office. Steer your client towards the Psychology Today referral website which is excellent and widely used by practitioners.
~ Panic. Forewarned is forearmed. Educate yourself about the types of abuse in your community and the populations you serve. If you are expecting to hear these types of disclosures (and why shouldn’t you?) your clients will have an easier time telling and you will have an easier time hearing. I have heard about some truly horrendous and damaging responses from both therapists and doctors who were not ready to hear an abuse disclosure. One damaging response can put off a patient’s healing for years or forever.
~ Promise to keep a dangerous secret. A lot of patients will ask us to keep what they tell us confidential before they want to disclose anything. Don’t paint yourself into a corner. When my patients ask me to keep their secrets, I always reply that it depends on what kind of secret they have and explain my role as a mandated reporter. That gives them more control on what they want to disclose.
~ Ignore a disclosure. Yes, I know you have less time to do more work than at any other time in your career. Working correctly with a disclosure does not have to take a great deal of time. Our patients are pretty savvy. They know we have busy schedules and lives, and they do too. The vast majority of people who disclose will not abuse the privilege. If they do, you can still be kind and containing at the same time. Or you can ask them to schedule a longer appointment soon for a full trauma assessment (something I hope to be coming soon to a medical and psychiatric clinic near you). Being busy is no excuse for being uncaring. It’s not business; it’s personal.
~ Forget to take care of yourself. Know your community population. If you are in low income, high crime area, your entire population may be filled with trauma. Taking a trauma informed approach to your practice could be the best thing you ever do for you and can avoid needless complaints and confrontations. Get therapy if you need it (and who doesn’t?). Do your own sympathetic downregulating exercises: yoga, tai chi, meditation, exercise, breathwork. The less you care for yourself and your own suffering, the less you will want to help anyone else.
There, that wasn’t so hard was it?! If you need more in-depth assistance I offer trauma-informed consultations for health care professionals, and I travel!