Behind the Human Curtain: The Courage to Look

2 11 2014

Wow…I was blown away when I read In the Ogre’s Lair: Seeing Light in Shadow by J. Scott Janssen, LCSW, in The New Social Worker Magazine. Scott tells a powerful story of helping a challenging client who was hiding behind his ‘curtain’, behind a very big and intimidating wall. What a blessing it was for this man’s life and for his transition into death that Scott persisted in providing support, even though it was a very stressful relationship. So much of what happens to our clients remains hidden. Sometimes when we consistently present ourselves as compassionate, sensitive and trustworthy people, the curtain will slowly move away-  just enough to allow room for hope and help to slip in.

Through his skillful storytelling In the Ogre’s Lair: Seeing Light in Shadow, Scott shares his experience with us and I included an excerpt below.

Read the full online article here.

I should have seen it coming when I slipped on the bullet casings strewn across the front steps. Or when I rang the doorbell and heard an angry-sounding voice bellow, “Who are you and what do you want?” I identified myself as the hospice social worker and waited…

“I don’t need a social worker,” he growled.

I’d read his medical history—respiratory disease, diabetes, hypertension, skin ulcerations that just wouldn’t heal, a long history of uncontrolled pain. And a single line entered under “Social History”—patient can be hostile and combative.

Our visit that day consisted mainly of him telling me what a bunch of incompetents his medical team had been and why it was their fault he was in such bad shape. He alluded to talks he was having with his lawyer and how he would “settle with those cranks” before he died. He came across as angry, self-righteous, and abrasive. And, yes, hostile and combative…

The visit tension hit its high note when I asked if he was having any suicidal ideation. It was a reasonable question—an ex-cop with guns, over sixty-five, male, socially isolated, terminal illness, secretive, hyper-vigilant, apparent anger issues, wanting to be in control but facing increasing physical decline, protective of his privacy but needing help, possible impulsivity, possible depression, possible aggression, possible PTSD—but Jack didn’t see it that way. He hit the roof.

Over the next many months, I called him regularly and offered visits, bracing each time for rebuff and/or complaint…No conversation, however, remained civil for long. He always found his way back to things about which he was angry, always went back on the attack…

Funny thing was, despite his sarcasm, complaining, and opposition to almost everything our nurses suggested, Jack’s medical condition was stabilizing. Steady care from our staff and Jack’s reluctant willingness to listen to a few recommendations here and there allowed his wounds to begin healing. His blood sugar was controlled, and so was his blood pressure. He even began taking more pain medication and getting more sleep at night. Taken together, his underlying respiratory disease began appearing more chronic, less terminal…

When Jack was finally discharged from hospice service because of this stabilization, I was relieved. I walked away thinking I knew him, thinking I’d seen him, and glad to be done with him. As far as I was concerned, he was an egotistical bully. He was insensitive, foul-tempered, devoid of empathy as well as the most remedial signs of social or emotional intelligence. Although I admired the determination and discipline it took to live alone with all the challenges he faced, these were no excuses for being a mean-spirited, anger-addicted pain-in-the-neck…

Sometimes I felt relief that I’d never see him again. At other times, I had a sense of dread that sooner or later, he’d be back…

On the morning I saw his name once again listed under the previous day’s new admissions, I swallowed hard…

The visit was to be our last. I walked in, and Jack was awake. He smiled wide and held out both arms as if to hug me. My first thought was that he was confused. “Hi, Jack. Remember me?”

His smile broadened (something I’d never seen before), and he said, “My social worker.”

He clasped my hand and continued holding it throughout the visit as I sat beside the bed. “I feel so much better now that you’re here,” he said.

Masking my surprise, and wondering if he was being sarcastic or setting me up, I asked him about what had been going on recently.

“It’s been a hard time.” His eyes appeared to water slightly, “I think I might be dying.”

No secretiveness, no defensiveness, no complaints, no blame or attacks… His memory and concentration were taxed, and he had a hard time finding words, but slowly, methodically, Jack searched for language to describe and process what he was experiencing…

Read the full online article here.

Other Resources

Janssen, J. S., (2004) Dawn is Never Far Away: Stories of Loss, Resilience, and the Human Journey

Janssen, J. S., (2013) Locked in the Vault — Survivor Guilt in Combat Veterans, The New Social Worker Magazine

Janssen, J. S., (2012) Just Plain Stephie: Conversations at the End of Life, The New Social Worker Magazine

The New Social Worker- free e-magazine www.socialworker.com

Lacay, S. (2013) Breaking Boundaries With Empathy: How the Therapeutic Alliance Can Defy Client/Worker Difference, The New Social Worker Magazine

The Therapeutic Alliance: An Evidence-Based Guide to Practice (2010)

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Creative Commons Attribution: privatenobby flickr.com




Trauma-Informed Medical Care? Not at my doctor’s office…

11 08 2013

meat words image courtesy of Victor Habbick at freedigitalphotos.net ZOMBIE MISTID-10076674

Yep, this topic is one of my passions: trauma-informed medical care, trauma-informed systems of medical-care, and the problem of its frequent absence in health-care settings. I have met some wonderful, compassionate medical professionals. Yet I routinely encounter those whose attitude and behavior causes patient anxiety, emotional distress, fear, and is sometimes psychologically retraumatizing. Even though patient contact may be limited to only a few minutes, it is still possible to create trauma-informed experiences that benefit the patient.

Here are some examples of what is not  trauma-informed medical care:

  • An RN case manager calls my husband after he is home from the hospital after a severe heart attack. Three times during the conversation she asks him why he had to go to the emergency room. Each time he replied that he was afraid he was going to die. (And the paramedics took him to the hospital.)  We filed a complaint and received prompt follow-up from the insurance company…but what happened in the medical provider’s system and in the nurse’s life and training  that caused such an insensitive encounter to occur?
  • At each of my frequent primary care visits, I am asked to fill out a long list of questions detailing all of my health problems. Anytime I have to discuss my medical history, I get very upset and my blood pressure rises significantly. I just prefer not to think about it, to focus on the progress, and not on the long list of medical diagnoses. Even though I explained that this process was upsetting to me, staff insisted I must comply as it was (the dreaded) policy. So I completed the awful form at home, scanned it into my computer so that each visit I just print it out, add the date and any new issue that requires attention and this does not upset me anymore. On one visit the nursing assistant who had been told before I did not want to use these forms, took me into the treatment room and then tossed a pile of these forms onto the chair where I was going to sit. She informed me that the copy I was bringing in did not have the doctor’s section on the back and I needed to use their double sided form. Big sigh…I tried not to sound belligerent as I said that my forms are scanned and printed- perhaps staff could just staple or tape their form onto the back of mine?  I handed the forms back to her and sat down. No response from her, but she never tried that again!
  • I had a recent appointment at a specialist’s office where I had been seen before but had to switch to a different doctor in the practice as mine left. The nurse said nothing but  “hello, have a seat”- no eye contact during the entire time. She then proceeded to rapidly ask me a long list of standard medical status questions. She displayed no compassion or concern for the fact that I stated my symptoms had worsened significantly in the last three months. I felt like a faceless piece of meat or at best, a shirt in a garment factory being checked by Inspector 32. This is not about the ten minutes it took to go through the medical questions that were important for the doctor to know. It is about how it was done and that it was not trauma-informed/trauma-sensitive as I was very anxious about the worsening symptoms, the impact on my quality of life, and what the future held for me.

Some people have developed Post-Traumatic Stress Disorder (PTSD) from serious health issues, near death experiences and many trauma survivors in the healthcare system frequently have additional medical, behavioral health or mental health needs. How can the healthcare system address the needs of people who have had traumatic experiences that are impacting their physical health as well as their emotional health? To start, every healthcare professional should make themselves familiar with the landmark Adverse Childhood Experiences (ACE) study of 17,000 individuals that demonstrated the strong correlation between childhood trauma/abuse and adult health problems. Watch the fourteen-minute summary video of the ACE study.

So what is Trauma-Informed Care (TIC)?

Trauma-Informed Care involves a focus on “What happened to you?” instead of “What’s wrong with you?”  While the healthcare profession typically focuses on individual diagnoses, symptoms, and treatments, I see the bigger issue as what is happening to people with medical issues, how it affects their ability to function and how it affects their quality of life. I frequently bring up the issue of quality of life with my physicians. I have never heard a medical professional talk about quality of life without me first raising the issue and bringing this perspective into the diagnosis and treatment process. TIC also encompasses the policies, services, and practices for both patients and staff. It minimizes the chance of individuals being re-traumatized by healthcare services.

The Fallot (2006) five guiding principles of Trauma-Informed Care  apply to patients and the entire organization including the employees. I elaborated on the definitions to enhance their applicability to medical settings.

1. Safety- ensure the physical and emotional safety of patients and employees. Shift to a whole person focus of “what happened to you?” instead of “what is wrong with you?” Make the physical environment welcoming, comforting, clean and safe. Value the patient’s experiences and perspectives so they feel safe. Ask them  “how are you managing to cope with these symptoms/disability/pain?” Or perhaps “how is this affecting your work and home life?”

2. Trustworthiness- provide clear and sufficiently detailed information about what patients and employees can expect and need to know; maintain appropriate professional boundaries. Return calls and requests for information consistently and in a timely manner.

3. Choice- prioritize patient and employee experiences of choice and control. Give patients options including evidence-based options so that they can make an informed decision; respond respectfully to their questions as they clarify needed information to make an informed decision. Tell them why you recommend a particular treatment, listen to their questions, and let them make an informed choice.

4. Collaboration- maximize collaboration and the sharing of power with patients and employees; it is the patient’s body so the final decision is theirs; work together with them in partnership; remember that other medical providers may be involved and multiple differences of opinions often occur that the patient must process; the provider seeks collaboration with involved other providers. Create a treatment plan together with the patient, follow it, and update it as desired by the patient through collaborative discussion. Listen to office and support staff ideas and concerns as they often have great suggestions to improve the practice and service for the patient.

5. Empowerment- recognize patient and employee strengths and skills; acknowledge patient experiences and their inner wisdom regarding their health and employee ideas regarding service provision. Patients are empowered when they are given enough information to make informed decisions. Allowing the patient to be in the “driver’s seat” may feel uncomfortable to some, but it can be very empowering to many patients.

 

Is TIC different from good customer service? Yes,  they are different although they have many similar components. A medical setting that has great customer/patient service is more likely to be trauma-informed for staff and patients, and less likely to trigger or re-traumatize a patient. However, TIC includes much more than just good customer service. In addition, there is the larger policy issue of identifying those children, youth, and adults who are trauma survivors when they enter the healthcare so that their needs can be effectively addressed with appropriate referrals and coordination of services.

So what kinds of things can make a medical or other healthcare setting trauma-informed? (Various resources are listed at the end of the blog.)

  1. Train all staff on the basics of psychological trauma and Trauma-Informed Care as well as the relationship between trauma and addiction, and the impact of childhood trauma on adult illness, disability, and death. This is a brochure on Medical Traumatic Stress: What Health Care Providers Need To Know related to pediatric illness, injury and traumatic stress from the National Child Traumatic Stress Network I was not able to find anything similar for adult trauma-informed medical care.
  2. Examine the environment, processes, forms, policies, etc. that staff and patients are exposed to and obtain input from patients through a focus group or other means to make progress toward changes to make services more trauma-informed.
  3. Ensure that any assessment tools are used as required by medical guidelines for assessing needs of trauma survivors. Have referral information readily available.
  4. Advocate as healthcare providers and patients for coordination in healthcare systems, collaboration with behavioral health and mental health providers,
  5. Practice good customer service and implement the five principles of Trauma-Informed Care.

This topic could fill a whole book, but I hope I have offered enough to give you a good start! Check out some of the resources below.

Author: Lesa Fichte, LMSW, Director of Continuing Education

Resources

Center for Pediatric Traumatic Stress, The Children’s Hospital of Philadelphia http://www.chop.edu/professionals/pediatric-traumatic-stress/about-pediatric-traumatic-stress/trauma-informed-care-for-healthcare-providers.html

SAMHSA National Center on Trauma-Informed Care http://www.samhsa.gov/nctic/

Brochure on Medical Traumatic Stress: What Health Care Providers Need To Know related to pediatric illness, injury and traumatic stress from the National Child Traumatic Stress Network http://www.chop.edu/export/download/pdfs/articles/traumatic-stress-pdf-cpts-mtsbrochure.pdf

Medical Trauma from the National Child Traumatic Stress Network http://www.nctsn.org/trauma-types/medical-trauma

The Adverse Childhood Experiences Study http://acestudy.org/ and http://www.cdc.gov/ace/index.htm

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study http://www.ajpm-online.net/article/PIIS0749379798000178/abstract

Using Trauma Theory to Design Service Systems: New Directions for Mental Health Services,  Maxine Harris and Roger D. Fallot (2001) http://www.amazon.com/Trauma-Theory-Design-Service-Systems/dp/078791438X/ref=sr_1_1?ie=UTF8&qid=1376250212&sr=8-1&keywords=harris+and+fallot

Trauma-Informed Services: A Self-Assessment and Planning Protocol, Community Connections: Roger D. Fallot, Ph.D. and Maxine Harris, Ph.D. (March, 2006) http://smchealth.org/sites/default/files/docs/tisapprotocol.pdf

International Society for Traumatic Stress Studies http://www.istss.org/Home.htm

Traumatic Stress: An Overview, American Academy of Experts in Traumatic Stress http://www.aaets.org/arts/art1.htm

Article: Some Medical Trauma Might Induce Later PTSD http://www.goodtherapy.org/blog/some-medical-trauma-might-induce-later-ptsd-0716132

How to Provide Good Customer Service in a Health Care Setting http://www.ehow.com/how_7372599_provide-service-health-care-setting.html

Customer Service in Health Care Optimizing Your Patient’s Experience by Karen A. Meek http://pacificmedicalcenters.org/images/uploads/KCMS_Customer_Service_in_Healthcare.pdf

University at Buffalo School of Social Work Institute on Trauma and Trauma-Informed Care http://www.socialwork.buffalo.edu/ittic/

Trauma-Informed Care Information & Resources, University at Buffalo School of Social Work http://www.socialwork.buffalo.edu/facstaff/tic_resources.asp

Video from the Cleveland Clinic on ‘Empathy: The Human Connection to Patient Care’. Provides great perspective on remembering that you don’t know what a person is experiencing or feeling inside; we all have struggles. https://www.youtube.com/watch?v=cDDWvj_q-o8&feature=share

University at Buffalo School of Social Work Trauma-Informed and Human Rights MSW Curriculum http://www.socialwork.buffalo.edu/about/tihr.asp

Trauma-Informed Certificate Programs and workshops from the University at Buffalo School of Social Work Office of Continuing Education http://www.socialwork.buffalo.edu/conted/trauma.asp

Photo credit: image courtesy of Victor Habbick at www.freedigitalphotos.net








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