We’re going to be talking about trauma-informed care this month in our social media feed. Please check us out on instagram @pelviccare, or take a look at our facebook page, Pelvic Care Physical Therapy. Links at the bottom of this blog entry!

What is trauma-informed care? 

Trauma-informed care is an approach to healthcare (or other services) that acknowledges the prevalence of trauma. It attempts to minimize practices and policies that could trigger past trauma or cause new trauma. Trauma-informed care is one facet of a holistic approach to healthcare because it acknowledges that people’s bodies and minds may respond differently to interventions because of their histories. 

The idea of “universal precautions” in healthcare requires providers to act as if all their clients carry infectious disease (even though they don’t). For example, universal precautions involves routine hand washing and sanitizing or disposing of potentially infectious materials. Universal precautions protect us all from healthcare-acquired infection because they require that everyone be treated with the same high standard of care. Trauma-informed care applies this same concept. Because trauma, like infectious disease, is so common, we improve all clients’ access to quality healthcare when we apply universal trauma-informed precautions.

What is trauma?

The DSM-V defines trauma as “exposure to actual or threatened death, serious injury, or sexual violation.”  I prefer the definition of the Trauma-Informed Care Implementation Resource Center; they define trauma as “exposure to an incident or series of events that are emotionally disturbing or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, and/or spiritual well-being.” Unfortunately, trauma affects nearly everyone at some point in their life. Some individuals find their adult lives significantly impacted by trauma that occurred in childhood. Trauma disproportionately affects veterans, people of color, people with lower incomes, and those in the LGBTQ community. Research indicates that trauma is associated with adverse health outcomes and poor health habits.

Why is trauma-informed care important to me?

My first few years of being a physical therapist were also the first few years I began seriously unpacking my own childhood trauma. This was a good and necessary stage for me, but it was a hard stage. I found that practicing physical therapy in a traditional outpatient orthopedic clinic was not psychologically or physically healthy for me. I also became aware that I was not able to serve my clients optimally, to do my best work as a deeply caring healthcare practitioner, within that system. I had limited time to spend with each client, and often was not able to cover all the interventions that would benefit the client. Because I was a pelvic floor specialist and because people with pelvic health conditions often have complicated histories, a lot of my clients came in very upset or crying about their conditions, and the impact on their life. Some acknowledged past trauma. Some had trauma caused by the medical system and their experiences within it. Being inside the experience of trauma myself, at that time, I viscerally knew how important it was for me to sit with these clients and their pain (both psychological/emotional and physical), to allow them to talk without interruptions, and to incorporate what they were telling me into the way I provided their PT. I found it impossible to do this deep listening, to provide the actual physical components of the physical therapy (the guided exercise, the manual therapy, the client instruction in self care techniques), and to complete my documentation during the time I was allotted within the system. There was just not enough time. I did everything I could for my clients, and so I took a lot of work home. It wasn’t healthy.

The number one reason I operate my practice, Pelvic Care Physical Therapy, as a cash-based or out-of-network practice, is to create more time each session with my clients. This extra time allows me to meet the clients’ practical physical therapy needs in a trauma-informed and collaborative context. People with pelvic floor concerns often need more time than those with just orthopedic concerns. A person with bladder, bowel, or sexual dysfunction often has at least two or more of these coincidentally (e.g., leaking urine with double unders during crossfit as well as pain with sex), as well as associated orthopedic (e.g., low back and hip and neck) issues, and sometimes complex lifestyle factors  (e.g., being a busy mom with little time left for herself and having a history of childhood sexual trauma). Pelvic floor physical therapy is essentially complex. Add to this the fact that since I am often interacting directly with people’s genitals, providing trauma-informed care is a must. Providing trauma-informed care requires extra time because in some circumstances it requires additional verbal explanation of procedures, client/provider co-education to permit collaborative care and power sharing, and provision of options and alternatives for physical treatment. 

Being a cash based practitioner allows me to provide my clients with maximally efficient and evidence based care in a trauma-informed context, and it helps me maintain a healthy work-life balance so I can avoid burning out. Burnout among healthcare providers is depressingly high; physical therapists are no exception. My main goal is to keep my compassionate, passionate heart available for my clients and I must stay healthy in mind/body/spirit to do this. The best healthcare requires this of its practitioners.

What does trauma-informed care look like?

Because trauma-informed care might look different in the hands of different providers and clients, I’m going to list a number of ways I try to incorporate trauma-informed care in my practice rather than provide definitive explanations. I want to posit an important caveat from the start: Providing trauma-informed care is a process not a product. It’s something we can’t master, we only try, and unfortunately we inevitably fail. Trauma and triggers are slippery and confusing, they change over time, they are multi–sensory. Like pelvic health, trauma is complex. I want to learn more about how to be a trauma-informed practitioner. Let me know if you have ideas.

Here are some ways I seek to provide trauma-informed care: how ive structured my practice

• Consultations

  • Because seeking pelvic floor physical therapy can be scary and finding it can be complicated, I offer free 15-minute phone consultations to clients before they get scheduled. I explain the cash-based model and provide a referral to another qualified pelvic floor specialist who takes insurance if this is the client’s preference (and I offer to stay in touch as a resource for other referrals, if they have ongoing need, even if they don’t become a paying client). As indicated, I explain what to expect from the first visit, including the details of an external or internal pelvic floor physical examination.

• Website

  • I provide detailed information about what to expect during a pelvic floor physical examination on my website: www.pelviccare.org. I am hoping to include more client education and resources for self care on my website in the coming year, to better empower clients and the broader community to heal themselves.

• Intake forms

  • Allows explanation  in an open ended format of preferred name, pronouns, gender, sex. 

  • Allows space to disclose a history of trauma, if relevant, without requiring it

• Time parameters

  • I provide both 85 minute and 55 minute initial appointments, and I prefer 85 minutes. Follow ups are typically 55 minutes

  • This allows us sufficient time for the subjective portion of the examination, which is important for clients who have a history of trauma intertwined with their conditions, or who simply have a complex physical/medical history. 

  • It permits time for more thorough explanation of examination and treatment options, as required/desired. It also offers time for clients to consider their options and articulate their opinions and questions before they decide what course of action to take.

  • It permits a thorough physical examination (necessary for accurate diagnosis and treatment), performance of initial treatment, and adequate time to instruct the client in their corresponding home exercise and self-care routines. Having enough time for instruction in what to do at home helps clients feel secure, and makes collaboration toward goals possible.

• Emphasis on co-education and client education for client empowerment

  • I believe client and practitioner should be on the same page about what is causing the condition, and what will be the most helpful to resolve the condition. If they are not on the same page, they should actively be communicating about their differences and preferences and the client always is boss when it comes to their body and chosen interventions.

  • This process involves providing visual and tactile models and verbal explanations, on my part, about anatomy and physiology, pain neuroscience, and other principles at play. It involves the client sharing what has worked and what hasn’t, their personal histories and preferences, and their medical knowledge with me. Sometimes it involves both of us, or just me, doing more research and bringing it back to the conversation.

• Emphasis on client as my boss

  • I want my clients to know they’re my boss because they’re paying me, and because they are boss of their body and that’s what we’re here to work on. I have a lot of knowledge and professional experience about physical therapy. They have a lot of knowledge about their body and their lived experience in addition to perhaps knowing a lot more than me about certain medical topics. I want to share the power with my clients because I believe it helps them heal faster and better.

• Non-verbal communication

  • Sometimes someone may not even know they are triggered, or may not feel safe/comfortable verbalizing it. Perhaps their concept of what is going on is different than mine. One of the superpowers that can come from having trauma is enhanced perception of non-verbal communication. I try to stay attuned to what’s happening verbally and non-verbally (including during manual therapy and exercise interventions), and respond accordingly, even if it “doesn’t make logical sense.” I also try to articulate out loud my clinical decision-making and any actions based on non-verbal information, so that I remain in a power-sharing collaborative mode with my client.

• Redirection

  • If a client seems triggered or alarmed, I change what we are doing. Usually, we stop what we are doing. I help the client find a position and an environment where they feel more in control. I sit with them and don’t try to do much until we figure out what, if anything, feels appropriate to do at the time. We might change the priorities of the session to prioritize resolution of the alarm over other physical therapy goals, for the day. The client is boss of this process. I try to take their lead since they may be familiar with what helps best when this occurs.

  • I don’t think it is appropriate to continue an intervention if that intervention induces dissociation. In these instances, I work with the client and their healthcare team as needed (e.g., mental health therapists or other professionals) to understand what range of activities induces dissociation and to figure out manual therapy interventions and movements that feel safe, so the client can stay inside their body, inside current conscious awareness, during physical therapy. I would like to learn more about this from my mental health peers.

• Access

  • Sometimes clients with trauma have intense responses to bodywork, exercise, or other physical therapy interventions that are not expected. From the outset, I let my clients know I am available to them via text or phone call in between sessions within 24 hours of contact, during the weekdays. (Of course I’m also available via email, although I’m terrible at checking it and ask for them to let me know via text if they’ve emailed!) I tell any clients who have an intense response to interventions that I want to be part of their problem solving team and I’d like to stay in touch about it so we can use the information about their response to provide better care in the future. I try to engage in collaborative problem solving about what we can change to provide a dosage (of exercise, manual therapy, or modality use) that is efficient but tolerable for the client, both psychologically and physically.

• Being a part of a healthcare team, and referrals

  • Sometimes people are traumatized by their experiences within the medical system. Sometimes the journey to pelvic floor physical therapy is convoluted, and has involved seeing many different specialists, each providing a different diagnosis. Sometimes people have had surgeries or other interventions they now feel were unnecessary. Some have felt violated by medical procedures performed, or practitioners’ words or actions. It’s important to me to avoid causing such trauma as a physical therapist, and I try to engage in persistent self reflection about this possibility in my practice. I also try to be a source of referrals to healthcare providers I’ve heard good things about, or directly know to be excellent providers. I would like to be a collaborative part of my clients’ healthcare team, and seek to provide documentation and communication with other providers to make this possible. These practices are important to reverse the tide of trauma sometimes acquired within the healthcare system.

• Consent

  • Most agree that verbal consent is required for palpation (whether internal or external) of the pelvic floor because these muscles are in the genital area. I also believe it is important to obtain verbal consent when I first touch a client (e.g., “Is it ok for me to touch your pelvis here to see how its aligned in standing?”), before I shift a client’s clothing, to assess whether draping is adequate for a client’s preferences/modesty, and prior to touching the abdomen/inner thighs/anterior throat, or any area of the body the client has verbally or non-verbally expressed as a protected area for them. I try to modulate the frequency of asking for verbal consent based on a client’s verbally and non-verbally expressed preferences.

• Options

  • I am really working on phrasing things as options, since attending Krystyna Holland’s amazing lecture on providing trauma-informed care at the Pelvicon 2022 conference in Atlanta this Fall. I used to say, “I’m going to do this or that, is that ok?” or “I’d like to look at this or that to figure out this or that, is that ok?” She pointed out that many folks dealing with active/activated trauma may not have the ability at the moment to say, “No, that’s not ok. I don’t want that.” Whoa. I needed to hear that. This is definitely a work in progress for me. Now I’m trying to say, “We could do this or we could do that, which do you prefer?” If a client’s like, yeah yeah yeah, just do the dang thing, I take their direction and am more direct from thereon. If options seem useful to a client, I keep offering options. If options seem overwhelming to a client, I propose specific interventions/methods but try to be sensitive about providing further information and more time for processing/non-verbal communication as needed.

• Environment

  • My practice is currently inside a yoga studio, which I think is a space very well suited for the practice of pelvic floor physical therapy. When I looked for an office, I prioritized privacy, calm, cleanliness, and multiple single use bathrooms en suite since around half of my clients have urinary urgency/frequency issues (or if not this, constipation). I come from a massage background, so I make my PT space up more like a massage room than a PT clinic. There is spa music playing quietly in the background, dim (or bright) light options available, and there are soft sheets. This stuff is really important if you are feeling nervous about your first PT appointment, or if you are wrapped up in active trauma and you don’t feel calm or safe. Most of my clients need help learning how to “let go” of their muscles/reduce unconscious muscle guarding so that they are able to build functional strength and coordination of their pelvic floor. A calm environment helps set the stage for this work.

To summarize: Under the umbrella of trauma-informed care, I stay tuned in to my clients’ verbal and non-verbal communication. My number one priorities are the client understands what we are doing and why, and is given opportunities to say no and make requests. It is of utmost importance that the client trusts they are safe, and knows they are in control of their body and what happens to it during physical therapy. At its heart, trauma-informed healthcare is about consent, collaboration, and sharing power.

Recommended Reading and Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604257/

https://www.traumainformedcare.chcs.org/what-is-trauma/

The Body Keeps the Score

Trauma and Recovery Judith Herman

The Courage to Heal Ellen Bass and Laura Davis

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Our first workshop was well attended and I so appreciate everyone that came out to share space with us and learn some embodied self care techniques. Thanks to everyone for making the event a success.

We are planning to put out a monthly newsletter with useful information about pelvic floor issues each month. Next month's theme will be "Why Cash-Based PT?" If you have a great idea for a monthly theme or a request to focus on a topic you're extra curious about, please text us at (405) 240-9575 and share your ideas!