You may have heard of Trauma Informed Care (TIC), but how much do you actually know about it? I normally like to keep things fairly light here at The PT Page. Even when talking about big issues in our profession I’m known to throw in some humor. Most jobs in healthcare are heavy enough as it is. I once had a patient tell me “Sometimes if you don’t laugh, you’ll just cry” and I felt that. However, I’ve been meaning to write this post on trauma informed care for a while now in order to raise some awareness and understanding for PTs.
In short, trauma informed care is how we adjust patient care based on any physical or emotional trauma they may have suffered. It’s become a popular topic in the last few years. Many big healthcare systems advertise being versed in trauma informed care or having staff trained in it. I think it’s especially important for PTs to have at least a basic understanding of trauma informed care. Trauma can have a big impact on a patient’s physical rehabilitation. It can also change how we approach our plan of care. I’ll talk about both of these in depth while giving you some concrete examples of what trauma informed care looks like in PT.
How does previous trauma affect rehab?
Let’s start with why it’s so important for us to understand this topic. Previous trauma can impact rehab in a number of ways. If the patient is dealing with musculoskeletal effects as a direct result of trauma this is especially true. Trauma heightens the nervous system. This increases its sensitivity to pain.
Many patients who suffer injuries as a result of domestic violence or other traumatic events often have high sensitivity and irritability of symptoms. Their symptoms often turn chronic for this very reason. Even if injuries are not a direct result from trauma, sensitivity can still be worse. Many of us know chronic pain often has an emotional or psychological component to it. This is partially due to heightened fight or flight systems and increased cortisol levels that can occur as a result of physical or emotional trauma.
Our body has physical responses to emotions. There’s quite a bit of research out there affirming this. It’s extremely common that whenever a patient experiences a mental/emotional trigger of a past trauma (any kind) the body will have a physical reaction. This works vice versa as well. A physical feeling can remind someone of a past trauma and trigger certain emotions.
Given this, when working with patients dealing with past trauma, we should be prepared for some emotions during sessions. The more prepared we are for this the more we can offer the appropriate support to the patient. It may take some extra education and practice learning what to say in these situations. If we’re being honest it is a little awkward, but it’s even more awkward if you as the physician don’t know how to handle it. I know, we’re physical therapists, not psych therapists – but we should be able to do more in these situations than just hand the patient a tissue and then say “ok, now let’s do some LAQs”. THAT’S awkward.
It’s also important to note those patients dealing with trauma might have trouble really engaging in their rehab. Many of them are dealing with depression or may have difficulty trusting others. This is going to affect their buy-in and follow-through. You may have to work extra hard to gain their trust and build a rapport or really sell that HEP to help with compliance.
If you feel like you need more resources or education on trauma and the body there are SO many great books out there. I’d definitely recommend The Body Keeps the Score by Bessel Van Der Kolk. There is even a paired workbook that patients can go through. I’d recommend taking it in small chunks. It definitely helped my understanding of trauma and the body. I’ve had patients read it and use the workbook with raving reviews as well. A couple others I haven’t gotten to yet but on my list are The Nervous System Reset by Jessica Maguire and The Biology of Trauma by Aimie Apigian
When treating those with past trauma you can expect them to maybe need a little extra TLC. If you’re worried about saying or doing the wrong thing I encourage you to look into some resources to help you feel more comfortable in these situations.
What is trauma informed care?
It’s obvious that trauma can affect a patient’s rehab. If we’re aware, we can then tailor the patient’s plan of care to lead them towards the best success. And this is exactly what trauma informed care is. Trauma informed care involves two main parts. It first recognizes the impact trauma can have on someone’s physical, psychological, or emotional health. Secondly, it encourages healthcare providers to adjust treatment approaches accordingly.
These two parts are implemented on the basic 6 core components depending on your resource. Here’s the six components
Safety
Trustworthiness / Transparency
Peer Support
Collaboration
Empowerment
Humility / Responsiveness
Now it’s all well and good to read those and be like “yep, great, I got it.” But what do some of these actually look like in practice? Or more specifically in PT? I want to take a look at each one, what it means when talking about TIC, and examples of it in PT practice
What does Trauma informed care look like in PT?
Safety
Trauma informed care focuses on setting up an environment and situation where the patient feels physically and mentally safe whenever they work with us. Some patients may feel more comfortable in a smaller, quieter place. Some may feel better in a more open space with lots of people around.
Patients may prefer a therapist of a certain sex. If you’re a male therapist and a patient asks for a female therapist due to past trauma please don’t take it personally. Vice versa for the ladies too. This has happened several times in my clinic. Most of the time the patient is actually extremely apologetic. They’re also quick to say the previous therapist did nothing wrong, it’s just their preference due to past trauma.
So know that the patient doesn’t feel any ill will towards you or question your competence. They just knew rehab wasn’t going to be as effective as it should be if it wasn’t a situation that allowed them to feel safe. That’s what we should want for the patient as well. If a patient is sitting there with their fight or flight system on because they don’t feel safe, that’s going to make your job ten times harder.
Trustworthiness & Transparency
In trauma informed care trustworthiness and transparency focuses on goal setting and decision-making. Basically all decisions and goals need to be a conversation between you and the patient and ultimately made together.
In PT I think this looks like having actual conversations with our patients about their goals and how they’re going to reach them. A lot of times we just write goals into our eval and give HEPs and that’s the extent of it. In TIC it should be more of a discussion between us and our patient about goals that are important to them, what will help them get there, and what the patient is willing and able to do.
This goes for treatments as well. There are so many options for treatments. In trauma informed care we should present the options to the patient and have a discussion with them about it. We should make it a shared decision versus a single sided decision on the clinician side.
Peer Support
This next one is a little trickier. When talking about TIC, peer support refers to making individuals with shared experiences an important part of the care team. The problem is many clinics, even when attached to a hospital, are siloed. It’s not like there’s a TIC support person on staff at all times. However, there are ways to integrate this idea of peer support
You may have gone through a trauma yourself. Of course, you should share what you are comfortable and ready to share with the patient. If you know of any support groups relevant to your patient’s situation you can recommend those. Over the last few years I have worked with a lot of patients who’ve experienced trauma. I of course do not give out names or details but I will mention I had a patient with similar trauma and blank helped them or they also struggled with blank. I’ve found this makes the patient feel a little less alone. They know then that someone else has had a similar experience and have also been fighting the fight. Two, I think it builds the patient’s trust in you knowing you’ve worked with someone battling these same issues.
I do want to caution you when acting as a person of peer support yourself. I think our human reaction is to try to sympathize in order to make the person feel better. Our intentions are good, but we run the risk of looking a little tone deaf. Avoid using the phrase “I know how you feel…” No surprise, trauma is personal. We all react in different ways and similar traumas can leave different scars on different people.
It’s very likely, you don’t know how that person feels, even if you’ve experienced trauma yourself. I find sometimes the best thing to say is “I can’t imagine how that must have felt.”
Collaboration
In TIC, collaboration between all healthcare providers and the patient is essential. Oftentimes, the pain these patients experience is multifaceted. This requires the skills of several different healthcare professionals. The more we and the patient talk, the better.
In PT I particularly find some collaboration with counselors and psychologists to be very helpful. I will often try to incorporate any coping techniques the patient has learned from other resources into their PT sessions if negative feelings start to arise. It’s important to include the patient in these conversations.
Encourage them to use techniques or resources given to them by other members of their healthcare team. This reinforces the idea that healing from their trauma is multifaceted. It reminds them of all the people supporting them and as the patient they’re a member of the team as well.
Empowerment
This principle refers to giving control back to the patient by fostering feelings of resilience and self-efficacy. Empowerment is closely tied to collaboration. However, it more focuses on encouraging patients to take an active role in their care by making decisions and encouraging tangible actions that lead to recovery. It also emphasizes the ability to recover.
Basically it is the “yes we can” portion of trauma informed care. In practice, it’s us reassuring the patient there is a path to getting better. A lot of patients, trauma or no trauma don’t always think rehab is possible. If they don’t believe there’s at least a chance, we’re missing a big piece of the puzzle. We can’t make the patient believe in themselves but we can show them a path. Hearing “you can heal” or “you can do this” goes a long way with these patients.
Many patients who’ve experienced trauma feel they’re not in control of most aspects of their life. Oftentimes, the trauma has sort of robbed them of that feeling of they can determine what happens to them. Or, that the feelings and aftermath of the trauma is now what controls them.
We can help reverse that feeling by giving them options for treatment but then having them make decisions. It may just be something as simple as “here’s two ideas I had for our session today, which do you think would help you more?”
We can also give them resources for tangible actions. For example, on the physical side the patient may be trying to increase activity and on the mental side they may be trying to increase social interactions. We can give them some resources for gyms or group fitness that’s appropriate for them. Ultimately though they have to decide which one and take the steps to join or actually go.
Humility & Responsiveness
In TIC this core value refers to the acknowledgement of biases, stereotypes, and historical trauma. A lot of us get really uncomfy when talking about biases and stereotypes – basically what we think about anyone based on race, gender, sexual orientation, ethnicity, age, geography, the list goes on and on.
If we’re being 100% honest sometimes we make assumptions on patients from day one based just on what they look like. I think a lot of us want to get defensive and say “No way I don’t have biases and I don’t stereotype people.” The truth is we all have biases. There’s not a single person in the world who doesn’t bias or stereotype to some degree.
Honestly, we as PTs get stereotyped by patients all the time. For example, I look young for my age. I have straight up been asked two seconds into an eval “You know what you’re doing right?” Frustrating, definitely. BUT in that scenario I’m the physician, I’m providing a service, and I’m gonna keep it professional. As the wise saying goes – we can’t control others, but we can control ourselves.
What matters most when it comes to our biases and stereotypes is what we do about them. Do we pretend they’re not there? Or do we acknowledge it and make the conscious choice to monitor what may be some unjustified thoughts and feelings we have about an individual.
Biases often come from past or cultural experiences. If you’re big enough to acknowledge your biases and stereotypes, I’d ask yourself why you feel that way. You’ll likely learn something important about yourself. I also encourage you to try this exercise: Ask yourself what biases you think your patients have when first meeting you. What were they? How’d it make you feel? Would you want your healthcare provider to think those things about you?
Working with patients who’ve experienced trauma can be both challenging and rewarding. It definitely takes some education and practice to use trauma informed care. I hope this post maybe helped you have a better understanding of TIC. Comment one helpful thing learned about trauma informed care that you’re going to try to integrate into your practice.
If you’re a PT who works with a lot of patients who’ve experienced trauma I’d love to know any books, continuing ed, techniques, or strategies you use. I see a fair amount of this so I’m always on the lookout for new stuff because what might’ve worked for one person, may not work for someone else. Thanks for reading about a heavier topic than usual. Like I said though, I really do think this is an important topic. If you’re looking for some lighter PT Page posts you should visit the blog page. If you want to make sure you don’t miss any new blog posts, hit the subscribe button below. You’ll get all new posts sent directly to your inbox, so you can stay up-to-date on all things PT.
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