Establishing a History of Trauma and Patient Advocacy in Light of #MeToo Viral Campaign

As emerging doctors in the early 21^st century we will set the tone for helping our patients reconnect with the world after a jarring interface with assault/ harassment that is out of proportion with their emotional and psychological perspective on life. This is not just a fad but a stake of civil unrest that had an earlier voice this year with the worldwide Women’s March. 

The following articles in reaction to the recent #metoo campaign provide personal stories and insights from survivors and their doctors. http://www.aafp.org/news/blogs/freshperspectives/entry/20171019fp-metoo.html

For people affected by gender based harassment, violence and abuse of power, these experiences are real and violating though they did may not amount to physical sexual misconduct by the aggressing party. In my own experience as a medical student, a patient without regard for the professional setting of the hospital placed me in a very uncomfortable situation. He knew that my role was to assess his symptoms, and after I asked him if he was ready to discuss this with me he proceeded to masturbate in his hospital bed. I wasn’t sure if I should believe what I saw and asked if he needed to use the restroom before our interview. He said no while never stopping his activity. At that point I told him I would not be conducting the interview until he stopped and was ready to act appropriately, and walked out of the room. I felt frozen and unable to stop the sexually harassing behavior when it was not acknowledged by the aggressor and felt that I had somehow failed. After that encounter, every patient room in the hospital felt too small and hostile for a few weeks. This encounter broke the trust I had with professional settings and rules of common social decency.  

As physicians and providers of healthcare, we should provide validation of stories from all vulnerable populations, showing them that their trauma is real and relatable so as not to further isolate the person.  We can do this by normalizing the spectrum of reactions and acknowledging that reactions may manifest in other ways such as mental health issues, physical stress, social isolation, inability to care for family members, or inability to function efficiently and at a high level at work. The provider, as the listener, should not insinuate that the abuse of power and harassment was unrelatable or unbelievable.  These experiences are the social determinants of health, and we need to meet the patient where they are in their struggle of revealing their truth.

The CDC provides many resources on violence prevention and the consequences that victims may experience as a result. Interestingly, some studies have shown long term repercussions of these events such as decreased likelihood to marry, which could be speculated to stem from a distrust of intimate partners, shame and guilt, and fear of future trauma.

https://www.cdc.gov/violenceprevention/sexualviolence/consequences.html

 

Physicians can also pick up on new health risk behaviors that may clue them in to inquiring about past abuse or violent events. When screening and counseling patients Trauma Informed Care in Behavioral Health Services suggests the use of the SLE screening or the STaT intimate partner violence screening tool and offers the following:

Advice to Counselors: Screening and Assessing Clients

• Ask all clients about any possible history of trauma; use a checklist to increase proper identification of such a history (see the online Adverse Childhood Experiences Study Score Calculator [http://acestudy.org/ace_score] for specific questions about adverse childhood experiences).
• Use only validated instruments for screening and assessment.
• Early in treatment, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma.
• When clients screen positive, also screen for suicidal thoughts and behaviors (see TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment; Center for Substance Abuse Treatment [CSAT], 2009a).
• Do not delay screening; do not wait for a period of abstinence or stabilization of symptoms.
• Be aware that some clients will not make the connection between trauma in their histories and their current patterns of behavior (e.g., alcohol and drug use and/or avoidant behavior).
• Do not require clients to describe emotionally overwhelming traumatic events in detail.
• Focus assessment on how trauma symptoms affect clients’ current functioning.
• Consider using paper-and-pencil instruments for screening and assessment as well as self-report measures when appropriate; they are less threatening for some clients than a clinical interview.
• Talk about how you will use the findings to plan the client’s treatment, and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment. It is helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions (Fallot & Harris, 2001).
• At the end of the session, make sure the client is grounded and safe before leaving the interview room (Litz, Miller, Ruef, & McTeague, 2002). Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment, what the client’s plan is for maintaining personal safety, and what the client’s plans are for the rest of the day.

Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 4, Screening and Assessment. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207188/

https://www.ncbi.nlm.nih.gov/books/NBK207188/

Further, Trauma Informed Care in Behavioral Health Services suggests that screening for histories of trauma is a primary prevention in the development of behavioral health disorders and health risk behaviors. It is our duty as physicians to address physical and psychosocial determinants of health at every interaction with patients. After all, we may only interact with a patient once over the course of their lives and cannot assume their last interaction with a physician is an accurate depiction of the person presenting to us.

As a medical student, I have learned several valuable lessons on the wards, possibly the most important of which is to never assume the previous record is complete or correct.  People have ever changing histories and truths that we must explore before simplifying an interaction to a diagnosis and treatment plan.

Lindsey Lee

DUCOM 2018