Helping patients deal with trauma
A medical appointment can be intimidating and scary for a child with a history of trauma. Still, this visit might be the first time a patient shares that they have been sexually or physically abused or that they are terrified to live with their fighting parents during COVID-19.
Your role as a primary care provider (PCP) is critical. Your interactions with your patient need to feel safe. As constrained as your time is, you must make every minute count toward establishing a connection.
Safety and Connection
When people are afraid, they are less likely to be transparent, explained Ceth Ashen, PhD, faculty member of The REACH Institute program Child/Adolescent Training in Evidence-Based Psychotherapies (CATIE). Dr. Ashen practices and provides consultation, supervision, and training in trauma-focused cognitive behavioral therapy.
As you learned in your REACH training, physical complaints such as hyper- or hyposomnia, stomachaches, headaches, panic breathing, or hypervigilance can have underlying emotional causes. Providing a safe space for young patients and establishing connections can encourage them to share what really brings them in — both physical and emotional concerns.
Dr. Ashen shared how pediatric PCPs can conduct trauma screening to identify physical and mental health needs and know when to refer to and collaborate with mental health professionals. Connection is the key to accurate diagnosis and quality care.
- Get a clear understanding of what the patient needs. Find out what brings the patient in to see you, whether it’s a routine physical or a specific complaint. Engaging with the patient will show you how to be helpful.
- Share the plan for the appointment. Tell the patient what will happen during the appointment, start to finish. Knowing what exams and tests you will do and how long they need to have their clothing off can be especially helpful to young people who have experienced trauma, as they may be anxious with uncertainty. Your description of the process can comfort them by making the visit safe and predictable.
- Create a connection with the patient. Your genuine curiosity, authenticity, empathy, and presence will be a game-changer for any young patient — especially for one who has experienced traumatic events and so is less likely to be trusting and forthright.Dr. Ashen offered the example of a 14-year-old boy who complains of insomnia, night terrors, headaches, stomachaches, and loss of appetite. To connect with this patient, you can:
- Use open-ended questions. For example, you might ask, “How has life been for you at home during the quarantine?” The boy responds,” I can’t stop worrying about my mom. She has had two major heart surgeries, and I am so scared that this COVID thing is going to kill her.”
- Make a normalizing statement, such as, “I see why you are concerned, because your mom has been sick in the past, and this virus is very scary.”
- Use empathy. For example, you might go on to say, “You love your mom and don’t want anything bad to happen to her. You are such a loving boy.”
- Engage in safety planning. “Let’s you and I talk with your mom and go over all the things that we can do to keep everyone in your family as safe as possible. We can make a game plan of who to call and what to do if anyone in your house has any symptoms.”
- Develop connections with caregivers. Caregivers are your critical partners in gathering the information you need to evaluate the patient and plan for effective treatment delivery. Ask the caregiver how the patient is doing and what are the chief complaints so you can develop an accurate diagnosis and treatment plan.
- Ask direct questions about past or current abuse and trauma. The answers are vital to a good plan for assessment, evaluation, and treatment. To help with assessment, Dr. Ashen recommends the evidence-based screeners from UCLA linked in Resources below. They can help not only with screening for trauma symptoms but also with referral to and collaboration with mental health professionals.
- Work as a team. In order to treat the whole patient, PCPs, psychologists, therapists, and caregivers all need to collaborate. As the patient’s PCP, you need to understand where physical meets mental health and vice versa so you know when to refer. Referrals and collaborations with mental health professionals must be seamless.
Dr. Ashen recommended post-traumatic stress disorder (PTSD) screening tools PCPs can use to identify any history of traumatic events and related symptoms:
- UCLA Brief Screen Child/Adolescent Trauma and PTSD
- UCLA Brief COVID-19 Screen for Child/Adolescent PTSD
Register with the developers at Behavioral Health Innovations to download the free screeners. Both have standardized scoring with clinical cutoffs that indicate when to refer for further psychological trauma assessment and treatment.