The Trauma-Informed Care Model As potentially valuable as they may be, medical encounters can also be stressful for abused patients. Because of this, healthcare providers should care for all patients in a trauma-informed manner. The nine principles of trauma-informed care are: 31 1. Respect Because abuse undermines a person’s personal boundaries and autonomy, they may be sensitive to any hint of disrespect. Many survivors say that being accepted and heard by a clinician helped them feel respected. 2. Taking time The time pressures in clinician/patient interactions may compound survivors’ feelings of being depersonalized and devalued. 3. Rapport Rapport is essential in every therapeutic relationship, but it is particularly necessary when supporting survivors of IPV. Good rapport not only increases patients’ sense of safety, it promotes clear communication and engenders cooperation. 4. Sharing information Some IPV survivors say they don’t know what clinicians do and, therefore, don’t know what to expect in terms of questions, procedures, or decisions. Having these things explained clearly and simply on an ongoing basis can help allay fear and anxiety. Clinicians should also seek ongoing feedback from patients about their understanding as well as any reactions they might have to questions or procedures. Sharing control A core aspect of sexual or physical abuse is the loss of control over one’s body, hence it’s vital for patients to have a sense of control with clinicians who unavoidably occupy a position of power. Sharing control of what happens in the clinician/ patient interaction enables individuals to be active participants in their own care, rather than passive recipients of treatment. 5. 6. Respecting boundaries Beginning a procedure without first asking for the consent of the patient, or asking very personal questions before establishing rapport can feel like a violation of personal boundaries (both physical and emotional). Fostering mutual learning The best teachers about the health effects of IPV and about how to work effectively with survivors are often survivors themselves. Clinicians who demonstrate genuine compassion and an interest in learning from their patients will be better positioned to respond effectively to future survivors of IPV. 7. 8. Understanding non-linear healing The degree to which a survivor is able to tolerate or participate in treatment may vary from one
healthcare encounter to the next due to the natural variability in the dynamics at work in IPV. Clinicians need to recognize and accept this variability and check in with patients at each encounter and adjust behavior as needed.
• Step 3- Create clinic-based policies and procedures. These will outline staff training efforts, use of EMR documentation, identification of “at risk” patients longitudinally, create follow-up plans, and streamline referral to internal and local community programs. • Step 4- Use the IPV Champion to build bridges and collaboration with local advocacy agencies and IPV experts. This ultimately allows for effective communication and “warm” referrals. • Step 5- Evaluate all clinical efforts regarding screening and periodically re-evaluate for dissemination to the clinical team. • Step 6- Provide general information to patients outlining healthy relationships as well as healthy conflict resolution strategies (e.g., pamphlets, posters, signage). BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE. Using Community Resources/Referrals Clinicians who may encounter survivors of IPV should explore all local support resources and keep an updated patient hand-out with their contact information. Establishing personal relationships with key personnel in community support organizations can not only improve a clinician’s understanding of the many social and legal dimensions of IPV, but it can facilitate referrals. Many community IPV programs include a confidential emergency shelter or safe house program. Some can provide temporary transitional housing or safe-at-home services. Although emergency shelter is usually a last resort for those who are in acute danger, the shelter offers a safe haven from violence and can also provide the survivor with information about rights and options as well as vital emotional and logistical support. In many programs, specialized services are available for children who have been traumatized by witnessing abuse. In shelter programs, women have a chance to meet other women who have sought shelter, which can help women break out of the profound social isolation that is so often a component of abuse. In addition, many IPV agencies offer counseling programs for survivors living in the community. These individuals may not need emergency shelter but nevertheless want to deal with the trauma of current or past abuse, and may be ready to take advantage of available support as they move forward with their lives.Many of these programs offer structured groups for parents of children exposed to IPV that deal with issues such as understanding the dynamics of violence, dealing with anger, understanding legal rights, understanding the effects of IPV on children, making and maintaining safety plans, and offering one another emotional support during important life decisions. These groups are often held in community settings so women not in shelter can also attend.
9.
Demonstrating awareness and knowledge of IPV
Many survivors of IPV look for signs of a clinician’s awareness of issues of interpersonal violence, such as in posters or pamphlets from local IPV-related organizations or the Family Violence Prevention Fund (www.endabuse.org). It’s also important that visible signs of a clinician’s awareness be inclusive, for example mentioning, or illustrating, that abuse can occur in same-sex couples. Office staff should receive periodic in- service training about IPV, referral resources, protocols, and office safety procedures. Time Management Clinicians may not screen for IPV because they think they don’t have enough time in their daily practice to inquire, assess, and respond appropriately. Judicious time management and an outlined protocol or established clinical process, however, will allow for universal inquiry, appropriate guidance, and targeted follow-up. Routinely asking about IPV (usually as part of the social history) should take no more than 10 seconds, and yet may have a dual beneficial effect: if the answer is negative, the clinician will be reassured that the patient is not at risk for abuse (or that the patient, if affected, is not ready or able to disclose at that time); and the patient will be made aware that the clinician is concerned, knowledgeable, and able to respond should IPV become an issue at any time in the future. Most patients with a history of being abused, although perhaps dealing with difficult medical and emotional sequelae, are not in acute danger at the time of the visit. If the patient discloses victimization, the physician should conduct a brief safety assessment (see above), offer information and hotline numbers, convey concern and support for the patient, and arrange a follow-up to discuss the abuse and possible options in greater detail. Only rarely will the clinician be confronted with a patient in extreme danger or who has acute needs. In this situation, as in the case of any medical emergency, urgent action is needed. While there are various guidelines outlining what patients may need from the health care system after experiencing IPV, there is little guidance on how to actually integrate and implement these practices within clinics. Treating IPV in a chronic care model and creating a team within clinical settings helps improve screening rates and provides interventions in a timely manner. The following six-point model summarizes how to create a sustainable system- level program: 32 • Step 1- Identify an IPV Champion (someone with on-site IPV expertise). • Step 2- Train all staff and define roles when responding to IPV (i.e., saturation training).
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