How to Use Trauma-Informed Care in Treating Sexual Assault Victims

In today's Osmosis blog, we're discussing trauma-informed care – what it is, how to apply it, and why it should be central to how healthcare professionals interact with and manage care for sexual assault survivors and other patients who have experienced trauma. 

For millions of people, experiencing trauma leads to complex physical and emotional health issues that can take months (or even years) to resolve. Trauma from a sexual assault has an added layer of complexity in that it often affects a survivor's self-esteem, levels of self-criticism, and attachment style. In using trauma-informed care principles to recognize, acknowledge, and respond to trauma in an appropriate and beneficial way, doctors, nurses, and other healthcare professionals can make a positive difference in patient outcomes. 

What is trauma-informed care? 

While no one person or organization is credited with the development of trauma-informed care, a research paper by mental health practitioners Maxine Harris and Roger Fallot in 2001 was published with the goal of educating child welfare, criminal justice, and healthcare providers on the best ways to work with trauma survivors. Their paper provided healthcare professionals with a structured approach to treating patients who've lived through a traumatic experience resulting in severe damage to their spiritual, emotional, and psychological well-being. 

The Australian National Trauma-Informed Care & Practice Advisory Group notes that trauma-informed care "…acknowledges and clearly articulates that no one understands the challenges of the recovery journey from trauma better than the person living it. This requires that practitioners are attuned to a person's experience and the dynamics of trauma and acknowledge, respect, and validate that experience." 

The primary goal of trauma-informed care is to interact with patients in ways that don't further traumatize them by shifting the conversation from "what's wrong with you" (e.g., blaming the patient by directly or indirectly implying that they're responsible for their traumatizing event) to "what happened to you" (both the traumatizing event as well as a personal history) to provide the most effective care and support possible. Reframing the narrative is the first step to providing practitioners with a supportive framework for addressing survivors' needs and concerns.  

What are the principles of trauma-informed care? 

By using trauma-informed care, clinicians can avoid further traumatizing survivors so that patients can focus on resilience and recovery. While there's no single model, there are fundamental principles that guide trauma-informed care:

Safety 

First and foremost, address the physical and emotional safety of the patient. Show empathy and respect to demonstrate that you are a safe person to interact with. Make sure that common areas are welcoming and privacy is respected. Stay calm. Listen to them. Talk with them (rather than at them). And, whenever possible, don't leave survivors by themselves. 

Trustworthiness and Transparency 

To build and maintain trust, make sure the reasons for all decisions and treatments are transparent to the patient. Provide clear and detailed information about the exam and treatment process, including explaining procedures, answering questions, and obtaining consent for every aspect of care. Survivors should also be informed about trauma's potential physical and psychological effects, along with receiving mental health support and resources.

Empowerment and Choice 

By prioritizing choice and empowerment, you foster a respectful space that encourages efficacy, agency, and dignity. Take the time to provide clear and appropriate information to patients about their rights and responsibilities, which enables them to determine the direction of their care. 

Collaboration 

Make a point of actively collaborating with traumatized patients. Because healing takes place in the meaningful sharing of power and decision-making, active collaboration with survivors helps provide them with a greater sense of well-being and security.  

Cultural, historical, and gender issues 

In preventing additional traumatization of survivors, it's vital to consider their specific needs based on their culture, history, and gender. To do that, clinicians and caregivers must actively work on addressing and moving past stereotypes and biases, provide gender-responsive services, and recognize and address historical trauma. 

How to screen for trauma using a Brief Trauma Questionnaire (BTQ) 

The use of trauma screening is a crucial part of identifying and treating survivors, helping to ensure they receive the right kind of care. A good screening tool for trauma is the Brief Trauma Questionnaire (BTQ), which has been used with a range of populations and found to be a reliable way to measure exposure to trauma. 

The BTQ aims to assess the types of traumas a patient may have experienced, including physical assault, sexual assault, and witnessing violence. The BTQ also assesses mental health challenges such as anxiety, depression, and post-traumatic stress disorder (PTSD) and can be used in various healthcare settings. 

Childhood trauma and the ACES assessment tool

Research supports that patients who have experienced trauma have an increased risk of adverse health outcomes such as post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, cardiovascular disease, and diabetes. It's important for healthcare providers to be aware of these potential health risks and integrate an approach that incorporates trauma-informed care principles.

The following screening questions (with rationales that healthcare providers can consider when incorporating trauma-informed care) are used to identify individuals who have experienced trauma and may be at risk for adverse health outcomes. Following trauma-informed care principles, these questions should be asked in a sensitive and non-judgmental manner and should be tailored to the individual's unique experiences and needs:

• Have you ever experienced a traumatic event or events? This question is open-ended and allows the individual to share their experiences in their own words.
• Have you ever experienced physical or sexual abuse? This question is more specific and can help to identify individuals who have experienced abuse.
• Have you ever witnessed violence or been in a dangerous situation? This question can help to identify individuals who have experienced trauma as a result of exposure to violence.
• Have you ever had symptoms of anxiety or depression? This question can help to identify individuals who may be experiencing psychological symptoms as a result of trauma.
• Have you ever had trouble sleeping or nightmares? This question can help to identify individuals who may be experiencing sleep disturbances as a result of trauma.
• Have you ever used drugs or alcohol to cope with stress or emotions? This question can help to identify individuals who may be using substances as a coping mechanism for trauma.
• Have you ever had thoughts of harming yourself or others? This question can help to identify individuals who may be at risk for self-harm or harm to others as a result of trauma.

This list isn't comprehensive and should be adapted to the individual's unique experiences and needs. If the patient is currently being abused or has a past risk factor, it's vital that healthcare providers are able to identify appropriate resources and support for individuals who have experienced trauma. Trauma-informed care approaches can help to ensure that individuals receive the care and support they need to heal and recover.

Is treating a victim of sexual assault different than treating other traumatized patients? 

Overall, whether you're treating a survivor of a sexual assault or another type of trauma, the basic principles of trauma-informed care apply. However, when it comes to successfully establishing a constructive caregiver-patient relationship with a survivor of sexual assault, one factor stands out: clinician comfort. Many medical students and clinical practitioners lack the confidence to interact effectively with survivors and are uncomfortable conducting forensic examinations. Fortunately, the solution is simple: provide additional education and training.

Some additional factors to consider when treating a survivor of sexual assault:

• Patients who have been sexually assaulted often feel ashamed, blaming themselves for what's happened. Reassure them that it's not their fault and they did nothing to deserve what's happened to them. 
• Reassure survivors that you believe them. Remind them that it takes a lot of courage to seek treatment. 
• Let them know they're not alone. Be sure to offer mental health resources and, if available, access to onsite counseling services. Share resources from RAINN and other victim advocacy organizations. 
• Be patient. Trauma triggers a range of potential reactions, many of them counterintuitive to what we may expect. Don't be surprised to encounter numbness, disassociation, confusion, anxiety, arousal, or agitation.  

Tips on treating traumatized patients 

1. Listen and encourage survivors to share their reactions when they're ready. Show empathy and offer support by not questioning or dismissing their experiences. 
2. Keep them safe. While it may seem obvious, it's crucial patients are moved to a secure, private location away from any potential danger. It's especially important for victims of sexual assault and violent crime since their attacker may be in the vicinity. 
3. With their consent, perform a medical examination to determine if any physical injuries need to be addressed. If the patient is a victim of sexual assault, make sure to rule out sexually transmitted diseases or pregnancy. Offer emergency contraception., 
4. Offer mental health support and resources. The effects of trauma are unpredictable. Having mental health resources available can help patients take the necessary steps to cope with their trauma. 
5. Thoroughly document the evidence. If you're treating a victim of assault, be prepared to report it to the police (healthcare workers are mandatory reporters in most places) and collect evidence in support of potential prosecution. 
6. Provide follow-up care. Survivors will likely need additional care, whether it's counseling and support services or further medical treatment. They may need clarification about what to do. Try to simplify and outline the next steps. 
7. Actively share your knowledge. Doctors, nurses, and other healthcare professionals should proactively educate themselves about trauma and its effects on patients (don't wait for someone else to require it) and share that knowledge with their peers.  

Why use a trauma-informed care approach? 

While further study of the application of trauma-informed principles needs to be explored, it has an observable range of benefits for patients and caregivers, including a reduction in avoidable care and additional costs.

When survivors feel validated, supported, and heard, their level of engagement is higher, they adhere more readily to treatment and have better overall health outcomes. Most importantly, patients recover more quickly and have less trauma to process in the long run. 

When a caregiver practices a trauma-informed care approach, providers and staff not only benefit from lower levels of personal stress and an increased sense of wellness but also possess a proactive process to guide treatment, see lower levels of re-traumatization and negative patient encounters, and the overall quality of services and patient satisfaction increases. 

Conclusion 

All trauma survivors deserve to be treated with care and respect while recovering from the physical and mental challenges of their experiences. By instituting and applying trauma-informed care practices, clinicians offer sexual assault survivors and other traumatized patients the best possible care and support, laying the groundwork for better outcomes for everyone involved. And when we know better, we have an obligation to do better. 

If you or someone else have concerns about sexual assault or domestic violence, find help in your area through the No More directory.

National Sexual Assault Hotline (Open 24 hours): 1-800-656-4673

Contributors

Maria Pfrommer, DNP, Ph.D., FNP-BC, RN, Director of Nursing Education at Osmosis
Stephanie Stevens, Osmosis Brand Marketing Lead

Resources

• https://www.sciencedirect.com/science/article/pii/S1555415520304748 
• https://psycnet.apa.org/record/2001-00826-001 
• https://www.rainn.org/articles/tips-talking-survivors-sexual-assault 
• https://journals.lww.com/academicmedicine/Fulltext/2022/08000/Encouraging_Trauma_Informed_Care_of_Sexual_Assault.18.aspx 
• https://www.tandfonline.com/doi/abs/10.3109/01612840.2015.1025319 
• https://www.nature.com/articles/pr2015197 
• https://www.cdc.gov/orr/infographics/6_principles_trauma_info.htm 
• https://www.ncbi.nlm.nih.gov/books/NBK207191/ 
• https://noviolence.org.au/wp-content/uploads/2020/05/Trauma-Practice-Paper-FINAL-002.pdf 
• https://www.apa.org/monitor/2022/09/sexual-assault-patients 

References  

Bateman, J & Henderson, C 2011, 'Trauma Informed Care and Practice, Consultation on the development of a national approach to Trauma – Informed Care and Practice (TICP)', Mental Health Coordinating Council, Sydney

Center for Substance Abuse Treatment. (2014). Trauma-informed care in behavioral health services. Treatment Improvement Protocol (TIP) Series, No. 57. Substance Abuse and Mental Health Services Administration (US). 

Kimerling, R., Trafton, J. A., Nguyen, B., & Street, A. E. (2006). Diagnostic accuracy of a brief screening measure for PTSD: The Brief Trauma Questionnaire. Primary Care Companion to The Journal of Clinical Psychiatry, 8(6), 344-348. 

Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Publications. 

US Department of Veterans Affairs. (2018). Trauma-informed care for healthcare providers. National Center for PTSD. 

Breslau, N. (2009). The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma, Violence, & Abuse, 10(3), 198-210.

Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Williamson, D. F. (2002). Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: implications for health and social services. Violence and Victims, 17(1), 3-17.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and post-traumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959-992.