Leaving this out of your patient’s medical history could cost their lives.
by Joyelle Brandt
I sat in the exam room answering the long list of questions my doctor asked about my medical history. Waiting. Waiting to see if she would ask. We got to the end of the exam, and there was no opening for me. Not even a “Is there anything else I should know about your medical history?” question. And I sighed on the inside, because I knew then that I would have to start the conversation. And I just didn’t feel strong enough that day, so I didn’t. I didn’t tell her that with my family’s history of bi-polar disorder and addiction I was more likely to die an early death of suicide than heart disease. I didn’t tell her that I have struggled with depression most of my life. I didn’t tell her that my childhood sexual abuse made every pelvic exam a horrific nightmare for me. I didn’t tell her a lot of things she should have known. But why?
I know the research shows that having a history of childhood trauma has significant impacts on health across a person’s lifespan, increasing the risk for chronic disease, mental illness, violence and being a victim of violence, and even shortening a person’s life expectancy by up to 20 years. This is critical information that needs to be shared with health care providers, and yet myself and most other survivors I know struggle to share this information.
So let’s take a look at some of the reasons why patients do not disclose their mental health and trauma histories to their health care practitioners.
- Cultural Stigma (Fear of being labeled and/or judged)
We have come a long way in recent years in mental health awareness. But the cultural stigmas around mental health and trauma are still strong, and no one wants to be “the crazy one.” The fear of labeling is about being pre-judged or dismissed because of your history, which leads to the next point:
- Fear of how it will be received
Most, if not all patients with a mental health or trauma history have had a negative experience when disclosing their history, not just to health care practitioners, but to anyone. Some of the reactions have included:
-accusing the person of lying (imagining their mental health or trauma issue)
-telling the patient they are just overly sensitive (dismissing or minimizing)
-using the information as an excuse for other medical conditions without doing any diagnostic investigation
– attributing health issues to the patient ‘just wanting attention’ or being a hypochondriac
-visible discomfort and avoiding eye contact with the patient after hearing the information
These are just a few of the painful reactions that patients have faced when trying to convey this very important information. I once had a doctor flip through my chart after I requested to see a female gynecologist. I was 16 years old and going for my first pap smear. His response to my request was to look through my medical history until he found the information he was looking for, and then say to me: “Oh, no wonder you want a female doctor. You’ve been tampered with.” This was in reference to the fact that I was sexually abused as a child.
- Avoiding fight/flight/freeze response
For trauma survivors, even talking about their trauma histories can trigger their bodies into the fight/flight/freeze response. This shows up in the body as increased heart rate, tremors, difficulty breathing or swallowing, nausea, etc. Given that lovely series of symptoms, it is understandable that they avoid talking about it whenever possible.
- Trained to secrecy
For survivors of childhood abuse, the fight/flight/freeze response can be even more pronounced because abusers train children into a culture of secrecy. In order to silence their victims, abusers will threaten not only the children’s lives but also their loved ones lives. They will tell the child that if she/he says anything, it will be the child’s fault and the child will get in trouble. Abusers will say anything to keep them silent. And even 30 or 50 years later, that early programming is very hard to break, as it was hardwired into the brain at such an early stage in brain development.
- Practitioners don’t ask
Finally, there is simply the issue that most health care practitioners never ask about mental health or trauma. This is understandable, given the lack of training in this area. But mental health and trauma are not something separate from physical health. They interact with and inform each other. Take for example the findings of the Adverse Childhood Experiences Study, which discovered that not only does early childhood trauma have a role in later chronic health and mental health ailments; it can shorten a person’s lifespan by up to 20 years. This is significant information that needs to be included in a patient’s chart, and taken into account when diagnosing and treatment planning.
So what can you do to ensure that this important health care information is included in your patients’ charts? Simply put, of the five issues above, three are beyond your control, but two are entirely in your control: the way you react, and a conscious choice to ask for the information. So how do you go about ensuring that your patients will feel comfortable disclosing to you?
After years of avoiding these conversations myself, I finally realized that I needed to create a tool to open this conversation with my health care practitioners. So I made my own form to take in to my doctor’s office. Just like the other patient intake forms, it has multiple choice check boxes, but these ones cover a patient’s trauma history, trauma impact and some ways to help the patient feel safer and less likely to be triggered. It is written in the form of a letter to my health care practitioner, assuming that I need to educate them about Adverse Childhood Experiences, because in my experience the health care system is not trauma informed.
After creating that form, I created one for health care practitioners to use, which will educate their patients about the impact of childhood trauma and the need to collect this information as part of their health care intake. When asking patients to fill in this form, my advice is to tell them that they can always update their chart at a later date if they are not feeling ready to disclose right now. Those who have a childhood trauma history will most likely have issues trusting any authority figure, because their trust was broken early in life. It may take time for your patient to be ready to open up about this issue.
When your patient is ready to disclose, the next important issue is how the health care practitioner reacts. While hearing stories of abuse can be very hard, try to maintain a calm, compassionate presence. Just talking about their abuse history will often cause a fight/flight/freeze response in your patient, and they don’t need your own trauma response to be added to it. The most helpful phrase to use is “I’m so sorry that happened to you.” What is not helpful is to push for too many details. Keep questions to a minimum and only ask what is absolutely necessary. Whenever you are discussing any details about their abuse history, let the patient know that they are always in charge and they have the right to stop the conversation at any point if it feels too much. When you are finished with the conversation, you could say something to the effect of: “Thank you for sharing this part of your story with me. I know that is not an easy thing to do, and it is important that I have this information. I appreciate you being willing to disclose that to me.”
Earlier this year I shared one piece of my trauma history with my family doctor. It was the fact that I have struggled with depression most of my life. Starting that process led to disclosing my history of childhood sexual abuse. So it’s finally out in the open, but I really wish I didn’t have to be the one to start that conversation every time.
Are you a health care practitioner interested in learning more about how you can create a trauma informed environment for your patients? Join me for an Introduction to Trauma Informed Care workshop in Port Moody March 18th.
To register for Introduction to Trauma Informed Care, send an email to firstname.lastname@example.org with your name, phone number and field of work. You will be sent an e-transfer invoice for payment.
Early registration discount available until March 1.
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