Enhancement Of Primary Care Treatment For Women Trauma Survivors
By Kelly R. Chrestman, Ph.D., Annabel Prins, Ph.D., and Mary P. Koss, Ph.D.
NCP Clinical Quarterly 6(4): Fall 1996
Community surveys reveal that approximately 15% of U.S. women have experienced either physical or sexual assault at some point in their lifetime, most often by an assailant known to the woman (1-3). Within primary care settings, the prevalence of women with histories of completed rape is 21% (4); the prevalence of physical assault or battering is 22.7%(5). Physical and sexual assault are as likely to produce posttraumatic stress disorder (PTSD) as exposure to combat. Indeed, the life-time prevalence of PTSD among survivors of physical and sexual assault is about 31%(2), similar to the prevalence reported for combat exposure (see Ford, Ruzek, & Niles, this issue). However, because of the high incidence of interpersonal violence in the U.S., women with assault-related PTSD constitute the largest single group of PTSD sufferers (3).
In addition to PTSD, survivors of physical and sexual assault are more likely than non-assaulted women to report a mental health problems, including fears and phobias, anxiety, chemical dependency, sexual functioning, depression, and somatization (6-8). There is also evidence that physical health can be adversely affected by criminal victimization. In addition to the acute medical consequences of violence, women with assault histories often report problems with chronic pelvic pain, other pain related syndromes such as headaches, functional gastrointestinal disorders, and premenstrual syndrome (9; see also Friedman & Schnurr, this issue). Finally, a history of physical or sexual assault is associated with detrimental health behaviors, including smoking, substance abuse, and high risk sexual behaviors (10). Given these detrimental health behaviors and chronic conditions, it is not surprising that women who have been victims of physical or sexual assault are frequent users of medical services including outpatient care, various procedures, x-rays, and hospitalizations (11-12). Clearly, violence against women is a medically-relevant issue.
Women who have experienced violence are more likely to turn to their primary care provider for help than to mental health professionals, police officers, or lawyers (4, 13). In other words, primary care providers will often be the first, and in many cases the only, health care provider to interact with the woman about her trauma-related symptoms. In this article, we provide a few guidelines for primary care providers on how to detect and respond to a history of interpersonal violence in primary care patients. We also examine the implications of such a trauma history for the delivery of medical care and procedures.
Detecting A History Of Interpersonal Violence
Despite strong recommendations from the American Medical Association that screening for interpersonal violence occur at all portals of entry into the health care system (14), research shows that women rarely volunteer this information without a direct invitation, and primary care providers, even those with psychiatric training, rarely ask about it (15). For example, the rate of physician inquiry about domestic violence is only 2-8% (16). Frequently cited reasons for not screening include personal discomfort with the topic, time constraints, fear of embarrassing or upsetting the patient, feeling unsure about what to do with positive identification, and feeling overwhelmed by the scope of the problem(15). Many have compared screening for interpersonal violence to opening the metaphorical Pandora’s Box.
However, experts in the area of interpersonal violence consistently and emphatically argue that the single most important service primary care providers can give to victims of violence is to ask about it (17). Direct questioning appears to be better for disclosure than paper and pencil self-report measures (18). Direct questioning also communicates personal recognition of the problem as a health care issue, and suggests to a woman that she is not alone and that help is available. Brown recommends that providers frame questions so that they educate the patient about the prevalence of interpersonal violence (e.g., "many women have experienced violence in their lives, often by someone they know...") (14). Brown also encourages providers to address frequently encountered fears about disclosure (e.g., "although violence is common, it is not uncommon for women to feel alone and scared about telling..") and common responses to victimization (e.g., "after experiencing violence, many women report problems with…"). Koss and Heslet encourage providers to avoid loaded terms such as rape, incest, battery, or domestic violence (9). They suggest describing the behavior in direct and non-judgmental terms. For example, sexual assault can be described as "forced or coerced to be sexual with someone when you didn’t want to" and physical assault or battering can be described as being "pushed, slapped, kicked, or hit…" Using a matter-of -fact approach can help the woman to feel that the provider will not be shocked or judgmental. Contrary to what is often assumed, most women (over 75%), regardless of age and assault history, believe that health care providers should regularly ask about trauma history (19).
Responding To A History Of Interpersonal Violence
Once a woman discloses a victimization experience, it is always appropriate to say, "I am sorry this happened to you"(20). This implies neither a judgment of the victim nor an indictment of the perpetrator, but focuses instead on the subjective experience of the woman. It is also appropriate to acknowledge the patient’s discomfort or fear if it is evident. However, it is important to avoid making assumptions about how the patient feels about the experience. For example, incest may seem clearly abhorrent and harmful to the primary care provider, but the incest survivor may have feelings of confusion encompassing both positive and negative feelings toward the event and the perpetrator. It is important to validate her experiences rather than assuming she will view the event from the same perspective as the provider or even another incest survivor. Using the woman’s own language and wording to describe her feelings will be perceived as more accurate and empathic.
In addition to understanding and validating the woman’s feelings, it is important to "normalize" the woman’s response to victimization. Providing corrective information about the prevalence of trauma and the range of reactions common to survivors can often help the woman to feel less ashamed about the violence and her reactions to it. For example, if she expresses concern that she is over-reacting, or behaving hysterically, the health care provider should state very clearly that she is not crazy (21). By learning that traumatic reactions are ways of coping with violence, (even if they seem "crazy" to the patient or to others), the woman can begin to understand her experience and the way it has affected her health and emotional well-being. Additional information can be provided to the woman in the form of hand-outs or brochures. Many of these are free of charge (22), and can be kept on hand for patients along with other routinely given educational materials (e.g., breast examination handouts, safer sex brochures, etc.). This type of "psychoeducation" not only normalizes the victim’s responses but is a critical aspect of recovery.
Once understanding, validation, and normalization have taken place, it is essential to assess current level of danger. Ashur has developed a number of "SAFE" questions for domestic violence that can be used in primary care settings (23; See Table 1) .
Table 1: SAFE Questions
Stressor/Safety
Can you tell me about the types of stress you experience in your relationship/marriage?
Do you feel safe in your relationship?
Should I be concerned about your safety?
Afraid/Abused
Are there situations at home or in your relationship where you have felt abused?
Has your partner ever threatened or hit you?
Are you in a situation like that now?
People in relationships often fight and argue; What happens when you and your partner
disagree?
Friends/Family
Are your friends/family aware that you have been hurt?
Does anyone in your family know that you have been physically hurt or threatened?
Do you think you could tell them, and would they be able to give you support?
Emergency Plan
Do you feel you have a safe place to go in an emergency?
If you feel you are in danger now, would you like help in locating a shelter or developing
and emergency plan?
These questions help to determine the level of danger and the need for intervention services such as shelters and legal protection. Because women who have been physically or sexually assaulted are at higher risk for revictimization (24), careful attention needs to be given to developing escape plans (e.g., extra clothing and important papers at a neighbor's house), referrals (e.g., telephone numbers for shelters and hotlines) and written documentation (e.g., detailed information on injuries sustained). Although mental health referrals should be offered, including referrals to shelters and rape crisis centers for both recent and past assaults, they should not be the only option. The goal is to empower the woman with knowledge to make decisions about coping with and ending violence, seeking support and assistance, and repairing her life.
Often, multiply victimized women are not able or ready to leave relationships, despite frequent abusive episodes, because of financial dependence, cultural or religious sanctions against separation, or fear of retribution. Ruddy and McDaniel suggest that a "readiness for change" model may give medical providers a better benchmark for measuring progress in these patients (15). This model recognizes that not all women will be motivated to change their relationship or to accept help. Within this model, progress is measured by movement from a "precontemplative" stage to an "action" or "departure" stage. Utilizing such a model can also be informative for evaluating the likelihood of future assault. For example, the most severe assaults occur when the woman is attempting to leave the relationship.
Implications Of Assault History For Medical Care And Procedures
Once the above steps have been considered, it is necessary to evaluate how a woman's trauma history has interfered with her functioning, both in general, and specific to medical situations. In particular, medical procedures involving physical contact or restraint, and procedures that are physically uncomfortable, painful, or perceived as life threatening, can recapitulate aspects of the assault. Examples of this include breast and gynecological examinations, use of a tongue depressor or oral thermometer, examination of teeth and gums, administration of viscous solutions for imaging procedures, restraints used for securing an IV, and/or palpitation of a specific area of the body(25) . In addition to certain procedures, physical characteristics of the health care provider can trigger reexperiencing of the trauma. One common example is an examination by a health care provider of the same gender or race as the assailant. Male health care providers are at particular risk because most women are assaulted by male perpetrators. Perceived differences in power or status can also serve as a trauma trigger. For patients who have been harmed by others more powerful or controlling than themselves, the practitioner-patient relationship can be experienced as a potentially exploitative situation. Identifying specific triggers within the primary care setting is an important step to providing trauma-sensitive treatments for assault survivors.
Regardless of trauma history, clear information about the rationale for a recommended test or procedure including risks and benefits, and treatment alternatives should always be provided. Because anxiety and depression often interfere with attention, concentration and retention of information, it is advisable to repeat the information on more than one occasion and to assess the patient’s understanding of the procedure ("Will you tell me what your understanding is of …."). Patient education materials can be especially helpful at this point. Information about what to expect during and after the procedure should also be provided. This should include information on how the procedure will feel, look, sound, and even taste, as well as information on who will be in the room, who will be performing or observing the procedure, and what the woman may feel like when the procedure is finished. Finally, "on-line" information during the procedure itself can facilitate a woman’s sense of predictability and control (e.g., "I am now going to place the speculum into your vagina so I can see your cervix. You may feel some pressure and discomfort. Try taking slow calm breaths and relax your stomach muscles").
Often, preparing in advance for the procedure can help the woman cope sufficiently to get through the procedure. If additional coping strategies are required, Chrestman, Hearst-Ikeda, and Wolfe suggest several levels of intervention, beginning with relaxation or distraction techniques such as listening to music or relaxation tapes on headphones, or having someone present during the procedure itself (25). If these interventions are ineffective, unavailable, or impractical, the woman may wish to delay the procedure while learning a more structured anxiety reduction technique. These types of coping strategies can be arranged through a mental health professional and can be usually learned in one to three sessions. If the mental health professional is affiliated with the primary care clinic, s/he could also be present before, during, or after the procedure. Finally, some women will need to be offered sedation to cope with even the most routine medical procedures. Two cautionary notes should be considered when using sedation. First, anti-anxiety agents must be used with extreme caution with women who have a substance abuse history. Second, some women may actually feel more anxious or out of control when sedated. Consequently, before electing sedation, the woman’s substance abuse history and previous responses to medications should be reviewed carefully.
Despite the best efforts of the primary care provider, a woman may become distraught, anxious, or even dissociative during an examination or procedure. For this reason, it is important to anticipate what might be helpful. If the patient has learned specific ways to interrupt panic or anxiety, she should be reminded and encouraged to utilize these techniques (e.g., cue controlled relaxation, self-hypnosis, focal meditation, neutral conversation). If the patient appears to be having a flashback or dissociative episode, it can be helpful to ask the woman to open her eyes, to focus on where she is, and to engage her in here and now activities (e.g., "will you tell me what you see on this wall?" ). If, in the rare event, the health care provider is unable to interrupt the woman’s reexperiencing, or she continues to be distraught, the procedure may need to be discontinued. If this occurs, the woman should be encouraged to continue talking and to identify and practice what she has done in the past to decrease her distress. If the woman routinely becomes dissociative or distraught, the treatment plan may need to include provisions for having someone present during or immediately after the procedure (25).
Conclusion
In this article, we have provided a few suggestions for how to detect and respond to primary care patients with a history of interpersonal violence. Although violence against women presents social and legal as well as a health care issues, primary care providers are in a unique and powerful position to impact the care of victims. For more information about the psychology of women's health in general, and the impact of interpersonal violence on women more specifically, see references 26 and 27.
References
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