Sensitive Practice

Working with adult survivors of childhood violence.   

Before a…chiropractor or doctor starts, they should…(ask):  ‘How can I  make you more comfortable here?…If there’s something I’m doing, the way I’m  touching you or the way I’m handling you makes you feel uncomfortable, let me know.  Anything at all that would make you feel uncomfortable in this room, let me know.’  That would be great.  For myself, that would really open the door for me to say, hey, maybe this is a safe place.  Maybe I can get a little direction here.  Or maybe I’ll stick with this (healthcare professional) and make myself feel better.11”

––Male patient and survivor of childhood sexual abuse
The most current and reliable lifetime prevalence estimates are that as many as one third of women and 14 per cent of men are survivors of childhood sexual abuse (CSA).2,3,6  Studies have reported that traumatized individuals have poorer physical and mental health and a lower health-related quality of life than non-traumatized individuals5,9,13 as well as higher incidence of conditions such as intractable low back pain10 and chronic headache.4  Given the prevalence rates and health problems, it is safe to assume that most chiropractors work with adult survivors of childhood sexual abuse on a very frequent basis.

This article will highlight some findings from an interdisciplinary qualitative research project designed to generate information about how health-care professionals (HPs) can work more sensitively, and therefore successfully, with adult survivors of CSA. This project was conducted in phases:  interviews with women and men survivors about their past experiences with HPs and ideas about practice that would be sensitive to their special needs as survivors, meetings of survivors and HPs to discuss what such “sensitive practice” would look like, and national consultations with HPs from 10 disciplines to create the Handbook on Sensitive Practice for Health Professionals.  The first edition8 that focuses on sensitive practice for women survivors was published in 2001 by Health Canada’s National Clearinghouse on Family Violence. A second, gender-inclusive, edition will be published in 2008.     

This research highlighted difficulties that many survivors experience when seeing HPs. Some of these difficulties can be best understood by first considering the dynamics of abuse.  The sexually abused child experiences a violation of body, boundaries and trust1 – actions perpetrated without the child’s consent that violate the physical body as well as physical, emotional and spiritual boundaries. A trusted adult such as a parent, relative, teacher, clergy, or coach is most often the perpetrator of the abuse.  As a result, most survivors we spoke with described their distrust of authority figures, and their fear of being abused by the HP.  One man said “I guess I’m [feeling]:  what if they violated me?  …it’s a big fear…” and another described his struggles during chiropractic adjustment, saying, “I feel like running.  Like…oh, man, I can’t stand this, I’ve gotta get out of here…”   Many described their learned passivity around authority figures and ambivalence about their bodies, which hamper active participation in their health care.  One man said: “…one of the other things with people who have been abused …is  they’re scared of authority figures, number one, and they can’t say no, number two, …so (HPs) really have to listen between the lines…” Many survivors also reported that a wide range of assessment and treatment procedures in addition to touch triggered memories of abuse. These experiences made seeing HPs extremely difficult, as illustrated by this woman, who said “And the goop that they put on me for the ultrasound gave me flashbacks, nightmares, insomnia; I just couldn’t deal with it.”7, p257

Survivors said that the most crucial concern for them when seeing an HP is to feel safe. “…I now am beginning to understand that my physical wellness is really very connected to my emotional state, and if I'm not comfortable, if I’m feeling unsafe, then I'm not going to progress as quickly as a (health-care professional) would want me to. (Woman survivor)7,p251 We conceptualized this feeling of safety as an umbrella: when open, it would allow the survivor to access and tolerate HPs’ evaluation and treatment.  

 The spokes that support the open, protective umbrella of safety are the “Principles of Sensitive Practice.” The principles describe HPs’ actions and attitudes that are most critical to facilitate survivors’ feelings of safety.  When absent, the umbrella of safety easily snaps shut, leaving the survivor unable to participate in the health care at hand. 

HPs’ deliberate and ongoing attention to the principles (highlighted in bold in this section) can help to address the long-term effects of childhood sexual abuse.  For example, abuse disrespects and disregards the child’s autonomy and boundaries; hence, the HP’s active demonstration of respect for the patient and for his or her boundaries is very important.  As one man said, “(feeling respected) to the person who has been abused, it certainly means a great deal.”11   The lack of control experienced when a child is abused needs to be countered by conscious sharing of control during treatment.  While this must apply to all components of treatment, seeking ongoing verbal consent stands out as very important, beginning with the first contact.  One woman explained the importance of consent, saying “being a survivor, I have to be in charge, I guess, and if I’m not in charge…it’s an awful feeling…I want that person out of here…”7,p255 A man reminded us that “ongoing (consent is required) – it’s not a blanket consent when you’re touching me.” 

Time pressures within a busy office can leave the survivor feeling like a ‘number’ in a similar way that s/he was objectified during abuse.  One man pointed out that “… (they) get you in, get you out … and it’s ‘hasta la vista, baby’…you feel like you’ve been …used and abused, and see you later.” Thus taking time to connect with the patient and putting ongoing effort into maintaining rapport are essential.  Sharing information both addresses fears about HPs’ actions and provides the opportunity to be heard  as a person who has valuable information to contribute to her or his health care.  A man explained that his chiropractor was excellent because “…he’s very professional… he does ask for consent before he touches me and he tells me exactly what he’s going to do…” A woman explained that this was absolutely essential for her because “…the element of surprise is just really, really difficult to deal with…(and if) there’s a preparation…(it reduces) that fear of the unknown, and (it reduces) the likelihood then that I will be triggered by something that is done … into remembering something that is abusive for me.”7,p255

Fostering a mutual learning process stresses that the survivor may be learning about caring for her or his body while at the same time, the clinician is learning about working more sensitively with a survivor, a process that is dependent on mutual respect and co-operation.  This is illustrated by the quotation at the beginning of this article. 

The final two principles speak to the importance of the clinician learning more about the long-term effects of interpersonal violence.  The research participants told us that it is important that HPs understand that healing from CSA is not a linear process and that the survivor’s ability to participate in and tolerate treatment may vary unpredictably over time. As one woman said, “Parts of my body at different times might be untouchable. It’s gonna change, depending on what I’m dealing with. So, you’re not going to be able to make a list and count on that every time kinda:  it’s gonna be a check-in every session.”7,p255  As a result, clinicians must indeed ‘check in every session’  invite the patient to verbalize discomfort, monitor body language that suggests decreased comfort and be willing to change treatment if the patient cannot tolerate a certain approach, whether temporarily or permanently.  The final principle emphasizes the importance of clinicians  demonstrating their awareness of interpersonal violence through their actions and using aids such as posters and brochures (e.g., from a local sexual assault centre).  One man reminded us of the need for “…posters in all the examining rooms.  You know, “Victims of child abuse are welcome”… “Boys and girls who have been victimized as children are welcome.”12,p512   

We believe that Sensitive Practice is a fine-tuning of patient-centred care that should be applied universally by all HPs.  We hope that this brief introduction has brought the experiences of survivors of childhood violence into greater focus for clinicians. The first edition of the handbook is available free of charge  – in  print or online – from the National Clearinghouse on Family Violence.  The second edition is scheduled for publication on the website of the National Clearinghouse on Family Violence in 2008.•

References:
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3. Briere J & Elliott, DM.  Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse and Neglect 2003; 27(10): 1205-22.
4. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. Southern Medical Journal, 1991; 84(3): 328-31.
5. Felitti V, Anda RF,  Nordenberg D, Williamson DF,  Spitz AM et al. 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 1998; 14(4): 245-258.
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7. Schachter CL, Stalker CA,  Teram E. Toward sensitive practice: Issues for physical therapists working with survivors of childhood sexual abuse. Physical Therapy 1999; 79(3): 248–261.
8. Schachter CL, Stalker CA, Teram E. Handbook on sensitive practice for health professionals: Lessons from women survivors of childhood sexual abuse. Ottawa: Health Canada. Population and Public Health Branch. Family Violence Prevention Unit  2001. Available online in English and French: http://www.phac-aspc.gc.ca/ncfvcnivf/familyviolence/pdfs/
nfntshandbook_e.pdf and http://www.phacaspc.gc.ca/ncfvcnivf
/violencefamiliale/pdfs/nfntsxsensible_f.pdf 
9. Schnurr PP,  Green BL (Eds.). Trauma and health: Physical health consequences of exposure to extreme stress. Washington, DC: American Psychological Association, 2004.
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11. Stalker CA, Schachter, CL, Teram E, Lasiuk, G.  Client-centered care: Integrating the perspectives of  childhood sexual abuse survivors and clinicians.  In: Trauma and Physical Health: Integrating Trauma Practice into Primary Care (Editors: VL Banyard, Edwards, V.K Kendall-Tackett.) London: Haworth Press. In Press.
12. Teram, E, Schachter, CL, Stalker CA, Hovey, A, Lasiuk, G.  Towards malecentric communication: Sensitizing health professionals to the realities of male childhood sexual abuse survivors.  Issues in Mental Health Nursing 2006;27(5):499-517.
13. Walker EA, Unutzer J,  Rutter C, Gelfand A, Saunders K, VonKorff M et al. Costs of health care use by women HMO members with a history of childhood abuse and neglect. Archives of General Psychiatry 1999; 56(7):609-13.