We've all seen it in a patient’s medical history: the mention of post-traumatic stress disorder (PTSD) or a history of trauma. When you see a new patient, this information may be acknowledged, and you'll keep it in the back of your mind as you go about treatment as intended, but treatment as intended may not be the best option for these patients.
Some therapists, both new and experienced, may not know how to properly address or treat patients with a history of trauma. Some may even wonder if it needs to be addressed at all. Part of being an informed therapist is realizing that trauma can and should be addressed in every setting where occupational therapy is provided.
Depending on the setting, addressing trauma and treating it may look very different, but there is one constant: it needs to be addressed. While a patient may not present with obvious signs and symptoms associated with a history of trauma, there are still internal processes and emotions which are likely maladaptive. These factors all have the ability to cause the patient distress and impact the therapeutic process. It is important be mindful of these factors in order to make all of your patients as comfortable and ready to engage as possible.
1. Be aware of the environment
Environmental stressors can increase the likelihood of traumatic reactions. You can limit these stressors by making the environment as universally comfortable as you can. While this may be difficult to do, especially in busy rehabilitation settings, always ensure there is a quieter, less stimulating space for patients to use if the need arises. Therapists can get caught up in their daily routines, with a never-ending list of demands each day. However, taking a few extra minutes to ensure accommodations are in place will go a long way.
If your daily routines and jam-packed schedules are getting you down, fight back! Check out our tips for fighting burnout in healthcare.
This may include supplying ample mats for patients to complete exercises on, the option of a pillow or blanket for added support and comfort, the ability to adjust the temperature (within reason) in the room, a water cooler nearby, room dividers for privacy, or even separate gym space for those who need more individualized attention. These staples will help a therapist set up a safe space to avoid triggering a patient, even before meeting them and learning about their specific preferences.
2. Have an open discussion
Nothing quite tops sitting down with a patient to learn what makes them feel most comfortable. In conversing with them you can cover their personal goals for therapy, their therapeutic needs, and any triggers you should avoid. This is typically done as part of an evaluation—usually in the occupational profile—so it should come as second-nature to therapists.
While there are innumerable types of trauma, childhood trauma can be especially impactful on a patient's demeanor and mental health. Learn more about an OT's role in treating childhood trauma here!
However, a patient’s treating therapist may be different from their evaluating therapist, and these situations can make it even more necessary to pick up on this crucial information quickly. This can certainly be done by looking back into the patient’s evaluation, but engaging your new patient in this conversation at the start of care is a good way to build rapport and show genuine interest in facilitating client-centered treatment.
3. Make use of relaxation and self-soothing techniques
Research shows each time you freeze in a traumatic response, the trauma remains unresolved causing the burden of that trauma to build within the body (Briere, Agee, & Dietrich, 2016). This increases the chances of re-traumatization following another event in the future. While therapists seek to avoid traumatization and re-traumatization as much as possible, this is rarely grounds for canceling a therapy session without providing any intervention.
If your patient is triggered or comes to therapy with high stress levels, this is an appropriate time to educate your patient. Education in any form is a billable treatment (under the CPT code ‘therapeutic exercises’) and can include relaxation techniques that decrease stress levels, improve focus on the task, and re-orient to the present environment. Relaxation techniques may include guided imagery and visualization, deep breathing, progressive muscle relaxation, simple weight-bearing activities, meditation, or reiki and yoga. Although you need a reiki certification to integrate this into your practice, basics of yoga can be used by any therapist. Some therapists opt for a 200 or 500 hour yoga teacher certification to use more advanced techniques in therapy.
It is important to note that this should not be forced on any patient. If your patient engages after some gentle encouragement, this is a good sign. On the other hand, if your patient is simply not responding to any attempts to calm or de-escalate the situation, it makes sense to cancel the session and document your attempts at providing services. Continual and persistent prompting and encouraging may have the opposite intended effect in such a situation.
4. Make recommendations as needed
There may be instances where you attempt to be sensitive to and cognizant of a patient’s history of trauma, but it does not seem to work. You may feel a patient’s traumatic history is causing excessive distress, impeding daily function, and/or limiting their ability to participate in therapy. If you notice this at any point during a therapy plan of care, it is within an occupational therapist’s scope of practice to refer this patient to services that can better address their trauma-related needs.
This can be done by accurately and appropriately documenting your attempts to treat as well as the patient’s subsequent response. The next step is to bring this concern to the attending physician at your facility (or the patient’s primary care physician) so they can make a referral to a psychologist, psychiatrist, or neurologist, if and when they are needed.
5. Be patient and build rapport
As with any other diagnosis, no two trauma patients look alike. They may present differently, respond to different treatments, comply with different recommendations, and ultimately improve at different rates. A good example of a patient who may respond to treatments is someone who makes eye contact and is willing to speak with you regarding their history and preferences. A trauma patient who is willing to engage in therapy may also be more open regarding what bothers them in the moment, as new stimulus arise.
A therapist will likely be able to try new modalities with a patient such as this due to their communicative nature. A trauma patient who is less receptive to an evaluation, isolates in bed or the corner of a room, and is standoffish in most all interactions may not engage in much treatment. This is an individual to slow the pace for, by making sure you downgrade activities as needed and focus on avoiding challenging behaviors which could set back therapy, such as lashing out or refusing therapy altogether.
These are important ways to address the presence of trauma in any setting and with any population. While there are modalities and techniques that occupational therapists have been trained to use for these purposes, it is always best practice to make a recommendation for an outside referral if you feel it is necessary. This will only serve the best interest of the patient and improve their overall function and quality of life.
- Briere, J., Agee, E., & Dietrich, A. (2016). Cumulative trauma and current posttraumatic stress disorder status in general population and inmate samples. Psychological Trauma(8)4: 439-446.doi: 10.1037/tra0000107.