This article was originally requested for publication in the Winter 2019-2020 edition of Massage Therapy Today by the Registered Massage Therapist Association of Ontario.
Mental health initiatives throughout Canada are enjoying a much needed-dose of public attention; as scientists try to understand how people work, intersections between the various disciplines of biological, psychological and social work become apparent. It can be difficult to stay within scope of practice mandates. Pain and mental health often overlap, and evidence is showing us how powerful a predictor a history of significant trauma can be for persistent pain and chronic health problems. Fortunately, more people are coming to terms with the realities of traumatic history and current health conditions, realizing the necessity of having of being trauma informed.
What is TIP?
Trauma Informed Practice occurs at the organizational level involving the development of systems within the organization that protect against traumatization, empower all persons interacting with the organization and provide hope for recovery. Trauma informed organizations implement trauma awareness at each level of the organization, ensuring that all persons who engage with it – staff and service users – are safe and well cared for. These organizations will ensure all staff are trained in trauma awareness and have access to help when they need it. They also ensure that at every level of interaction, the service user can expect to be met with compassion, competence and care. The four basic principles of TIP, implemented at each level of an organization, are:
Safety and trustworthiness
Communication, collaboration, and choice
Strengths-based skill building
Principle 1: Trauma Awareness
Trauma awareness begins with a baseline understanding of what trauma is and how it manifests in a person's life. In Trauma and Recovery by Judith Herman, M.D., traumatic events are described as “..extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.” These events can include natural disasters, witnessing extreme or repetitive violence or being the victim of a violent or sexual crime. Within the scope of trauma disorders are variants; PTSD is generally associated with single overwhelming events such as a car accident. Developmental PTSD occurs in the formative years, when the brain is developing and alters the course of normal neurological, psychological and behavioural development. Complex PTSD can occur in childhood and adulthood and involves perversions of intimate relationships. It disrupts the developing sense of self or alters the already developed personality. In both D-PTSD and C-PTSD, normal attachment and attunement processes in intimate relationships are subverted, leaving the person unable to form stable relationships and self regulate emotional and behavioural responses. While they each have their own characterizations, all three include the primary symptoms of PTSD: hyperarousal or vigilance, intrusion of thoughts, feelings and memories about the trauma, and avoidance of situations that may carry the threat of retraumatization. These efforts are constructed to keep the sufferer safe – sometimes to their own detriment.
As of 2008, some 3 million people in Canada were living with lifetime PTSD symptoms. Ten years later, as more refugees arrive in Canada and the effect under reporting has on the statistics, this number may be much higher. Beyond the statistics, individuals living with D/C-PTSD may find it difficult to form healthy relationships. Feelings of shame, guilt, and fear can impede help seeking, compounded by the prevalence of stigma. As such, trauma awareness includes understanding that a person with PTSD – especially from traumas associated with moral or interpersonal violations – may not respond as expected to the relationship building process. D/C-PTSD slows development of the therapeutic alliance for them. Therapists working with trauma survivors need to proceed carefully, aware that the trust given freely by other patients may need to be earned more gradually.
Principle 2: Trustworthiness and Safety Given the disruptions to normal relationship building for those living with D/C-PTSD, RMTs will want to pay close attention to this process. While we have clear guidelines for informed consent that satisfy the legal obligations of health care providers in Ontario, they leave something to be desired for developing a sense of safety and trust in the therapeutic alliance.
Current consent practices for RMTs are laid out in the Ontario Health Care Consent Act, 1996, that read as a checklist. It leans heavily on the notion that consent is a single event, typically occurring just before administration of the treatment proposed. This “event model” of informed consent certainly makes consent clear and concise for the clinician but patients may fail to understand fully what is being discussed or sense their participation in the decision making process undesirable. It can also create a situation in which the patient defaults to the idea “I've already said yes, I can't turn back now.” Contrary to this model is the “process model” that sees consent as an ongoing dialogue that develops as treatment and response to care unfolds.
Using the process model consent becomes a longer thread in the fabric of the therapeutic alliance, built in to the entirety of the relationship occurring at all treatment stages. By repeatedly returning to and soliciting the patient's consent, the clinician is effectively communicating that the patient's voice, opinions, and needs matter to them and that the patient matters. This can be quite different from previous relationship experiences for patients with D/C-PTSD and observing the possibility that the world at large can indeed be benevolent. For RMTs this can look like asking the patient about any adjustments to the treatment plan the RMT is considering or asking if the patient needs to make any changes. It can be as simple as checking in during the massage to ensure the patient experience is within the boundaries of what the patient wants it to be. All of this reinforces the boundaries of the relationship, giving it structure and predictability – something the patient can rely on. And this can be a wonderful opportunity to learn what it feels like to trust and be safe.
Section 4: Principle 3: Communication, collaboration, and choice
If empowerment of the person living with a trauma disorder is the primary goal of TIP, then it may well be that communication, collaboration and choice are the most vital parts of meeting that goal. Creating clear boundaries, building trust, and fostering a feeling of safety are rooted in being able to communicate transparently. By modelling clear communication to their patients, RMTs can help them find their own voices. It is imperative that the patient is encouraged to collaborate and choose where their boundaries lie, within your legal and personal boundaries. Participating in their own treatment planning and boundary setting can provide a sense of agency. A powerful tool for encouraging boundary building is the “no-go zone,” especially for patients who have disclosed a history of interpersonal trauma. By empowering them to self determine what parts of their bodies are in or out of bounds, patients are given the right of personal autonomy. Clear communication and opportunity to collaborate and choose, are foundational to learning the skills needed to build healthy, respectful, safe, and trustworthy relationships.
Principle 4: Strengths Based Skill-building
To RMTs, this last principle may be confusing. It is not within the scope of practice for an RMT to help a patient discuss their current trauma-recovery skills the patient wants to work on. These are areas of work reserved for trauma specialists such as a Social Workers and Psychotherapists. However, a trauma informed RMT can keep in mind that the fundamental skills that have been deranged by traumatic experiences include self advocacy, identifying safety, and building trust. With these in mind, the RMT can always ensure their conduct provides a person opportunity to practice these skills.
By having the opportunity to collaborate on treatment plans and boundaries, patients get the chance to practice self-advocacy. By empowering a person to exercise their agency, you give them a safe relationship to practice exploring outside of previously secure boundaries or establishing new or stronger ones. By describing your legal and personal boundaries clearly and concisely, you are giving a person accustomed to chaos an opportunity to experience structure and safety. When you remain consistent in these practices of eliciting the patient's voice and respecting it, you are providing the opportunity to develop the skill of trust. In treatment, these habits can look like monitoring non-verbal communications and checking in, insisting on enthusiastic consent, allowing declarations and evolution of no-go zones, and facilitating the patient's pacing, and adapting treatment to the patient's ability to receive care. Keeping these basic relational skills in mind, RMTs can structure their conduct and their practices around participating in a relationship that fosters the development of these skills. Being cared for by safe and trustworthy people is an important part of learning how to identify safe, trustworthy people and believe in their benevolence.
Trauma Informed Practice is not about treating trauma, nor is it a violation of the scope of practice of an RMT. TIP is about structuring your conduct in your treatment room, the policies of your practice, and the way care for all persons who interact with your organization is executed. Whether one is an RMT or an accountant, the benefit of encountering a trauma informed practitioner is finding a pocket of the world that is as safe as it declares itself to be. By being a Trauma Informed Practitioner, you can be sure that those living with trauma can learn one of the most basic skills a human being can ever have: to trust.
Herman M.D. (1992). Trauma and Recovery. New York, NY: Basic Books Laddis (2018).
The disorder-specific psychological impairment in complex PTSD: A flawed working model for restoration of trust, Journal of Trauma & Dissociation, vol 1, 79-99 Lidz PhD (1988).
Two Models of Implementing Informed Consent Archives of Internal Medicine vol 148 Van Ameringen (2008).
Post-traumatic stress disorder in Canada. CNS neuroscience & therapeutics, 14(3), 171–181.
Centre for Excellence in Women's Health (2013). Trauma Informed Practice Guide. Retrieved from: http://bccewh.bc.ca/category/post/trauma-violence-mental-health/