Reflection: Trauma Informed Care

In preparing acupuncture students to tackle safety issues in their future practices, there’s a category of topics I think of as pre-safety, or concepts to spend some time reflecting on before diving into trying to implement safety by means of policies, manuals, etc. Being an acupuncturist and a small business owner requires you to put yourself out in the world in all sorts of ways; your work is as personal as an artist’s. Creating safety in your practice is like an investment; it helps protect you, your patients, and also your long-term commitment to your work. It’s worth spending the time to develop a solid internal foundation for your approach to safety, as opposed to just going through the motions to be externally compliant.

The first topic on the pre-safety list is Trauma Informed Care.

POCA Tech spends a lot of program time on topics related to TIC, so this post will only briefly address what TIC is and focus mainly on how it informs our approach to acupuncture safety.

Trauma-informed care seeks to:

Realize the widespread impact of trauma and understand paths for recovery;
Recognize the signs and symptoms of trauma in patients and staff;
Integrate knowledge about trauma into policies, procedures, and practices; and
Actively avoid re-traumatization.

1. The first core principle of TIC is: endeavor to help people feel physically and psychologically safe. TIC recognizes safety as inherently valuable, as opposed to something you have to do just to stay out of trouble.

TIC often involves certain practices, such as checking in for clear consent and simplifying paperwork as much as possible. For example, Trauma Informed Oregon’s Standards of Practice specify that “Intake forms and processes have been reviewed and modified to reduce unnecessary detail that might be triggering to individuals who are seeking or entering services.” (Bureaucracy itself can be a trauma trigger.)

But TIC is also about policies and organizational structure. It’s oriented not only towards people seeking treatment but also toward the people and systems that provide the treatment. Safety is nurtured by structures, which means safety won’t just happen as a result of good intentions; it requires planning and implementation.

And in TIC, perceived safety concerns are as valid as any other kind of safety concern. The patient who believes that an acupuncture needle has broken off in their body, whether or not it actually happened, represents a valid safety concern.

2. TIC recognizes the prevalence of trauma, which means that many, many people are dealing with the effects of trauma in some form and it very often shows up in their behavior. A common instruction in TIC is, Don’t ask “what’s wrong with you”, ask “what happened to you?”

Similarly, TIC requires “abandoning the notion of trying to change people’s behavior by punishing, blaming or shaming them.”

A punitive attitude toward safety is inherently self-defeating. As a practitioner, you need to do whatever you can to NOT fire up the fear conditioning circuits of the human brain -- especially when people are behaving in ways you don’t want them to. (This applies to you too.)

3. TIC suggests that in order to create safety, it’s not useful to try to micromanage or control individuals, but it’s very useful to take a big picture view and analyze environments and systems.

In terms of acupuncture safety, once again this applies to the acupuncturist as much as the patient. What do you need from your practice environment and your practice systems to support you in working as safely as possible? Safety isn’t an exercise in individual will power, so if you make a safety mistake, don’t beat yourself up -- ask yourself what created the conditions to allow you to make that mistake. Then work on those conditions.

4. TIC seeks to avoid creating adversarial relationships (see above: nothing good comes from firing up the fear conditioning circuits of the human brain). This isn’t the same thing as being conflict-avoidant. Conflict can be healthy; boundaries need to be established and navigated and that isn’t always smooth or easy. However, one of the goals of conflict should be to actually resolve it and get to a place where it isn’t necessary anymore.

Sometimes a person’s trauma (particularly if they’re unaware of it) shows up as constant conflict and drama that never get satisfactorily resolved but instead lead to repeated broken relationships. Safety incidents can have their origins in emotional dysregulation for either the patient or the practitioner. When people are triggered, things are likely to unravel fast.

Here is a list of common trauma triggers in healthcare settings, according to Laurie Lockhart MS:

authority figures
sensory cues of past events
lack of power/control
feeling threatened or attacked
caught by surprise
feelings of vulnerability and rejection
sensory overload
shaming

All of these can contribute to creating safety problems. Approaching your patients with an eye to avoiding these, as well as any other element that contributes to an adversarial relationship, will make your practice safer.

5. Training is important, but training is not sufficient.

Trauma Informed Oregon’s Standards of Practice(while not all applicable to acupuncture clinics) are mostly about what an organization does, not just what individual people have learned. As noted above, a lot of what an organization needs to do to be trauma-informed is to establish good structures and a generally safety-positive culture. (Individual acupuncturists can do this in their practices as well.)

In my experience, however, if you make the effort to enact TIC in your practice, you’ll also, inevitably, make mistakes with it. TIC in many cases represents a different way of being in the world and so requires repetition, trial and error. It’s painful to make trauma informed care mistakes, but it’s much better than not trying at all. Even if you don’t make mistakes, even if you’re doing everything right, you’ll still trigger people because humans and their experiences of trauma are diverse. In other words, enacting TIC means accepting that you’ll screw up sometimes and you’ll constantly be working on it.

The answer to “is X trauma-informed?” (where X may equal “your practice) is not yes/no; it’s on a continuum of more/less, where you are always aiming for more, and probably also always being closer to the “less” end of the spectrum than you wish you were.

Making safety requires tolerating everybody’s imperfections, including your own. And it pretty much precludes the attitude of, “if everyone were just properly trained, there would be no safety problems, and if there are safety problems, it means you should have known better!”

6. Another core principle of TIC is transparency. Like other forms of organization related to safety, creating and maintaining transparency takes work. Things have to be well-organized to a certain degree before they can be transparent, because chaos is inherently confusing. Transparency also has a cooperative element to it; people have to make the effort to pay attention in order for transparency to be effective.

In terms of acupuncture safety, transparency includes clear policies and procedures that everyone knows about (or would know about if they were paying attention), as well as practices like regular safety meetings.

We believe that using the AERD is a form of transparency.

To be trauma informed is “to provide predictability, safety, trustworthiness, and neutrality as ways of valuing the individual.” (Mandy Davis) A lot of what we’re advocating on this blog is a predictable, neutral approach to acupuncture safety that’s grounded in being 1) well-organized and 2) tolerant of humans being human. In our experience, those two elements fit together quite nicely.

Next up on the pre-safety reflection list: risk.