July 29th, 2017 SOWK 699

Trauma and Mental Health

Complex Trauma: Abuse

and Neglect within the
Healthcare System
Wanqui Muya
Lindsay Schroeder
Monica Sesma
Outline

1. Experiences and Reflections

2. Introduction through trauma lens
3. The Perpetrators
4. The Victims
5. Group Activities
6. Ethical and Practice Issues
7. Self-Care plan
8. Final Thoughts and Questions
Experiences, Stories, and Reflections

▶ Have you seen failure,

abuse, or negligence in
the health system?

▶ If yes, do you feel

comfortable sharing you
story or example?
 A Moment to Reflect...

▶ Have you witnessed such abuse or neglect?

What did you do?

Were you prepared to act?
Did you know what to do?
Did you know how and to whom you should report it to?
Does the handling of this situation fit well with you?
How could you be prepared to handle this in the future?
Introduction
 Uri Bronfenbrenner:
Bioecological Theory of Development

→ The cause
→ The process
→ The recovery
DSM-5 Trauma Definition

▶ According to the DSM-5 (APA, 2013) trauma is direct personal

experience of an event that involves actual or threatened death or
serious injury, with the response involving fear, helplessness, or horror.
▶ The DSM-5 lists events that have the potential of being traumatic,
including: combat, assault (sexual and physical), terrorist attacks,
torture, natural disasters, automobile accidents, and life threatening
illnesses, as well as witnessing death or serious injury to another.
▶ When one considers the common denominators of these events,
such as real or perceived threat to one’s life or well-being and
diminished personal power, it becomes clear that negative
experiences in the mental and medical health setting have the
potential to be traumatic (Hall & Hall, 2013)
 Health System

A health system
consists of all
organizations,
people and actions
whose primary
interest is to
promote, restore or
maintain health
(WHO, 2017)
Our Health System Practices
May Contribute to Trauma
 What is Medical Trauma?

▶ Trauma experienced as a result of medical procedures,

illnesses, and hospital stays can have lasting effects. Those who
experience medical trauma can develop clinically significant
reactions such as PTSD, anxiety, depression, complicated grief,
and somatic complaints. In addition to clinical disorders,
secondary crises—including developmental, physical,
existential, relational, occupational, spiritual, and of self—can
lead people to seek counseling for ongoing support, growth,
and healing. (Hall & Hall, 2013)
 Literature Review

▶ Gap in the literature on trauma caused by psychical and mental health systems
▶ Magazine/social media articles on the effect of medical and psychological
mistreatment/maltreatment/negligence/abuse of health systems and their implications BUT
NOT scientific papers
▶ Study on psychiatric hospital setting indicates that 82% of patients reported that institutional
events and procedures caused trauma and harm (Trauma Within the Psychiatric Setting,
2003).
▶ Studies indicate that mental health consumers have experienced traumatic, humiliating, or
distressing events during their hospitalization (Trauma Within the Psychiatric Setting, 2003)
▶ Medical and psychological specialists avoid or stop providing care for high-risk or
complicated case/patients due to fears of lawsuits or clients’ complaints (Zuger, 2004)
 What Can Prevent Medical Trauma?

➤ Good health services (effective, safe, quality personal and non-personal health
interventions to those who need them, when and where needed, with minimum waste of
resources).
➤ A well-performing health workforce -Being responsive, fair and efficient to achieve the
best health outcomes possible, given available resources and circumstances.
➤ A well-functioning health information system (ensures the production, analysis,
dissemination and use of reliable and timely information on health determinants, health
systems performance and health status).
➤ A well-functioning health system (equitable access to essential medical products ,
vaccines and technologies: quality, safety, efficacy and cost-effectiveness)
➤ A good health financing system (adequate funds for health, people protected from
financial catastrophe or impoverishment associated with receiving medical services)

➤ Leadership and governance (strategic policy frameworks, the provision of appropriate

regulations and incentives, attention to system-design, and accountability).
The Perpetrators
 General Practitioners: Gate Keepers
▶ Lack of/poor referrals→ Referrals are the link between primary and specialty care. The
importance of appropriate referrals is that specialists are more likely than general practitioners
to provide evidence-based care which goes on to provide better outcomes for disease
management ( Lin et. al, 2011)

▶ Lack of time→Dugdale, Epstein & Pantilat (1999) suggest that a physician's risk of malpractice
claims is related with visit length. A study by Levinson et al. (1997)found that physicians with
less than two claims of malpractice over their lifetime, had longer routine visits with clients than
those physicians with more than two claims which had shorter routine visits.

▶ Misdiagnosis→Misdiagnosis can lead to serious harm to a patient and their family. Pinaccle
Care (2016) reported on a survey that found that 64% of doctors said that up to 10% of the
misdiagnoses they have experienced directly resulted in harm to the patient; and another
study that “found that 28% of 538 reported diagnostic errors were life-threatening or resulted in
the patient’s death or permanent disability” (p. 1).
 General Practitioners: Gate Keepers

▶ Medical Errors→ Errors to treatment can leave patients permanently mentally and physically
disabled and afraid of seeking further interventions. In the case of Mrs. Edwards vs. Dr. Howells
(1992) the patient suffered brain damage as result of being prescribed an overdose of a Vitamin
D supplement (British Medical Journal, 1992) Similar case was in 1988, with Predergast vs. Sam &
Ltd where brain damage occurred due to a pharmacist misreading a doctor's’ prescription (BMJ,
1992)
▶ Sexual Abuse→ there exists an inherent power imbalance between patients and healthcare
professionals largely because the patient seeks the health care professional for help, which
places the professional in a position of power (Perez, 2013)
▶ Abuse of power -Penfold (1998) describes the impact of the abuse of power in that “victims as
result of life circumstances of interactions with others realize that the relationship is damaging and
that they must leave it. Terminating the relationship rarely end the victims problems. Often they
are left with more difficulties and distress than they started out. The after effects of sexual abuse
by a professional can be extreme, and many victims suffer from post-traumatic stress disorder” (p.
12)
General Practitioners: Gate Keepers

Ideal steps to referral: (Meherotra et. al, 2011, p. 42)

 Emergency Departments

▶ Are often the first point of entry into the health care system.

▶ Experiences: “I didn’t know where else to go”. No time for complex issues, only quick fixes.
▶ Patients can feel staff being judgmental, abrupt, and cold. Are staff on power trips? Or is
their behavior a result of complex trauma they have experienced?
▶ Staff rely on bias instead of concern towards the number of visits on record. What’s the
actual root of their problem? Are we meeting their needs?
▶ Is a well known way to cue jump, consult a surgeon or specialist. Some GP’s suggest it by
telling patients to “Say you have chest pain”
▶ The Triage process can trump critical thinking about patient needs, especially if mental
health in nature without proper “psych room”. The lack of space and staff in departments
mean long waits for assessment and treatment, causing some to suffer in waiting rooms.
Recall the women miscarrying in the ER waiting room bathroom reported in the news? It
was awful. I remember saying to my coworkers “Imagine this was you!”.
 Specialists and Programs

▶ It is hard to convince your GP to refer you onto a specialist when you lose
confidence in their skills. Patients can feel undeserving or are too loyal.
▶ Some GP’s hold complex patients much too long, causing irreversible damage,
while others don’t even try to find solutions before referring out, essentially
“dumping” patients onto specialists out of frustration or due to a lack of skill..
▶ GP suggests urgency level on referrals, often “URGENT” when it’s routine, and
often after patient has waited years for the referral and is in dire straits.
▶ In my department GIM, Central Access and Triage staff often guess at referral
status. As a result, I have my doctors re-triage our referrals that include doing
testing so we can “meet and treat” vs “meet and greet”.
▶ Long Waitlists: Screening programs, diagnostic Tests, Some treatment, including
programs and even for surgery.
 Organizational Culture
▶ Organizations that serve traumatized clients can use prevention and interventional strategies that
surround vicarious trauma by focusing on organizational culture, workload, environment,
education, group support, supervision, and resources for self care. Bell et al. (2003).
▶ Maintaining the status quo is easier than to accept organizational change.
▶ Poorly defined or over-defined roles. “I don’t know WHO does that, I don’t DO that”, instead of
pulling together to get the job done.
▶ Power struggles between everyone. In my role I’ve noticed that people will make excuses to not
help one another.
▶ Lack of interdisciplinary cohesion, and between departments.
▶ Traditional power struggles between medicine and nursing (and SW?) regarding advocacy roles
for patients. (Mallik, 1998).
▶ Management seems non-existent, replaced by administration who can’t/ don’t relate to staff
concerns. Who recalls the Code of Conduct that came out when Stephen Ducket was in
charge?
▶ Underfunded, lack of resources = frustration.
 Policies, Procedures and Protocols are great but...

▶ Do they pertain to every patient and situation? Who decides?

Even if a Dr. asks me to do something against policy, it’s MY
licence on the line.
▶ Are you encouraged to report abuse under the Protection for
Persons in Care Act? Have you?
▶ Would stereotyping/bias change your practice?
▶ Forcing patients through to discharge because “most patients”
are able to manage at home by now doesn’t say ALL will be
able to. Do you know how to challenge a policy?
▶ Using unofficial translators is widespread but dangerous!
▶ Asking the Domestic Violence question in ER but not knowing
the protocol if you get a “yes”. Some nurses force a patient
into help, despite them stating that they are not ready to
disclose further.
▶ Are patient Rights relayed to every patient? Are these rights
well advertised? Explained in layman’s terms?
▶ How many of you have been involved in a legal case at work?
A Growing Mistrust Towards The Healthcare System

▶ Many people with chronic conditions

are failing to receive appropriate care
due to poor quality of care available,
access issues, and belonging to a
disadvantaged subgroup.
▶ 33-49% were not advised on health risk
behaviours
▶ “47-67% were not asked ideas or
opinions on treatment” (Epping-Jordan,
et. al., 2004, p. 299)
▶ What are some other signs of mistrust
you’ve seen?
 Language: Medical Terms and Jargon

▶ “Communication between clinicians and patients is one of the most

important aspects of the health care relationship”.
▶ Used in a way that confuses, misleads, alienates, insults, shifts blame
onto the patient, dehumanizes.
▶ Establishes distance by turning people into objects. “I’ve got a hip
next”
▶ Reflects and shapes our thinking and behaviour as healthcare workers.

Cayton (2006, p. 484)

Language: Activity One

▶ Imagine you find this language in your health file or

chart...
“Thank you for seeing this 33 year old mother of three, who
complains of migrating joint pain, fatigue, malaise,
drenching night sweats, and unexplained weight gain. I
have tried to explain that she’s not a spring chicken, and
that she’s tired because she chose to have so many kids.
She refuses to try antidepressant medication, and doesn’t
appear to frequent the gym. I anticipate psychosomatic in
nature, no proof of night sweats”.
 Mental Health Under and Misdiagnosed

▶ Posttraumatic Stress Disorder (PTSD) and other manifestations of trauma are under recognized
in routine clinical practice and settings (Zimmerman & Mattia, 1999)
▶ Anxiety disorders, characterized by somatic symptoms (restlessness, fatigue, poor
concentration, irritability, muscle tension, or sleep disturbances) coupled with excessive
worrying, apprehension, or fear--are among the most common psychiatric conditions
encountered in primary care settings and are still underdiagnosed and undertreated (Zanni,
2012)
Mental Health Over Diagnosed

🔶 False positive problems with DSM-5 and ICD-11🔶

 Mental Health Documentation

▶ Pathologizing discourses
▶ Key to get resources (i.e.
insurance, funding)
▶ Ket to get the “right” treatment
or intervention
▶ Ket to avoid mistreatment
▶ Influences identity and self-
stigma
Lack of Multidisciplinary Teams

▶ Risk of understanding
the situation from one
angle
▶ Risk of misinterpreting
the information
▶ Risk of not offering a
comprehensive
treatment plan
▶ Lack of communication
among specialists
Insurance Companies

▶ Denying the coverage of

health services
▶ Limiting resources and services
▶ IC are not “trauma-informed”
service
▶ Trauma can take long recovery
processes: Who decides how
many counselling sessions?
The Survivors (Victims)
Indigenous Peoples

▶ Indigenous peoples experience significantly higher rates of ill health and have
dramatically shorter life expectancies than other groups living in the same countries,
all of which are influenced by the negative and traumatic impacts of historical and
ongoing colonialism (Browne et. al, 2016)

▶ Jacklin et. al (2017) present a study in which Indigenous participants with diabetes felt
that diabetes care was mediated by “traumatic historical relations between
Indigenous people in Canada and the government, most often materializing in
avoidance of health care systems, mistrust of physicians and resistance to other
service providers” (pE108).

▶ The participants furthermore avoided and resisted health care providers when their
interaction triggered and brought back memories of negative childhood experiences
from residential schools (Jacklin et. al, 2017).

▶ It is important to note that the demeanour in which professionals interact and

conduct assessments of patients can also trigger memories of trauma.
Indigenous Peoples
▶ Structural violence: is deeply embedded in
history, individual and institutional racism,
and inequitable social policies and
practices (Browne et. al, 2016)
▶ Structural violence creates the conditions
which sustain the proliferation of health and
social inequities (Browne et. al, 2016)
▶ Structural violence and discrimination
shape the way in which indigenous people
receive health care and the occurrence of
both experiences may also trigger
traumatic events related to
colonialism/residential schools.
▶ Discrimination: “research confirms that
Indigenous peoples experience individual
and systemic discrimination when seeking
health care, despite efforts within the
healthcare sector to promote cultural
sensitivity and cultural safety” (Browne et.
al, 2016, p 3).
▶ Essentially trauma affects health and the
ability to access health services is hindered
by discrimination and triggers to trauma
which are embedded in the health care
system which then perpetuates avoidance
and therefore becomes a cycle of being
unable to get health needs addressed.
 Refugees and Retraumatization

▶ Refugees entering the system may not fully trust the system due to
circumstances in their countries of origin; and therefore, building and
establishing a relationship may take time.

▶ The assessment process during questioning may catch clients off guard who
may experience unease at the questions posed during assessment.
▶ Patients can be unfamiliar with the biomedical practice of preventative
medicine such as in regards to immunizations and their children (Jackson et.
al, 2016) Expand
▶ Clients who have experienced torture such as but not limited to: forced stress
positions, pulling teeth out with pliers, pull out nails out of hands and feet,
beaten with blunt objects etc. (Jackson et. al, 2016) may find medical
procedures as triggering and frightening to these past experiences.
 LGBTQ2
▶ LGBTQ populations experience a variety of health issues that are unique to
their demographics to which therefore require specific care.(Whitehead et.
al, 2016)

▶ Health care providers may lack the knowledge of these health issues
because of a personal reluctance to delve into this area (i.e. religious views),
meaning that such clients may be misdiagnosed and/or not have these
health issues addressed.

▶ Stigma based on sexuality/gender can prevent this demographic from

accessing screenings and preventative care. Stigma also refers to “outness”
in which studies have shown that increased levels of stigma correlate with
decreased levels of sexual identity to health care providers (Whitehead et.
al, 2016).
▶ Patients may have past negative encounters with professionals in the system,
making them afraid of re-living such experiences.
 Sexual Abuse Victims

▶ Studies in the area of sexual abuse have discovered a relationship between child sexual
abuse and “serious and chronic adult physical effects i.e liver disease, obesity, cancer etc.
(Having, 2008).

▶ The relationship between abuse and health/mental health means that survivors of CSA will
most likely be in contact with the health care system; and such contact may result in
retraumatization.
▶ Sexual assault is complicated by social stigma and stereotypes and victims of the assault can
sometimes receive criticism and blaming for the event. Such blame and shaming can
sometimes come from professional contacts (i.e ER visit) during interactions in the health care
system (Esposito, 2008).

▶ Esposito (2008) explains that patients with PTSD from sexual assault, healthcare visits can be
reminders of a sexual assault; and that “routine dental work or Papanicolaou examination
which is intrusive to the body and may evoke hidden reminders and intense distress” (p. 70)
▶ Labour and delivery can evoke symptoms PTSD when a woman with a history of SA trauma
goes into labour (Esposito, 2008).
 Pediatric Medical Traumatic Stress

▶ McGarry et. al (2013) define Paediatric medical traumatic stress as: “the psychological and
physical responses experienced by children and their families as a result of encountering
pain, injury, serious illness and invasive medical procedures” (p. 1115)

▶ Parents also experience stress as they watch their child and pain and have to make difficult
decisions to their child’s medical treatment in the context of the concern for their child’s
future Therefore parents are also tasked with helping their child cope as an inpatient in
hospital settings (McGarry et. al, 2013).

▶ Families who are exposed to traumatic stress from a health care experience often fall into
two groups which are resilient families, and families who struggle with the treatment process
(Children’s Hospital of Philadelphia, n.d.)

▶ The Pediatric Traumatic Stress Toolkit (2004) is a toolkit provided to professionals with a guide
to be able to effectively assess and treat medical traumatic stress in children and their
families; and focuses on addressing the emotional and physical side of trauma (National
Child Traumatic Stress Network, n.d)
Specific Patient Populations
▶ Hall & Hall (2013) mention that patients experiencing specific treatment regarding HIV;
stays in ICU; heart attacks and strokes; grief and depression; and
childbirth/gynecological treatment are all at risk for developing medical trauma

▶ Patients with pre-existing mental health conditions, specifically from past traumas can
also be at risk for developing trauma symptoms; however, this can be difficult to isolate
and identify the medical trauma as a cause for symptoms of trauma because of the
previous trauma history (Hall & Hall, 2013)

▶ Psychiatric patients who have experienced childhood abuse in which (Hammer et. al,
2010) explain that through the trauma-informed care perspective, it is suggested that
“the use of S/R (seclusion and restraint) with previously abused inpatients may result in
retraumatization due to mental associations between childhood trauma and the
experience during S/R” (p. 568).

▶ Carmen and Rieker (1998) explained that “many survivors of abuse reported personal
experiences with abusers who had restrained them and locked them away in closets,
car trunks, and rooms,” (p. 192)
 Chronic Illnesses

▶ Mystery Illnesses: Diagnosis currently unknown, yet patients are

“othered”, neglected, misdiagnosed, ridiculed. Specialists decline
referrals and patients continue to suffer for years, and some go into
financial ruin as they pay for treatment in the US, or by
Naturopaths, etc. not covered by our healthcare system. Once
symptoms become serious, doctors scramble, and submit urgent
consults that could have been avoided.
▶ “Each new symptom, each failed remedy, each wrong diagnosis
Takes us further into the inner shadowy terrain. Stripping away layer
after layer of identity”.

(Mortimer, 2015)
 Healthcare Workers

▶ Vicarious trauma: “Pronged occupational exposure to demanding interpersonal

situations with inadequate support” (Devilly et. al., 2009, p. 373).
▶ “Higher levels of exposure to traumatized patients is a significant predictor of
vicarious trauma” (Devilly et. al. 2009, p.374).
▶ Are we encouraged to process these experiences by our employers? Is it
adequate?
▶ “Nurses eat their young” is usually perceived as an inevitable consequence of the
profession”. (Lally, 2009, p.17). Bullying is a major issue in healthcare. Have you seen
it?
▶ Health care workers often take home their worries, especially if an error was made.
Is litigation on our minds?
▶ We often ignore our own health needs. Especially when it pertains to our mental
health. We don’t want to waste someone’s time. We fear judgment from others
telling us “you should be used to this” or “you should know better”.
Activity Two: Video

▶ Watch video to 6:27 and discuss interventions a social

worker could take in addressing the trauma the patient
faced and how this may impact patients further
interaction in healthcare.

https://www.youtube.com/watch?v=LWTesIihoQY
Ethical or Practice Issues

▶ Counsellor/Social worker needs competence and training in trauma

▶ Transparency and informed consent process
▶ Trauma could be assess and treated
▶ Not all trauma survivors conform to DSM-5 or ICD-11
▶ Other therapeutic tools/techniques/interventions must be trauma-
informed
▶ Do not misuse consultants’ resources
▶ Do not impose your beliefs or values
▶ Be humble and careful with your “expertise” and skills
▶ You need to establish professional boundaries
▶ Remember that therapeutic alliance is a key aspect
▶ Refer to appropriate professional and specialists
▶ Trauma could be passed within our family and community
▶ Avoid re-traumatization practices
▶ Use evidence-based practices
▶ Do not rush!!! Trauma can take years to heal and recover from
 Self-Care: What We Use

▶ Lindsay: I debrief heavy days with coworkers,

meditate, work in my garden, socialize with
friends, and hold impromptu dance parties.
▶ Monica: I practice mindfulness, listen to my
favorite music, read awesome and inspiring
authors, and have coffee with friends.
▶ Wangui: I go for walks, watch pointless and funny
YouTube videos, read my Bible, and paint.
“The care that counselors provide others will only be
as good as the care they provide themselves”
ACA, n.d.
 Uri Bronfenbrenner:
Bioecological Theory of Development

→ The cause
→ The process
→ The recovery
Reflection

What can we do for the clients,

patients, people?

How could we transform this culture

and systems?
Final Thoughts
Resources

▶ Pediatric Medical Traumatic Stress Toolkit for Health Care

Providers (2004) available at:
http://www.nctsn.org/trauma-types/pediatric-medical-
traumatic-stress-toolkit-for-health-care-providers
▶ University of California: Pediatric Medical Medical Trauma
Presentation available at:
https://www.youtube.com/watch?v=OuLT9v75FNE&t=198
4s
▶ Alberta Health Services Insite
References
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Bell, H., Kulkarni, S., & Dalton, L. (2003). The Journal of Contemporary Human Services, (84), 4, 463-470.

Cayton, H. (2006). The alienating language of health care: Editorial. Journal of the royal society of medicine, 99, 484.

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Epping-Jordan, J. E., Pruitt, S. D., Bengoa, R. & Wagner, E. H. (2004). Improving the quality of health care for chronic conditions. Qual Saf Health Care, 13, 299-305. Retrieved from:
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