I have been askedseveral times by healthcare providers about how to go about asking somebody if they are an abuse survivor. This may seem tricky at first but it does get easier in time. The healthcare provider has the ability to set the tone for an open relationship, validate a survivor’s experiences and feelings, and pave the way for open communication about this and other difficult issues depending on how the question is asked.
It is a popular fear that by asking a person about abuse that it can re-traumatize him or her and this usually is not the fact if the asking is done in a professional and compassionate way. It is important to ask about abuse in a variety of different ways, because some adults do not label traumatic events as “abuse” because of stigma or fears. In my many years of working with abuse survivors I have had people describe their abuse as “fighting” even though it may clearly be domestic violence, or chalk up a date rape to a “misunderstanding” in spite of the fact the survivor said no or was injured. It is important to not only ask about abuse but also to ask about feelings and trauma symptoms.
For example:
“While you were growing up, did anybody hurt you?”
“Were you ever touched or talked to in a manner that was upsetting?”
“In your current relationship with spouse/partner and family, how is conflict handled?”
“Have you ever been subject or coerced into unwelcome sexual advances or activity?”
“Is there anything about your current life or history you think is important for me to know at this time?”
Give specific examples:
“Abuse can be physical such as hitting, slapping, shoving or breaking possesions; verbal such as name calling or belittling; sexual such as touching or forced activity; financial such as having no control or access to money. Have you ever dealt with this in your past or current relationships?”
It isn’t always easy for adults to disclose a history of abuse. It is not unusual for a survivor to initially deny then admit to abuse once the survivor realizes they can trust the caregiver. This isn’t due to game playing but is actually an appropriate example of the survivor expecting a provider to earn their trust.
Once somebody does admit to a history of abuse or current abuse, it is important that follow up is provided. Obviously if somebody is currently in an unsafe relationship a safety plan must be made with provisions for the client’s safety and the safety of any children in their care. A safety plan can be as simple as a plan to call police, a stash of emergency cash/credit cards/paperwork/clothing, and a backup place to stay. Validating an abuse survivor’s feelings is incredibly important. By simply asking how he or she feels about the history of abuse, listening to the answer, and inviting them to tell you more about it you are helping to open the door to healing. Ask the survivor what he or she feels would be helpful-do they feel as if their symptoms are resolved? Would they like to explore the issue further with you or a counselor? Do they have a support system that they can rely on? Asking the client about their current symptoms can also be indicative of whether or not counseling is indicated. Do they have flashbacks? Nightmares? Intrusive thoughts? Efforts to avoid thinking or talking about the abuse? These symptoms indicate counseling may be helpful.
Counseling doesn’t have to be expensive to be effective. In this area there are many low-fee counseling agencies staffed by master’s level practitioners who are not yet licensed. The most important predictor of a good therapeutic outcome is the client’s comfort level with the practitioner. Encourage her or him to call around and ask questions.
It’s my HOPE that by the time a woman goes into labor her support people, midwife, doula, doctor, coach are aware of her history and the woman has had some time to do some work on the issue if needed. This isn’t always the case. Situations such as failure to progress, disassociation (ie-”checking out”), or an extreme emotional reaction such as panic or fear can indicate that a woman is being triggered in her trauma.
Reassurance and validation are powerful tools. Getting a woman’s permission to be touched should be a no-brainer, but sadly it’s not always in today’s rushed hospital settings. For an abuse survivor this is important in giving her a sense of safety. Realizing that a rushed and frustrated caregiver telling a woman to “relax and this won’t hurt as much,” or “open your legs so we can get this over with” can be the same phrases that were said by a perpetrator. It never hurts to err on the side of professionalism and respect. Minimizing exams and interventions to only the ones that are needing, providing informed consent, reminding the mother that she has choices and power can help a mom feel more in control. For a mom that is disassociating due to pain or trauma triggers helping her become grounded by focusing on a safe person or object in the room can help bring her back into her body.
Believe it or not, a sensitive and skilled caregiver can often sense if a woman is being triggered. I encourage caregivers to listen to their gut instincts and ask a woman if there’s something going on that she needs to acknowledge. In the throes of labor obviously deep psychodynamic work is not going to be done, but reassuring a woman that you are there for her, support her, and that once the baby is out you can get her help for the emotions that are coming up can be useful.
A really fantastic book about this subject is called “When Survivors Give Birth” by Simkin & Klaus. I encourage it for all providers and abuse survivors.
