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ISBN: 978-0-8261-2959-8Digital Product
Student Resources
Provided to Supplement
MANAGING THE PSYCHOLOGICAL
IMPACT OF MEDICAL TRAUMA
A Guide for Mental Health and Health Care Professionals
Miche l l e F laum Ha l l , EdD, LPCC-S Scot t E . Ha l l , PhD, LPCC-S
Appendix A. Trauma Resources 1
Appendix B. Secondary 7–Lifestyle Effects Screening (S7-LES) 3
Appendix C. Medical Mental Health Screening 6
Appendix D. Support Organizations for Chronic Illness: Cancer, Cardiac
Disorders, and Diabetes 10
Appendix E. Mindfulness Resources 13
Appendix F. Recognizing Signs of Acute Stress Disorder in Postpartum
Women in the Hospital Setting 16
Appendix G. Experience of Medical Trauma Scale 22
Appendix H. New Roles for Mental Health Professionals Before, During,
and After Severe Maternal Events 29
Appendix I. Understanding the Emotional Effects of a Diffi cult Childbirth
Experience 32
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
CONTENTS
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
1
A TRAUMA RESOURCES
WEBSITES
ORGANIZATION WEBSITE
Centers for Disease Control
and Prevention
www.cdc.gov
Health Care Toolbox: Your
Guide to Helping Children
and Families Cope With Illness
and Injury
www.healthcaretoolbox.org
Mayo Clinic www.mayoclinic.org/diseases-conditions/
post-traumatic-stress-disorder/basics/defi nition/
con-20022540
National Child Traumatic Stress
Network: Pediatric Medical
Traumatic Stress Toolkit for
Health Care Providers
www.nctsn.org/trauma-types/medical-trauma
National Institute of
Mental Health
www.nimh.nih.gov/health/topics/post-traumatic- stress-
disorder-ptsd/index.shtml
Somatic Experiencing
Trauma Institute
www.traumahealing.org
(continued)
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
2
ORGANIZATION WEBSITE
Substance Abuse and Mental
Health Services Administration
(SAMHSA)
www.samhsa.gov/nctic/trauma-interventions
Trauma Informed Practices
and Expressive Arts Therapy
Institute and Learning Center
www.trauma-informedpractice.com
U.S. Department of
Veterans Affairs
www.ptsd.va.gov
World Health Organization www.who.int/en
BOOKS
AUTHOR(S) TITLE/PUBLISHER Suzette Boon, Kathy Steele, &
Onno van der Hart
Coping with Trauma-Related Dissociation: Skills Training for
Patients and Therapists (Norton Series on Interpersonal
Neurobiology). W. W. Norton.
John Briere & Catherine Scott Principles of Trauma Therapy: A Guide to Symptoms,
Evaluation, and Treatment . SAGE Publications.
Elizabeth K. Carll (Ed.) Trauma Psychology: Issues in Violence, Disaster, Health, and
Illness (Volume 2, Health and Illness) . Praeger Publishers.
Judith Herman Trauma and Recovery . Basic Books.
Bessel van der Kolk The Body Keeps the Score: Brain, Mind, and Body in the
Healing of Trauma . Penguin Books.
Ulrich F. Lanius, Sandra L. Paulsen,
& Frank M. Corrigan (Eds.)
Neurobiology and Treatment of Traumatic Dissociation .
Springer Publishing Company.
Lisa Lopez Levers (Ed.) Trauma Counseling: Theories and Interventions .
Springer Publishing Company.
Peter A. Levine In an Unspoken Voice: How the Body Releases Trauma and
Restores Goodness . North Atlantic Books.
Peter A. Levine Healing Trauma: A Pioneering Program for Restoring the
Wisdom of Your Body . Sounds True, Inc.
Sheela Raja Overcoming Trauma and PTSD: A Workbook Integrating Skills
from ACT, DBT, & CBT . New Harbinger.
Babette Rothschild The Body Remembers . W. W. Norton.
Robert Scaer The Trauma Spectrum: Hidden Wounds and Human
Resiliency . W. W. Norton.
WEBSITES (cont inued )
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
3© Michelle Flaum Hall and Scott E. Hall
INSTRUCTIONS
The S7-LES is a self-administered screening tool to help assess changes in
many areas of your life as a result of your medical procedure or diagnosis.
Please check the response that most accurately refl ects your experience at
this point in time.
B SECONDARY 7–LIFESTYLE EFFECTS SCREENING (S7-LES)
YES NO
Developmental
1. Since my medical procedure/diagnosis, I have had to alter my
life plan or have been unable to reach important milestones
(e.g., delayed graduation or marriage, relocation)
2. I am experiencing emotional diffi culties as a result of this
(e.g., stress, anxiety, or depression)
Intrapersonal (Self)
1. Since my medical procedure/diagnosis, I feel more negative
about myself and/or my abilities (e.g., self-confi dence, feeling
worthwhile)
2. I am experiencing emotional diffi culties related to these changes
(e.g., stress, anxiety, or depression)
(continued)
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
4© Michelle Flaum Hall and Scott E. Hall
YES NO
Relationships
1. Since my medical procedure/diagnosis, I have noticed strain
on my relationships with others (e.g., friends, family, signifi cant
others, coworkers)
2. I am experiencing emotional diffi culties related to these changes
(e.g., stress, anxiety, or depression)
Career/Occupation
1. Since my medical procedure/diagnosis, I have noticed negative
effects on my career/educational performance
(e.g., competence in duties, ability to advance)
2. I am experiencing emotional diffi culties related to these changes
(e.g., stress, anxiety, or depression)
Existential
1. Since my medical procedure/diagnosis, I struggle with thoughts
about what it all means for me and my life (e.g., endings, lack of
meaning, limited freedom, or loneliness)
2. I am experiencing emotional diffi culties related to these changes
(e.g., stress, anxiety, or depression)
Avocational/Leisure
1. Since my medical procedure/diagnosis, I have noticed changes in
my ability to do things I once did for fun/health/relaxation
(e.g., leisure activities, hobbies, or civic involvements)
2. I am experiencing emotional diffi culties related to these changes
(e.g., stress, anxiety, or depression)
Spiritual
1. Since my medical procedure/diagnosis, I have noticed changes
in my spiritual beliefs or practices (e.g., belief or relationship
with God or a higher power, spiritual activities such as religious
service attendance)
2. I am experiencing emotional diffi culties related to these changes
(e.g., stress, anxiety, or depression)
(cont inued )
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
5© Michelle Flaum Hall and Scott E. Hall
INSTRUCTIONS FOR USING THE SECONDARY 7–LIFESTYLE EFFECTS SCREENING TOOL
FOR CLINICIANS ONLY
The S7-LES assesses the presence of negative or maladaptive responses
(secondary crises) to medical events, illnesses, and procedures in relation to
seven life domains. The tool is a self-administered checklist that can be com-
pleted by patients in a provider’s offi ce after a medical procedure, hospital
admission, life-threatening diagnosis, or any other circumstances deemed
appropriate by providers.
The S7-LES can be used as a screening tool to detect areas in which patients
struggle and to help determine when a referral to a mental health professional
may be necessary. It is important that you consider any “yes” response to
indicate that follow-up with a mental health professional could be helpful in
preventing serious emotional consequences of medical trauma. By referring
patients to mental health professionals to address psychological/emotional
changes and crises in life domains, health care providers can work collabora-
tively to ensure overall health and well-being.
Suggested administration intervals: 2 weeks, 1 month, 3 months, 6 months
This copy is for individual use only—not for duplication, distribution, or institutional use .
For more information about using this tool, please contact:
Michelle Flaum Hall, EdD, LPCC-S
E-mail: [email protected]
Phone: (937) 545-7392
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
6© Michelle Flaum Hall and Scott E. Hall
C MEDICAL MENTAL HEALTH SCREENING
1. I have had previous traumatic experiences in my life Yes No
Sexual trauma
Physical trauma or injury
Trauma from medical experiences or illnesses
Witness to traumatic event
2. I have experienced depression at some time in my life Yes No
3. I currently struggle with depression Yes No
I am being treated
I am NOT being treated
4. I feel I have a high level of stress in my life Yes No
Family/relationship stress
Work or school-related stress
Health-related stress
Other:
5. I do not have healthy coping strategies for handling stress Yes No
6. I experience anxiety about a lot of things in my life Yes No
7. I do not have adequate social support to help me handle stress Yes No
8. I use distraction and avoidance to cope with stressful situations Yes No
(continued)
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
7© Michelle Flaum Hall and Scott E. Hall
9. I have been diagnosed with PTSD (current or past) Yes No
10. I am fearful about receiving medical treatment Yes No
I have a fear of pain
I have a fear of needles or IVs
I have a fear of blood
I have a fear of being out of control
11. I worry about an upcoming medical procedure
or diagnosis
Yes No
I worry about being under anesthesia
I worry about how I will cope with pain or discomfort
I worry about how my family will cope with my illness
or procedure
I worry about the outcome of my procedure
I worry about how my procedure will affect my life
12. I have been diagnosed with stress-induced physical conditions Yes No
such as irritable bowel syndrome (IBS), ulcers, or
high blood pressure
13. I tend to be pessimistic about many things (e.g., the future,
my health)
Yes No
14. I have a diffi cult time trusting people Yes No
15. I use substances (e.g., alcohol, cigarettes, drugs) to help me
manage stress
Yes No
16. I have close family members who have been diagnosed
with PTSD or depression
Yes No
17. I feel that my life or well-being could be threatened by my
medical condition or upcoming procedure
Yes No
18. I have a diffi cult time coping with changes in my routine or
environment
Yes No
19. I struggle to follow through with goals related to my health
(e.g., diet, exercise)
Yes No
20. I do not feel very hopeful about many things in my life Yes No
(cont inued )
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
8© Michelle Flaum Hall and Scott E. Hall
INSTRUCTIONS FOR USING THE MEDICAL MENTAL HEALTH SCREENING TOOL
FOR CLINICIANS ONLY
The Medical Mental Health Screening tool assesses risk factors that can
contribute to adverse psychological responses (specifi cally, traumatic stress
responses) to medical events, illnesses, and procedures. It is a prescreening
tool and should be used as a means of fl agging risk factors and intervening
appropriately in order to prevent or minimize adverse emotional reactions
to medical care.
The tool is a self-administered checklist that can be completed by patients
during preadmission to the hospital for a scheduled procedure, in a provider’s offi ce prior to hospital admission, or in other circumstances deemed appro-
priate by clinicians.
It is important that you consider any items marked “yes” as potential
risk factors for a traumatic stress response to a medical procedure or illness.
Factors such as preexisting mental health conditions, past history of trauma
(especially physical, sexual, and medical traumas), and personality factors
(such as pessimism, general mistrust, diffi culty with change) represent a
potentially challenging recovery for the patient.
The following are subscales for the Medical Mental Health Screening tool.
Add up the items marked “yes” under each subscale and note the instruc-
tions for addressing items in each subscale.
Note that multiple risk factors indicate greater potential for adverse emotional responses in patients .
Subscales and Follow-Up
Past Trauma History (1):___/1
Clinician notes past trauma history and ensures that care is patient-centered,
sensitive, and caring. Note that if the patient is being admitted for greater
than 24 hours, plan to administer the Experience of Medical Trauma Scale to
screen for patient distress.
Medical Anxiety (10, 11, 17): ___/3
If any items are checked “yes” in this subscale, the clinician should consult
with the patient prior to the procedure to determine a plan for addressing
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
specifi c fears or anxiety. Consultation with a mental health professional may
be necessary to ensure proper management of anxiety.
Current or Past Mental Health Issues (2, 3, 6, 9, 16): ___/5
Clinician notes current or past mental health history and ensures that care is
patient-centered, sensitive, and caring. Follow-up with a mental health pro-
fessional may be necessary.
Personality Factors (13, 14, 18, 19, 20): ___/5
Clinician notes specifi c personality factors and ensures that communication
is patient-centered, sensitive, and caring. Follow-up with a mental health
professional may be necessary.
Lifestyle and Coping Factors (4, 5, 7, 8, 12, 15): ___/6
Clinician notes lifestyle and coping factors and identifi es specifi c resources
that may be helpful upon discharge (i.e., stress management resources, men-
tal health referrals).
This copy is for individual use only—not for duplication, distribution, or insti-tutional use .
For more information about using this tool, please contact:
Michelle Flaum Hall, EdD, LPCC-S
E-mail: [email protected]
Phone: (937) 545-7392
9© Michelle Flaum Hall and Scott E. Hall
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
1010
D SUPPORT ORGANIZATIONS FOR CHRONIC ILLNESS: CANCER, CARDIAC DISORDERS, AND DIABETES
C ANCER
ORGANIZATION DESCRIPTION
American Psychosocial Oncology Society A national association that provides patients
with a hotline and list of mental health
providers who specialize in the psychosocial
aspects of cancer; promotes research and
education for professionals.
Website www.apos-society.org
Cancer Support Community (CSC) This nonprofi t organization is dedicated
to providing free and personalized direct
services such as education, wellness activities
(e.g., nutritional education and yoga), and
support for mental and emotional health
to its members. CSC has a presence in
all 50 states in hospitals, cancer treatment
centers, and stand-alone locations within the
community to serve its members.
Website www.cancersupportcommunity.org
(continued)
11From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
11
ORGANIZATION DESCRIPTION
CancerCare This organization based in New York offers
online education and information, referrals
for mental health services from oncology
social workers, support groups in a variety
of formats (in-person, phone, or online), and
community programs for patients living in
New York, New Jersey, or Connecticut.
Website www.cancercare.org
American Cancer Society The American Cancer Society’s website has a
wealth of information about cancer, including
the psychosocial impacts of living with
cancer. There is also a database of support
programs and services that can be searched
by zip code or city and state.
(Support Services Locator)
Website www.cancer.org/treatment/
supportprogramsservices/app/
resource-search
C ANCER (cont inued )
C ARDIAC DISORDERS
ORGANIZATION DESCRIPTION
Mended Hearts A national and community-based nonprofi t support organization
with volunteers and support groups in 48 states and partnerships
with over 460 hospitals nationwide. Offers in-room hospital visits
from peer volunteers, and “online visiting” and “phone visiting” to
provide support and encouragement for those recovering from
heart-related medical procedures.
Website www.mendedhearts.org
(continued)
12 From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
12
ORGANIZATION DESCRIPTION
WomenHeart: The
National Coalition
for Women with
Heart Disease
This nonprofi t advocacy organization provides education specifi c to
women living with heart disease and other cardiac disorders. The
WomenHeart site includes information on prevention and heart
health, as well as a database of support groups for women, searchable
by state.
Website www.womenheart.org
American Heart
Association
This well-known, national nonprofi t is dedicated to empowering
patients who live with heart-related illnesses by providing education,
resources geared toward prevention, and a database searchable by
state and zip code to fi nd the nearest branch offi ce. A robust online
support site features opportunities for patients to connect and
patient stories and blogs.
Website www.supportnetwork.heart.org/home
DIABETES
ORGANIZATION DESCRIPTION
American Diabetes
Association
A national nonprofi t organization dedicated to advocacy,
education, research, and patient empowerment, with
branch offi ces and online education and support tools.
Under the tab “Living with Diabetes,” patients can explore
mental health implications of living with diabetes, including
“diabetes distress.”
Website www.diabetes.org
Diabetes Hands Foundation A nonprofi t organization that focuses on advocacy and
promoting social connectedness among people living with
diabetes through its two online social networks (including
one in Spanish) with over 50,000 members.
Website http://diabeteshandsfoundation.org
C ARDIAC DISORDERS (cont inued )
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
1313
E MINDFULNESS RESOURCES
WEBSITES
ORGANIZATION WEBSITE
American Mindfulness Research Association www.goamra.org
Mindfulness: Taking Time for What Matters www.mindful.org
Mindfulnet.org: “Everything you need to know
about mindfulness on one website”
www.mindfulnet.org/index.htm
Palouse Mindfulness: Free MBSR Training www.palousemindfulness.com/
selfguidedMBSR.html
MBSR Training from University of Massachusetts
Medical School
www.umassmed.edu/cfm/
stress-reduction
Center for Contemplative Mind in Society www.contemplativemind.org
Heart Math/Inner Balance www.heartmath.org
National Center for PTSD www.ptsd.va.gov/professional/
treatment/overview/mindful-PTSD.asp
Sounds True, Inc. (collection of books and
resources)
www.soundstrue.com/store
14 From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
14
BOOKS
AUTHOR(S) TITLE(S)
Burdick, D. Mindfulness Skills Workbook for Clinicians and Clients
Emerson, D., & Hopper, E. Overcoming Trauma Through Yoga
Farrarons, E. The Mindfulness Coloring Book
Follette, V., & Briere, J. Mindfulness-Oriented Interventions for Trauma
Forsyth, J., & Eifert, G. The Mindfulness & Acceptance Workbook for Anxiety
Gunaratana, B. Mindfulness in Plain English
Hanh, Thich Nhat Peace Is Every Step: The Path of Mindfulness in Everyday Life
Kabat-Zinn, J. Wherever You Go, There You Are: Mindfulness for Beginners
Full Catastrophe Living
Langer, E. Mindfulness: 25th Anniversary Edition
Orsillo, S., & Roemer, E. The Mindful Way through Anxiety
Santorelli, S. Heal Thyself: Lessons on Mindfulness in Medicine
Williams, M., & Penman, G. Mindfulness: An Eight Week Plan for Finding Peace in a
Frantic World
Williams, M., & Teasdale, J. The Mindful Way through Depression
APPS
• Buddhify: Mindfulness and Meditation for Modern Life
• Calm ( www.calm.com )
• Headspace ( www.headspace.com )
• Meditation Timer
• Relax With Andrew Johnson
• Mindfulness
• Inner Balance (with sensor from HeartMath: www .heartmath.org)
• Mindfulness Daily
(continued)
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
1515
APPS (cont inued )
• Stop, Breathe, & Think
• Mindfulness Coach
• Omvana— Meditation for Everyone
• Mindfulness—E veryday Guided Meditations
• Mindfully Me
• Insight Timer
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
16© Michelle Flaum Hall and Scott E. Hall
16
F
SUPPORT NEEDED
C DO: If you suspect your patient is experiencing intrusive symptoms, consult with a mental health professional. Ask sensitive, open-ended questions about her current state, such as “I noticed you tossed and turned in your sleep last night. How was your sleep?”
D AVOID: Being insensitive, dismissive, or judgmental. Do not say things such as “It’s over, just don’t think about it,” or “Try to think happy thoughts before you fall asleep.”
RECOGNIZING SIGNS OF ACUTE STRESS DISORDER IN POSTPARTUM WOMEN IN THE HOSPITAL SETTING
SYMPTOM BEHAVIORAL SIGNS
Intrusion symptoms
(Memories, dreams, fl ashbacks)
A woman can reexperience a birth trauma
by having involuntary recurrent images,
thoughts, illusions, dreams/nightmares, and/
or fl ashbacks related to the event. Intrusive
symptoms can be a cause of sleep diffi culty
and can exacerbate symptoms of anxiety
and depression (such as poor concentration,
hypervigilance, exaggerated startle response,
and negative mood). Signs can include
agitation upon waking and fi tful sleep.
17From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
17© Michelle Flaum Hall and Scott E. Hall
SYMPTOM BEHAVIORAL SIGNS
Distress with
exposure to stimuli
While still in the hospital, a postpartum woman who has experienced
birth trauma will be surrounded by stimuli related to the event. Signs
of distress can be physical (tachycardia, perspiration) or can manifest
as irritability, fear, or unwillingness to comply with requests. Can show
an exaggerated startle response to stimuli. Stimuli that can trigger
distress include alarms/beeping or other sounds, medical instruments,
medical professionals who were present during the trauma, family
members who were present during the trauma, the baby, bright lights,
odors, and procedures.
SUPPORT NEEDED
C DO: Recognize that your patient has experienced a jarring medical event and that it could have been traumatic for her. Many aspects of the hospital environment were present during her traumatic event, and she is still in this environment. Pay close attention to tachycardia as a sign of emotional distress, and ask your patient how she is feeling emotionally.
Be sensitive and use a warm tone of voice when providing instruc-tions, and so on. Administer the Subjective Units of Distress Scale (SUDS) or Acute Stress Disorder Scale (ASDS) and share results with a mental health professional.
D AVOID: Forcing any procedure, or saying things like “You just need to comply — it’s for your own (or your baby’s) good.” Do not force any intervention. If patient shows signs of signifi cant distress, contact a mental health professional.
SYMPTOM BEHAVIORAL SIGNS
Negative mood Inability to experience positive emotions. The
patient may show little to no joy during time with
her baby or family. She may be detached or seem
numb to the events happening around her; aloof;
withdrawn.
Women who have experienced birth trauma can
feel a fl ood of different and sometimes confl icting
(continued)
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
18© Michelle Flaum Hall and Scott E. Hall
SUPPORT NEEDED
C DO: Gently “check in” with your patient, inquiring about how she is feeling (not only physically, but emotionally). Ask her if she would like to speak to someone about her feelings, and try to normalize this for her (sometimes a woman might refuse because she feels a stigma for talking to a counselor). A woman can benefi t from verbalizing her thoughts, feelings, and experiences about the trauma—if she feels safe in doing so.
D AVOID: Saying things like: “Cheer up!” “Put on a happy face!” or “You should be glad or grateful that you survived/your baby survived or is healthy/that the bad part is over.” Also, do not give empty reassurance such as “This is so rare—it won’t happen if you decide to have another baby in the future.” These only minimize the patient’s feelings, and could shame her into staying silent about her inner experiences.
SYMPTOM BEHAVIORAL SIGNS
emotions, including: fear, sadness, terror, guilt,
disappointment, happiness, anger, elation, joy,
sorrow, embarrassment, and confusion. She may
express these different emotions at times, or be
overwhelmed by them and express nothing, seeming
numb, cold, or detached.
(cont inued )
SYMPTOM BEHAVIORAL SIGNS
Dissociative symptoms (Altered sense of
reality or disturbance in memory)
When dissociation occurs, it can seem like
your patient is “out of it” or spacey, dazed,
robotic, or confused about basic facts or
her surroundings. Sometimes people lose
concept of time (which can easily happen
in the hospital setting). Some women might
speak of an “out-of-body” experience, like
fl oating above their own body or seeing
the procedures happening to them. When
patients experience fl ashbacks, they may have
signifi cant distress after seeing images, reacting
as if the event were actually occurring.
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
19© Michelle Flaum Hall and Scott E. Hall
SUPPORT NEEDED
C DO: Be calm and clear with your communication, and be accurate when adding psychosocial comments in her records. Pay attention to her behaviors and document them appropriately. Dissociative symptoms exist on a continuum: Your patient can seem a little dazed, or at the extreme, she can lose complete awareness of her surroundings. It is important to consult with a mental health professional immediately if you see signs of dissociation.
D AVOID: Minimizing or ignoring these symptoms, or trying to distract your patient from these experiences by suggesting she “just watch TV to get her mind off of it.” Do not mistake dissociation for normal, compliant, or agreeable behavior, or assume that behaviors are the effects of pain medication. These are serious symptoms that need to be addressed by a mental health professional.
SYMPTOM BEHAVIORAL SIGNS
Avoidance symptoms (Avoiding distressing
memories/thoughts/feelings or external
reminders of the event)
Women who have experienced birth
trauma may attempt to avoid any
memories or discussion about the birth
experience, or may try to avoid reminders
of the experience. She may refuse certain
procedures, parts of the hospital, people
who were present during the trauma, and at
the extreme she may want to avoid spending
time with the baby.
SUPPORT NEEDED
C DO: Be sensitive to your patient’s feelings, recognizing her current context. Stay focused on providing excellent care, and be calm and direct when requesting compliance. While it is important to be supportive, it may also be necessary to challenge your patient to follow her plan of care. You may need to consult with a mental health professional.
D AVOID: Forcing your patient to comply, or to “face her fears” regarding specifi c reminders of the trauma. Statements such as “There is nothing to be afraid of!” or “You just have to do it!” are not supportive of your patient.
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
20© Michelle Flaum Hall and Scott E. Hall
SYMPTOM BEHAVIORAL SIGNS
Arousal symptoms (sleep disturbance) Insomnia is common following a trauma.
Signs of high arousal following a birth
trauma can include fi tful sleep or inability to
go to sleep, which can indicate nightmares
or an overly active sympathetic nervous
system.
SYMPTOM BEHAVIORAL SIGNS
Poor
concentration
Because of the intense stimulation and activation of the sympathetic
nervous system that occurs during a birth trauma, a woman may have
diffi culty concentrating on cognitive tasks or stimuli. She may ask you
to repeat information or instructions several times or seem aloof with
health care professionals or family/friends.
SUPPORT NEEDED
C DO: Ask her how she slept, and if she is having any problems with both the amount and the quality of her sleep.
D AVOID: Assuming that because her eyes are closed, she is resting comfortably. After a birth trauma, your patient may often need to lie quietly with her eyes closed—with as little stimulation as possible.
SUPPORT NEEDED
C DO: Be patient if you need to repeat information or instructions, recognizing her current emotional state. Ask her if she is having any diffi culty concentrating, and if there is anything you can do to help. Provide important instructions in writing so that she can consult them when necessary.
D AVOID: Taking it personally, or getting agitated/impatient if you have to alter your communication to meet her current needs.
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
21© Michelle Flaum Hall and Scott E. Hall
SUPPORT NEEDED
C DO: Keep your movements careful. If you notice hypervigilance and an exaggerated startle response in your patient, you should slow down your pace and be mindful of noise, bright lights, and effects of physical touch. Ask her about preferences, and make accommodations if possible. This may include turning down alarms/monitors or dimming the lights. If you notice these symptoms, consult a mental health professional.
D AVOID: Doing “business as usual” when your patient is clearly negatively impacted by stimulation. Do not make offhand remarks such as “Wow! Aren’t you jumpy today!” or any other statement that would minimize her current state. Recognize if there are patterns in tachycardia, such as a rise in heart rate during physical examinations or discussions with medical professionals.
This copy is for individual use only—not for duplication, distribution, or institutional use .
For more information about using this tool, please contact:
Michelle Flaum Hall, EdD, LPCC-S
E-mail: [email protected]
Phone: (937) 545-7392
SYMPTOM BEHAVIORAL SIGNS
Hypervigilance and
exaggerated startle
response
Because of a birth trauma, a woman can become hypersensitive
to stimuli around her. As a result, her behaviors can become
exaggerated in an attempt to detect threats in the environment. Her
sympathetic nervous system was likely activated for an extended
period of time during the trauma, and her instinct is to protect
herself at signs of threat. A traumatized individual can react instantly
to stimuli that might not bother others, such as sudden noises or
movements. Signs of exaggerated startle response include jumping,
fl inching, shaking, and accelerated heart rate in response to stimuli
such as sudden speech or movements by others, noises from hallway,
alarms or beeping, and physical connection.
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
22© Michelle Flaum Hall and Scott E. Hall
22
The Experience of Medical Trauma Scale (EMTS) is a questionnaire
completed by health care professionals to assess factors that contribute to
a patient’s distress while in the hospital setting and that can exacerbate a
traumatic stress response to medical care. Such factors are distributed in the
following categories: communications with clinicians, physical discomforts,
environmental discomforts, and emotional discomforts.
INSTRUCTIONS TO CLINICIAN
The following questionnaire should be administered by a clinician ( nurse, physician, or mental health professional ) in the acute care setting following a
severe event, sentinel event, or in any circumstance in which a patient may
have experienced trauma due to the nature of the illness, procedure, or
unique circumstances.
For any items scored a 2 or above, clinicians should create a plan for
improvement that includes consultation with the patient. For Emotional
Discomforts items scored a 1 or above, plan to consult a mental health
professional (clinical mental health counselor, clinical social worker, or
psychologist) immediately.
In the event that a mental health professional is not accessible while the patient is at your facility, ensure that a referral for follow-up mental health care is included in the patient’s discharge plan .
EXPERIENCE OF MEDICAL TRAUMA SCALE
G
23From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
23© Michelle Flaum Hall and Scott E. Hall
Plan of Action to Ameliorate the Patient Experience
For Communications items scored 2 or above:
Patient Remarks:
Provider Response and Plan:
NOT DISTRESSING/NOT EXPERIENCED
SLIGHTLY DISTRESSING
MODERATELY DISTRESSING
DISTRESSING EXTREMELY DISTRESSING
0 1 2 3 4
Communication
Interactions with
medical staff (assistants
and technologists)
Interactions with
nurses
Interactions with
physicians
Interactions with
surgeons
Communications too
detailed/technical
Communications too
quick/confusing
Communications too
vague
Communications too
infrequent
Communications too
frequent
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
24© Michelle Flaum Hall and Scott E. Hall
Plan of Action to Ameliorate the Patient Experience
For Physical Discomforts items scored 2 or above:
Patient Remarks:
Provider Response and Plan:
NOT DISTRESSING/NOT EXPERIENCED
SLIGHTLY DISTRESSING
MODERATELY DISTRESSING
DISTRESSING EXTREMELY DISTRESSING
0 1 2 3 4
Physical
Discomforts
Medication side
effects
Pain
Medical
procedures
Experience of
body in stressful
positions
IV placement and
sensations
Restriction of
movement
Uncomfortable
gown/bedding
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
25© Michelle Flaum Hall and Scott E. Hall
NOT DISTRESSING/NOT EXPERIENCED
SLIGHTLY DISTRESSING
MODERATELY DISTRESSING
DISTRESSING EXTREMELY DISTRESSING
0 1 2 3 4
Environmental
Discomforts
Restriction of food
Restriction of water/
fl uids
Limited personal
hygiene
Limited privacy
Exposure to sounds
(monitors, alarms,
etc.)
Exposure to lights
(i.e., fl uorescent
overhead lighting)
Exposure to odors
Observing other
sick/injured patients
Threat of germs,
infection
Lack of personal
clothing
Lack of personal
space
Lack of typical
routine/schedule
Lack of typical diet
Exposure to needles
(continued)
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
26© Michelle Flaum Hall and Scott E. Hall
Plan of Action to Ameliorate the Patient Experience
For Environmental Discomforts items scored 2 or above:
Patient Remarks:
Provider Response and Plan:
NOT DISTRESSING/NOT EXPERIENCED
SLIGHTLY DISTRESSING
MODERATELY DISTRESSING
DISTRESSING EXTREMELY DISTRESSING
0 1 2 3 4
Exposure to blood
Experience being
monitored (heart
rate, blood pressure,
etc.)
Experience of
private areas being
touched
Experience of
private areas being
seen by staff
Exposure to
temperature
Experience of being
confi ned to bed
(cont inued )
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
27© Michelle Flaum Hall and Scott E. Hall
Plan of Action to Ameliorate the Patient Experience
Emotional Discomforts items scored 1 or above? ____________ YES
____________ NO
If YES, consult Mental Health Provider: ________________________ Name
Patient Remarks:
Provider Response and Plan:
NOT DISTRESSING/NOT EXPERIENCED
SLIGHTLY DISTRESSING
MODERATELY DISTRESSING
FAIRLY DISTRESSING
EXTREMELY DISTRESSING
0 1 2 3 4
Emotional Discomforts
Feeling disoriented
Feeling isolated
Fear for own well-being
Fear for own life
Feeling anxious
Feeling powerless
Feeling vulnerable
Concern about quality of medical care
Feeling numb or detached
Feeling depressed
28 From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
28© Michelle Flaum Hall and Scott E. Hall
Additional Notes/Comments:
Administered By Date
This copy is for individual use only—not for duplication, distribution, or institutional use .
For more information about using this tool, please contact:
Michelle Flaum Hall, EdD, LPCC-S
E-mail: [email protected]
Phone: (937) 545-7392
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
29© Michelle Flaum Hall and Scott E. Hall
29
H
PROTOCOL FOR PATIENT, FAMILY, AND STAFF SUPPORT
Due to the intense nature of severe maternal events (e.g., postpartum hem-
orrhage, venous thromboembolism [VTE], severe hypertension) and the
ensuing emotional reactions of patients, their families, and even providers,
it is imperative that we look to integrated teams that include mental health
professionals to help manage the psychological impacts of this type of med-
ical trauma. While mental health services have sometimes been viewed as
an afterthought when considering the acute needs of women during such
events, given the steady rise in maternal morbidity and increasing awareness
of the benefi ts of integrated care, it seems timely to consider new roles for
mental health professionals within this treatment context.
The following outlines roles and tasks for mental health professionals
(e.g., clinical mental health counselors, clinical social workers, and clinical/
counseling psychologists) before, during, and after a severe maternal event.
During Pregnancy
At OB/GYN offi ce:
� In the last trimester (or sooner, if necessary), OB/GYN screens for pregnancy risk factors for severe maternal event
� OB/GYN or other clinician administers the Medical Mental Health Screening to assess mental health risk factors that can complicate patient coping and recovery
NEW ROLES FOR MENTAL HEALTH PROFESSIONALS BEFORE, DURING, AND AFTER SEVERE MATERNAL EVENTS
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
30© Michelle Flaum Hall and Scott E. Hall
� If pregnancy risk factors AND mental health risk factors are present, OB/GYN should refer patient to a mental health provider prior to childbirth
With a mental health provider:
� Review the Medical Mental Health Screening
� Provide resources for stress management and anxiety reduction that are customized to pregnancy risk factors and mental health risk factors
� Explain process of integrated teaming to patients, including mental health provider’s role during and after childbirth
� For high-risk patients, provide coaching to learn stress-management skills (e.g., mindfulness-based stress reduction) and create a stress-management plan to use during the birthing experience and plan for follow-up mental health care
During a Severe Maternal Event
During the event, a mental health professiona l will serve on the interprofes-
sional treatment team and will:
� Provide ongoing assessment of mental health status of patient
� Administer the Experience of Medical Trauma Scale (EMTS) and coordinate a plan for resolving factors contributing to patient distress
� Provide emotional support for patient and family
� Coach patient in stress management techniques
� Be a skilled communicator; take emotional “temperature” in the room and convey accurate assessment of psychological state to nurses for charting
� Be a witness to events, which can help during debriefi ng
� Call a huddle with providers to update on mental status and discuss necessary steps to ensure emotional safety (see TeamSTEPPS resources for interprofessional teaming resources; teamstepps.ahrq.gov )
Follow-Up Care
When patient is stabilized:
� Assess mental health status and screen for traumatic stress response (use screening tools: Breslau’s Posttraumatic Stress Disorder [PTSD] Scale, Impact of Events Scale)
� Provide emotional support for patient, family
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
31© Michelle Flaum Hall and Scott E. Hall
� Schedule meeting with patient/family/providers for debrief prior to discharge
� Consult with providers to ensure that follow-up mental health care is suggested
At discharge:
� Provide resources to patient and family to educate about the psychological effects of severe maternal events (including Understanding the Emotional Effects of Your Childbirth Experience tool)
� Connect patient/family with aftercare, as needed
� Schedule postdischarge follow-up meeting with patient, as needed
� Conduct assessment/follow-up with providers to screen for vicarious traumatization, if necessary
NOTE: This protocol requires the collaboration among members of an
effective interprofessional team. It requires that hospitals have a staff of
mental health professionals trained to meet the unique needs of women
experiencing birth trauma. Training for OB/GYNs, nursing staff, and mental
health professionals in a team-based communication curriculum such as
TeamSTEPPS is strongly suggested to enhance patient safety and provide
the best possible care. Integrated care throughout a woman’s pregnancy,
especially if she is high risk, can help the patient and family by ensuring that
both physical and mental health needs are being addressed. Mental health
professionals who could be cross-trained to perform such tasks include
clinical mental health counselors, clinical social workers (master’s level),
and psychologists (PhD or PsyD). Training in crisis management and inter-
professional teaming are a suggested requirement for mental health profes-
sionals. For hospitals that do not have adequate mental health professional
staff, consider contracting with mental health professionals from the commu-
nity and/or contacting nearby universities with graduate training programs
in clinical mental health counseling, clinical social work, and professional
psychology.
For more information about integrating mental health professionals into
treatment teams for managing the psychological impacts of severe maternal
events, contact:
This copy is for individual use only—not for duplication, distribution, or institutional use.
For more information about using this tool, please contact:
Michelle Flaum Hall, EdD, LPCC-S
E-mail: [email protected]
Phone: (937) 545-7392
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
32© Michelle Flaum Hall and Scott E. Hall
32
I
Your recent childbirth experience was a diffi cult one, and now that you have
been discharged from the hospital, you will begin the journey toward heal-
ing. While it is certainly important that you follow your provider’s recom-
mendations regarding your physical healing, it is equally important that you
address your mental and emotional health in the days and weeks to come.
The physical signs of your childbirth experience are obvious to you: You
may have scars, lingering pain, limited energy and strength, and possible
physical changes as a result of the birth experience. What may be less
obvious are the emotional impacts, so it will be helpful to pay attention to
your thoughts and feelings, and to watch for signs of depression and anxiety.
Childbirth and caring for a new baby can bring on so many different emo-
tions. While women and their families often expect to feel joy following the
birth of a child, when childbirth brings unexpected challenges—and even
trauma—feelings can become quite complicated. The following are just a few
of the more diffi cult emotions you may experience following the birth of
your child.
UNDERSTANDING THE EMOTIONAL EFFECTS OF A DIFFICULT CHILDBIRTH EXPERIENCE
33From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
33© Michelle Flaum Hall and Scott E. Hall
While many of these emotions are quite normal following a diffi cult
childbirth, it will be important to watch for signs of more serious mental
health concerns in the weeks and months ahead.
Signs of depression include feeling sad, low, defl ated, “blue,” hopeless,
helpless … these are just a few examples of the emotional experience of
depression.
Depression can also cause a lack of interest in things you normally like,
and it can even cause you to feel apathy toward your baby, children, and
family. Depression can also cause low energy, diffi culty concentrating, and
disruptions in your sleep and appetite. At its most severe, depression can
cause scary thoughts of harming yourself and even shocking thoughts about
harming others, including your baby. It is important for you to seek the help
of a mental health professional if you experience any of the symptoms of
depression.
Remember that the healing process is a time of transition, and that you
need the support of others to help you regain your footing as a woman,
mother, partner, family member, and friend. It helps to express your thoughts
and emotions, and to remember that an extreme event such as your child-
birth experience can lead to extreme reactions.
Signs of an anxiety disorder such as posttraumatic stress disorder
(PTSD) include feeling excessive worry and panic, numb, depressed, irrita-
ble, and spacey or dazed. Signs of PTSD can also include insomnia, having
Sad Vulnerable Worried
Confused Fragile Terrifi ed
Disappointed Defeated Numb
Fearful Helpless Irritable
Angry Jealous/Envious Disoriented
Grief-stricken Shocked Disconnected
Relieved Hopeless Disillusioned
Lost Detached Panic-stricken
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
34© Michelle Flaum Hall and Scott E. Hall
an exaggerated startle response (e.g., jumping at sudden movements or
sounds), having nightmares or fl ashbacks about the childbirth experience,
feeling detached from one’s body, and avoiding reminders of the experience
(e.g., avoiding doctor visits). It is important for you to seek the help of a
counselor if you experience any of these symptoms.
As you continue to heal from your childbirth trauma, you may experience
diffi culties in different areas of your life, such as in your relationships, career,
identity, and spirituality. When people experience trauma, there can be a rip-
ple effect through every part of their lives. The following are some possible
effects of your childbirth trauma. If you notice these, consider contacting a
mental health professional who can help guide you through your journey
toward emotional healing.
RELATIONSHIP CONCERNS
The trauma of your childbirth experience was likely diffi cult to endure, not
only for you, but also for those who love you. While it is not uncommon to
experience stress in relationships as you heal, there are some signs that may
indicate a more serious concern, such as:
� Diffi culty talking with your partner and family about your experience, or for your partner to listen to you share your thoughts and feelings
� Isolation from your partner and/or family and friends
� Eruptions of anger or chronic irritability that contribute to signifi cant tension in the relationship
� Diffi culty with or lack of interest in physical closeness
� Fear of sexual intimacy (after you have been cleared to engage in intercourse)
� Feeling numb toward others and/or disinterested in social contact
In order to maintain healthy relationships during this challenging time,
try to communicate as clearly as you can. Good communication can help
both you and your loved ones cope with the ups and downs of this time.
OTHER CONCERNS THAT MAY ARISE
In addition to mental health concerns and relationship issues, a diffi cult
childbirth can also lead to challenges in other areas of life. Women who expe-
rience birth trauma can struggle to make sense of the event and what it all
means to them; it can be diffi cult to accept that their childbirth experience
was so fearful, chaotic, or at the very least, disappointing.
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
35© Michelle Flaum Hall and Scott E. Hall
Women who endure life-saving medical interventions resulting in
permanent physical changes (e.g., hysterectomy) can struggle to regain a
healthy identity and can grieve their inability to give birth in the future. Birth
traumas can also lead to a questioning of all areas of life, from a belief in a
higher power to career and lifestyle choices.
How Family and Friends Can Help
� Take time to listen. It is not uncommon for women to need to talk about details of their childbirth experience, perhaps numerous times. Remember that your role as a listener is to simply be present, with a caring attitude.
� Do not try to problem solve. One thing that gets in the way of active listening is a need to solve problems. When women share their thoughts and feelings about the birth experience, listen without interrupting or giving suggestions of action steps.
� Communicate clearly and patiently. Due to the many emotions and physical challenges women face following a diffi cult childbirth, it can be diffi cult to communicate effectively. Slow down and make an effort to listen and share your own thoughts and feelings clearly and concisely.
� Do not try to rush the healing process. While it can be tough to get through this diffi cult time, it is important to have empathy for women who have experienced a birth trauma and to give them space to heal in their own time and in their own way.
� Ask how you can help. Sometimes women can feel very alone as they try to heal from a traumatic childbirth experience, and they may not ask for help from others or know exactly how others can be helpful. Check in and ask how you can assist in the healing process. Does she need to talk? Help with the baby or other children? Time alone or with others?
� Suggest talking with a counselor. Sometimes women do not recognize when they might be experiencing more serious emotional effects of a diffi cult childbirth. If you are seeing signs of depression or anxiety, express your concerns in a respectful, gentle manner. Talk about additional options for support, including speaking with a mental health professional.
� Take care of yourself, too. Family and friends of women who experience a traumatic childbirth often work hard to support the healing process. While being a caregiver and support person is an extremely important role, it can also be exhausting—both physically and emotionally. Make sure you are taking care of your basic needs and that you also have the emotional support you need in order to stay healthy during the healing process.
From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.
36© Michelle Flaum Hall and Scott E. Hall
CONTACT A MENTAL HEALTH PROFESSIONAL
It is not uncommon for women who experience a birth trauma to seek the help
of a mental health professional, such as a clinical mental health counselor,
psychologist, or clinical social worker. Even when people have supportive
family and friends, sometimes it can be helpful to talk with someone who
is neutral and unbiased—and who is there to listen and empower you to
achieve greater emotional well-being. Mental health professionals can
provide support and guidance, as well as diagnose and treat mental and
emotional disorders such as depression and anxiety. To fi nd a mental health
professional in your area, you can ask your health care provider for a
referral, contact your insurer for a directory of providers, or visit the website
www.psychologytoday.com to view profi les of therapists in your area.