Ep 285 – Trauma-sensitive Intake Forms: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

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0:01:36.0 S2: Hi and welcome to "I Have a Client Who... " Pathology Conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology. And I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients but we need to figure out a way to do that safely, effectively and within our scope of practice. And sometimes as we have all learned, that is harder than it looks. 

0:02:23.8 S2: Today's story comes from a massage therapist who is trying to become more sensitive to the needs of their clients, but they wanna do that with some sensitivity. It gets complicated and it goes like this, "My apologies in advance, but I'm not sure how to make this short and sweet. It's nuanced, so I feel like it requires a bit of wordiness. Recently, a client noted that they wanted to inform me that a recent event had triggered a trauma response. And they weren't sure where to list that or how to share that with me. Thankfully, they let me know, they appreciated that my online forms are secured and HIPAA compliant, so they felt comfortable filling out a new client intake online to note this change. And they were comfortable, verbally telling me about it before the start of the session without getting specific just so we could watch for signs together, and so I could provide space or make adjustments if needed during this session. I've been working over the past few years to learn about trauma responses and work on strengthening my skills to provide a trauma-informed framework of care within my scope of practice, but I'm certainly not an expert and still in the beginning stages of learning." 

0:03:41.6 S2: "I've taken some classes and read up on the four Rs of trauma-informed care. Obviously, I always have more to learn. But in the meantime, I work with a few clients with whom I have discussed my limitations and how I work to create as safe a space as possible and how we communicate to provide safe touch without retraumatizing and without going outside of scope. As a side note, I'm sure there are other clients I've worked with without knowing they have a history of trauma which is another reason I'm focused on this. This client was open and honest, thankfully, and she shared the challenges she faced in how to bring all this to my attention. But not every client might be like that, so it was a good reminder that my intake form doesn't address history of trauma directly and I don't have a way for a client to inform me of this ahead of time in a way that feels easy and safe for them without them having to complete an entirely new form. Have you explored ways to allow clients to provide general information on past trauma or triggers for those who wish to share without them feeling forced into sharing details that might retraumatize them? My initial thought is updating my intake to include a check mark for history of trauma past or present, and creating a new updated health history form that is simplified and simply asks for any updated information periodically after a client has completed their original intake form." 

0:05:11.0 S2: "But another part of me wonders if adding a checkable box for history of trauma might be triggering all on its own. And lastly, now that I have a few clients with known trauma who are referring me to others, I should probably have a disclaimer regarding what trauma-informed care is as a massage therapist so clients know I'm not trying to be a pseudo mental health therapist, and so I can better define boundaries to avoid stepping out of the scope. Do you have any thoughts on this?" 

0:05:43.3 S2: Well, thank you so much contributor. It was a little bit on the long side but every sentence was important. And as you say, this is highly nuanced and a 10 to 15-minute podcast is not going to offer comprehensive actionable solutions but maybe we can start or continue a conversation about this important topic. Listeners might remember I did some episodes on trauma-informed care last year and I will put links in our show notes. These episodes also prompted me to write an article for Massage and Bodywork on the topic as well and you'll find a link to that in the show notes as well. The first thing I wanna say about this before we continue, is that I am not, not, not any kind of expert on the intersections between trauma-informed care and massage therapy. And I don't wanna convey in any way that I have advanced education or credentials in that extremely important area. However, I have learned a lot about this topic and I have some thoughts about this question that might be helpful to our contributor and maybe even to you. 

0:06:57.0 S2: First, let's back up for a moment and offer a couple of important definitions. I'm gonna take these from that Massage and Bodywork article, but I got these definitions originally from the Substance Abuse and Mental Health Services Administration which is sometimes called SAMHSA. And SAMHSA says trauma is the result of an event or series of events or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening, and this has lasting adverse effects on the individual's functioning and physical, social, emotional or spiritual well-being. Traumas can affect individuals, families, groups, communities, specific cultures and whole generations. It generally overwhelms an individual's or community's resources to cope and it often ignites the fight, flight or freeze reaction at the time of the events. 

0:07:55.9 S2: It frequently produces a sense of fear, vulnerability and helplessness. Then SAMHSA defines trauma-informed care as this, they say trauma-informed care is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment. It also involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals who already have histories of trauma. And it upholds the importance of consumer participation in the development, delivery and evaluation of services. 

0:08:57.0 S2: This approach has been codified by some experts into the four Rs of trauma-informed care. And those four Rs are, realize what trauma is and how it can affect individuals, families, communities and societies, recognize the signs of trauma, respond to trauma in practice and in general policy and resist retraumatization through insensitivity and poor communication. And of course, this is what our contributor was referring to with the four Rs of trauma-informed care. And we just said a lot, but here's what it really boils down to, a trauma can be physical, emotional or both. It can affect an individual, a family, a community, whole cultures, even whole generations. The impact of traumatic events can lead to feelings of fear and vulnerability and helplessness, but informed sensitive care can help survivors to rebuild a sense of control and empowerment. 

0:10:05.8 S2: Can you see a role for massage therapy here? Because I can. Some experts suggest that the incidence of trauma of one kind or another is so prevalent in our culture that it is safe to assume that practically everyone has had this kind of experience at least once. And for the caring professions, that means we need to be extra sensitive to the needs of our clients, whether they disclose any history of trauma to us or not. One of the things I find especially intriguing about the way primary care physicians describe providing trauma-informed care, is that most of the things they feel they need to do differently, things like making lots of eye contact and describing each part of a procedure and getting consent and being on the same physical level as the patient and preparing the room ahead of time so the patient doesn't have to hear them rummaging around for equipment while they're on the table and helping to reorient the patient to time and place if they feel disjointed or disconnected. These are all habits that we practice early and often, they are practically written into the DNA of what it means to be a compassionate and sensitive massage therapist. 

0:11:20.0 S2: For listeners interested in pursuing more education about this, you have many options. I will put a link to a class designed and presented by a massage therapist who I think does great work. She helped me a lot when I was putting my original article together and I think her work is terrific, but it isn't hard to find classes like this. Let's return to our contributor's two main questions. First, they wanna know about ways to allow clients to provide general information on past trauma or triggers for those who wish to share without those clients feeling forced into sharing details that could retraumatize. They thought about adding a place in their intake form for a history of trauma or maybe creating a new updated health history form that simply asks for any new health history information periodically after a client has completed their original form. They also wonder if adding a checkable box for history of trauma might be triggering all on its own. 

0:12:21.9 S2: This is a fascinating question. To me, a check box seems a bit dismissive but maybe a check box with a space where a client can enter information about their history if they choose to might be helpful. And their other question, they said, "I have a few clients with known trauma who are now referring me to others, so I should probably have a disclaimer regarding what trauma-informed care is as a massage therapist so clients know I'm not trying to be a pseudo mental health therapist and so I can better define boundaries to avoid stepping out of scope. Do you have any thoughts on this?" 

0:13:00.2 S2: Well, of course I do. I think an updated intake form with the area where you invite clients to share about their trauma histories if they choose to, is a great idea. And you can include here a short statement about why you ask and what your role is in this context. I'm just spitballing here but maybe you could build from something like this, "Many people have a history of physical or emotional trauma that impacts their ability to receive bodywork. If I can do anything to help you feel more comfortable during our time together like adjusting the lighting, changing the way you are draped, avoiding certain areas or other accommodations, please let me know. My job is to help you feel as safe and as comfortable as possible as we work together." That simple statement opens the door for conversation, it makes clear that your interest is all about creating an effective experience for them in the context of massage. And then you can make referrals to trusted talk counselors as needed. We don't need to know the details of our client's traumatic histories to be helpful to them, but we can use our compassion and our empathy along with some good advanced education to bring our very best to their table. And that's what we're here to do. 

0:14:24.5 S2: Hey everybody, thanks for listening to "I Have a Client Who... " Pathology Conversations with Ruth Werner. Remember, you can send me your "I Have a Client Who... " stories to ihaveaclientwho@abmp.com, that's ihaveaclientwho, all one word, all lowercase @abmp.com. I can't wait to see what you send me and I'll see you next time. 

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