Top tips for supporting patients with a history of psychological trauma

Introduction

Experiencing traumatic events over our lifetimes is common, with some estimating that 70% of individuals worldwide will experience some form of event or set of events that an individual feels is physically or emotionally harmful or life-threatening.¹ Most individuals who experience a traumatising event will not go on to develop lifelong symptoms of trauma;² however, some individuals will be left with long-term psychological and physical symptoms of trauma. There is also reason to believe that rates of psychological trauma are on the rise. For example, rates of domestic violence were higher during the COVID-19 lockdowns,³ and individuals who had COVID-19, particularly those who were treated in intensive care, have been shown to be at increased risk of developing psychological trauma symptoms.⁴

Recent research supports that psychological trauma is relevant to dentistry, as having a history of trauma has been identified as an important predictor of poorer oral health.^5,6,7 Equally, in the current context of rising trauma statistics, it is likely that more and more patients presenting to dental surgeries will have a history of psychological trauma, making it more vital than ever that dental staff understand how to recognise and respond to psychological trauma symptoms.

This article aims to provide all members of the dental workforce with key information and tips on how to support patients with psychological trauma.

• 1. Be aware

Psychological trauma symptoms may result when an individual's natural coping resources are overwhelmed, for example by 'events or circumstances that are perceived as physically or emotionally harmful or life-threatening'.⁸ Examples include single incidents (ie serious road traffic accidents, single attacks or sexual assaults, witnessing a traumatic death, and many more) and prolonged or repeated instances which may be hard to escape from (ie domestic abuse and emotional, physical, and sexual abuse occurring in childhood or adulthood). Psychological trauma symptoms tend to be more severe or have a more enduring negative impact following the latter type of traumatic event, particularly when abuse occurs in childhood.⁹ Common psychological trauma symptoms that an individual may experience after exposure to single-incident and prolonged/repeated trauma are summarised in Table 1.^9,10,11

Table 1 Psychological trauma symptoms

Individuals with psychological trauma can find it particularly hard to tolerate dental treatment as there are aspects of the dental experience that pose challenges for them.¹² For example, lying horizontal and being unable to see much of what is happening can cause individuals with a trauma background to feel powerless and vulnerable. Dental care can be especially triggering for physical and sexual abuse survivors. Being on a lower level than the dentist (who may be seen to loom over them), having the dentist touch them, place objects in their mouth, and potentially cause pain, can all lead individuals to re-experience previous abuse. As you might expect, for these patients, routine dental care can trigger intense negative emotions.¹²

• 2. Know how trauma symptoms may appear in dental settings

We have three instinctive ways of responding to threats in our environment. These are called the fight, flight, and freeze responses, and they are thought to originate from our evolutionary history. In many circumstances these are adaptive since they prepare us to respond to danger in ways most likely to keep us safe. However, these responses can also be activated from feeling anxious regardless whether the threat is real/present or perceived/no longer present. It's also important to note that we can become primed to more quickly activate these emotional states. Traumatic experiences, particularly when these had a prolonged duration, can cause changes to our nervous system.¹³ As a result, individuals with psychological trauma can more easily be tipped into these highly reactive emotional states and struggle to return to optimal functioning. The 'Window of tolerance' is a helpful schematic that visually depicts this.¹⁴ For example, in Figure 1 you can see how experiencing traumatic events can lead us to have a narrower 'window of tolerance', meaning it is harder to stay in this state of optimal levels of arousal wherein we can function effectively.¹⁴ People with trauma symptoms can also find it harder to regulate their arousal meaning their emotions can fluctuate more between the highly intense 'fight/flight' red zone and the 'freeze' blue zone. What this means in reality is that patients with psychological trauma may be more likely to appear angry, aggressive, and confrontational in dental environments when they are experiencing high levels of anxiety. Alternatively, these patients may appear withdrawn, detached, overly compliant, and unresponsive, if their anxiety stimulates the 'freeze' response (more on this in tip 3). As for the 'flight' response, the patients who you don't see/see infrequently/or who fail to return for repeat appointments despite obvious benefits of doing so, may be adopting this response.

Fig. 1

Adapted 'Window of tolerance' schematic showing levels of emotional reactivity for individuals with a) no trauma symptoms and b) for individuals with psychological trauma symptoms

• 3. Recognise and address dissociation

Dissociation is akin to the 'freeze' response and this typically occurs when we perceive fighting/fleeing is not possible or could place us in further danger.¹⁵ Individuals who have experienced prolonged interpersonal trauma previously may have used this freeze response in an adaptive way to physically and psychologically survive the trauma. However, this response can become a 'habit' and an individual can find their body uses this response in other stressful situations, particularly those that are reminiscent of the trauma, that aren't necessarily physically dangerous. This means that people with a trauma background can be more likely to dissociate in the dental environment. It is important that dental staff are able to recognise signs of dissociation as patients who are dissociating may be unable to fully consent to the treatment that is taking place (Table 2 ^15,16,17). They may not be able to verbalise if they are in pain or would like to stop the procedure and some individuals may be so detached from the present that they lose large chunks of time in their memory.^15,16 Therefore, dissociation can result in high levels of distress at the dentist and, if not addressed at the time, could contribute to these patients not returning for repeat dental treatment.

Table 2 Symptoms of dissociation

If you suspect your patient may be dissociating pause what you are doing and follow these steps:

• i. Check in: Ask them what is going on - 'Susan is something happening right now?' 'Are you able to hear me?'

• ii. Reassure: Tell them they are safe - 'You are (NAME), you are in the dental surgery with (PRACTITIONER NAME/anyone else who is present).' 'You are not in danger.'

• iii. Normalise: Let the client understand that dissociation is a normal bodily process that evolved to keep us safe, that even if it is scary, it is not dangerous and it is their body doing its best to protect them. If you feel able, you could explain a bit about the 'freeze' response using the 'Window of tolerance' diagrams.

• iv. Help the client to self-soothe:

• º Help your client re-engage with the present using their senses. Ask them to try to push their feet into the floor or their body into the dental chair. Encourage them to focus on these points of contact and notice how their weight is being supported. Consider offering the client something cold to hold or drink, ask them to focus on the sensation of coolness moving through their skin/body

• º Ask the client to recall where they are in the present - the date, time, location, and who is with them. Alternatively, to help reorient them in the present you could ask them to list, either out loud or in their head, things that they can see noticing the different colours and textures, in their surroundings.

• v. Make a contract with them on what they would like you to do if this happens again: Ask them if there's anything they would like you to do differently if they dissociate again.

Remember that the steps above are a guide: helping them to feel safe is the most important thing.

• 4. Know how to respond to disclosures

Spontaneous disclosures of trauma in dental settings are rare. In fact, research has found that individuals previously exposed to interpersonal violence ie those subjected to physical, emotional, or sexual abuse, have greater difficulty trusting individuals in perceived positions of authority.¹⁸ Rather it is more likely that trauma is communicated indirectly eg the patient displays psychological trauma symptoms (Table 1). Therefore, we should behave in a trauma informed way, whether or not we are aware of any trauma. It is important that you have the skills and confidence to sensitively respond to disclosures because your interactions with these patients have the potential to generalise to their relationships with other professionals. For instance, research has found that safe, trusting, and empowering relationships, at any point in the recovery journey, can play an important role in mitigating the long-term consequences of psychological trauma.⁹ As dental practitioners in a patient facing role, you have an opportunity to have a hugely positive impact on people's lives, none more so than those with trauma histories. If these individuals feel safe and supported by you, a representative of the medical profession, they may feel more able to seek support for their trauma symptoms from mental health professionals.

See Table 3 for some tips on how to sensitively respond to disclosures.¹⁹

Table 3 Tips for responding to disclosures

• 5. Remember the 'Look, listen, and link'²⁰ of psychological first aid

Look:

• For psychological trauma symptoms (Table 1)

• For basic needs that are not being met, eg homelessness, lack of access to nutritional meals, etc

• At the wider context: are others surrounding them at risk, are they currently isolated from sources of support?

Listen:

• Is the patient safe to talk or are others with them?

• Ask about patients' needs and concerns. Many people prefer this approach over specific questions about their trauma background. eg 'Is there anything we can do to help/to make you feel more comfortable?'

• Remind the person that they are safe (if this is true), and that you ask to try to help them

• Maintain appropriate eye-contact. Too little may show disinterest, too much may be intimidating

• Check your body language. Try to maintain a relaxed posture

• If patients do disclose to you, check that you have accurately understood what they have told you. eg 'What I've heard you say is…', 'So what I understand is…', 'Is this right?', 'Have I understood you correctly?'

Link:

• Encourage the individual to reconnect with supportive others or previous social networks

• Give information: make the individual aware of organisations, helplines, and mental health services which could help them

• Encourage the individual to approach their GP if trauma symptoms are persisting.

• Take care with language

Research has shown that the language some dental practitioners use can increase the potential of experiencing intrusive trauma memories at the dentist, especially for childhood sexual abuse (CSA) survivors. For example, some patients who previously experienced CSA reported that well-intentioned phrases like 'this will not hurt' can trigger intrusive memories of their abuse due to similarities with what their abusers told them.¹² For instance, sexual abusers of children commonly begin their abuse by either reassuring their victims that the abuse will not hurt, or by explaining that any unpleasantness will benefit them in the end.²¹

To reduce the potential of patients re-experiencing previous abuse, dental practitioners should avoid stock phrases like 'this won't hurt' and instead should offer as much information as possible about dental procedures and any pain/sensations that may be experienced.¹² Reports from CSA survivors also suggest a number of other adjustments that dental practitioners could make to reduce the likelihood of patients re-experiencing trauma memories. For example: saying what you will do before you do it; regularly checking comfort levels; offering breaks in procedures where the patient need not remain motionless; offering, where appropriate, the opportunity to sit up in the dental chair rather than to lie in a reclined position; and offering the patient a mirror to observe any treatment.¹²

• 7. Remember the five principles of trauma-informed care²²

  • i. Choice:

• • Try to involve patients in all decision-making about their dental care

• • Ensure the patient has enough information to make informed choices about their dental treatment

• • Respect patients' wishes and decisions, eg don't pressure patients to accept a referral to mental health services if this isn't what they want. Remember that due to trauma they may feel lack of safety or control in relationships

  • i. Collaboration:

• • Try to work collaboratively with patients, enquire about their concerns and what they need and use shared decision making try to meet these needs as much as possible

• • Ask at the beginning of consultations what needs to happen during procedures for the patient to feel safe/relaxed

  • i. Trustworthiness:

• • Be transparent with patients to facilitate a trusting relationship

• • Be clear about what will happen in procedures; say what you will do before you do it and what sensations the patient can expect

• • Be open about what you can and can't do in regard to helping patients with their trauma symptoms, eg be clear about the limits of your knowledge and experience and refer patients to more appropriate sources of support where relevant

• • Be clear about the limits of confidentiality

  • i. Empowerment:

• • Validate the patient's experiences and feelings

• • Empower the patient to have a voice in terms of the dental care they receive

• • Support the patient to access sources of support and make informed decisions

  • i. Safety:

• • Prioritise the physical, psychological, and emotional safety of patients

• • Look out for signs that your patient is physically unsafe

• • Offer a safe environment; ensure the examination or meeting room is sufficiently private, without unnecessary interruptions

• • Offer information on sources of support for patients displaying trauma symptoms

• • Offer onward referral to mental health services

• • Remain committed to doing all you can to avoid re-traumatisation for patients.

• 8. Prioritise self-care

It is important to recognise the impact of working alongside patients with psychological trauma on your own emotional wellbeing. 'Secondary trauma' is a real possibility for all who support individuals experiencing trauma symptoms. This term is used to describe the negative emotional states that can be triggered in the moment by hearing patients recall their trauma experiences. Secondary trauma can be so severe that practitioners themselves experience short-lived trauma symptoms.²³ Practitioners can also develop 'vicarious trauma' which refers instead to the longer-lasting negative consequences following repeated exposure to the trauma experiences of others. This can wear down our own personal coping resources and resilience.²⁴ To mitigate the effects of secondary and vicarious trauma, dental practitioners can be aware of the ABC acronym of self-care (Table 4).²⁰

Table 4 The ABC acronym of self-care

• 9. Be aware of sources of support

For patients:

• Compile handouts, posters, websites, and crisis helplines which can offer support in your local area. eg NHS Inform, 111, Citizen's Advice, Women's Aid groups, social prescribing, local mental health services…

• Encourage patients to confide in their GP/ supportive friends and family members. Remember that positive relationships can play an important role in mitigating the impact of trauma

• Offer referral to local mental health services

For yourself:

• Know how to access existing protocols eg gender-based violence, managing violence and aggression, human trafficking, adult and child protection, confidentiality, and information-sharing

• Remember what you already know about supporting the anxious patient. Many of the skills and adjustments can apply to supporting patients with psychological trauma

• Compile a directory of resources where staff can find out more, eg NHS Inform, MIND, World Health Organisation, phone numbers for local mental health services

• Have resources advertising staff wellbeing services on hand

• Arrange regular clinical supervision.

• 10. In summary

Aspects of care and treatment that involve physical examination or invasive physical procedures carry a higher risk of being experienced by people affected by trauma as distressing. As a result, dental patients with a trauma background are more likely to avoid/drop out from treatment.^6,9 This could explain recent findings of psychological trauma being an important predictor of poorer oral health.^5,6,7 Equally, as psychological trauma is on the rise, and since spontaneous disclosures of psychological trauma to dental practitioners are rare,¹⁸ it is becoming more important than ever that dental staff are skilled to recognise and respond to psychological trauma symptoms. This article has aimed to provide information to support: the identification of common psychological trauma symptoms; sensitive management of heightened distress, dissociation, and disclosures should they arise; and has aimed to provide guidance on how practitioners can be prepared, ie compiling resources for patients and staff to facilitate signposting.

Overall, our hope is that the top tips above can increase awareness of how psychological trauma symptoms may present in dental settings, and enable the entire dental workforce to competently respond to these patients in ways unlikely to retraumatise and which minimise attrition rates.