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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


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)

http://www.cdc.gov

http://www.healthcaretoolbox.org

http://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/basics/definition/con-20022540

http://www.nctsn.org/trauma-types/medical-trauma

http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml

http://www.traumahealing.org




2


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 )

http://www.samhsa.gov/nctic/trauma-interventions

http://www.trauma-informedpractice.com

http://www.ptsd.va.gov

http://www.who.int/en


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


(continued)



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)



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)



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)



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)



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)



(cont inued )



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

mailto:[email protected]



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)



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 )



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


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 .




Phone: (937) 545-7392




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)

http://www.apos-society.org

http://www.cancersupportcommunity.org

11From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.

11


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


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)

http://www.cancercare.org

http://www.cancer.org/treatment/supportprogramsservices/app/resource-search

http://www.mendedhearts.org



12 From Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals © Springer Publishing Company, LLC.

12


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


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 )

http://www.womenheart.org

http://www.supportnetwork.heart.org/home

http://www.diabetes.org

http://diabeteshandsfoundation.org


1313

E MINDFULNESS RESOURCES

WEBSITES


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

http://www.goamra.org

http://www.mindful.org

http://www.mindfulnet.org/index.htm

http://www.palousemindfulness.com/selfguidedMBSR.html

http://www.umassmed.edu/cfm/stress-reduction

http://www.contemplativemind.org

http://www.heartmath.org

http://www.ptsd.va.gov/professional/treatment/overview/mindful-PTSD.asp

http://www.soundstrue.com/store

http://www.umassmed.edu/cfm/stress-reduction

http://www.palousemindfulness.com/selfguidedMBSR.html

http://www.ptsd.va.gov/professional/treatment/overview/mindful-PTSD.asp


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)

http://www.calm.com

http://www.headspace.com

www .heartmath.org


1515

APPS (cont inued )

• Stop, Breathe, & Think

• Mindfulness Coach

• Omvana— Meditation for Everyone

• Mindfulness—E veryday Guided Meditations

• Mindfully Me

• Insight Timer



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.




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.


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)



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.


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 )


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.



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.


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.




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.


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.



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.





Phone: (937) 545-7392


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.




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



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




For Physical Discomforts items scored 2 or above:

Patient Remarks:






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







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)




For Environmental Discomforts items scored 2 or above:

Patient Remarks:






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 )




Emotional Discomforts items scored 1 or above? ____________ YES

____________ NO

If YES, consult Mental Health Provider: ________________________ Name

Patient Remarks:





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



Additional Notes/Comments:

Administered By Date





Phone: (937) 545-7392




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



� 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



� 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.




Phone: (937) 545-7392




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



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



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.



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.



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.

http://www.psychologytoday.com

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