Communication within healthcare, both physical and mental healthcare, is a passion of mine. What could be more personal than an interaction with someone who is trying to understand the working of your body or your mind?
I made a video on this topic relating to this post. Let me know what you think in the comments.
This strange, and potentially unsettling, type of intimacy, is complicated by the asymmetrical power balance. Healthcare professionals— doctors, nurses, therapists, dentists, midwives and so on— are in positions of power relative to their patients. This is not only due to their status as the person in the room holding medical knowledge and skills, but due to their agency where patients may have little (or none). A patient lying on an operating table, for example, may have signed the consent form, but in that moment— anaesthetised and immobilised— the agency lies with the surgeon and the medical team. When agency is gone, trust becomes the lynchpin around which everything else revolves. Vulnerability is the word that springs to mind.
Taking this vulnerability into account, I wanted to write a quick guide for healthcare professionals who want to make people with BPD feel safe when they come into their care. I have been inspired by some of own personal experiences, which I may share at a later date. I could probably write a whole book on this I feel so strongly about it (!), but for now quick is the key word!
1.Understand (and respect) that people with BPD have a trauma history and how that might impact feelings and responses Trauma, including experiences of abuse, has commonly (but not always) featured in the lives of people with a BPD diagnosis. Trauma has a way of shaping how a person sees themselves, others and the world around them. These ways of relating to themselves, others and the world, may become heightened in healthcare settings due to the asymmetrical power relations between professional and patient. For example, someone who has been physically hurt as a child may believe they are deserving of pain. This may perhaps affect their relationship as an adult with pain, including expressing pain, their stance on pain killing medicines and so on, for example.
Even though interactions and actions within healthcare settings are being carried out with the intention of healing, the patient may be reminded of similar past experiences that were done with the intention of hurting (causing physical and/or emotional pain). It's really valuable for healthcare professionals to remember the possible parallels that patients with difficult personal histories may feel when they are in medical settings. Themes like pain, loss of control, loss of privacy come to mind, as well as experiences such as being objectified, invaded, criticised or scrunitised. Healthcare often requires people to situate themselves, physically and/or emotionally, in positions and situations that evoke vulnerability. Uncover. Open. Recline. Show. The feeling of vulnerability here can be amplified to painfully loud volumes if you are a survivor of certain types of trauma.
What may look 'silly' or like an 'overreaction' may actually be a person re-experiencing a traumatic memory and this is a time to be respectful, thoughtful and try to establish trust. Let the patient express their feelings, cry or show anxiety without silencing them or criticising them. Ask them what may help. I know time is precious, but giving a few moments to someone in distress is priceless.
2. Communication, communication, communication
I can't stress this enough. Communication is everything, and not just verbal but non-verbal too. Taking a moment to warmly say hello to your patient and tell them your name is generally a great start and (strangely) one that too many professionals miss. It takes an insignificant amount of time and energy to introduce yourself, but the impact is significant.
In terms of non-verbal essentials, there's a lot to be said for when professionals turn to look at their patient (at least now and again), rather than solely staring at the computer. I know information inputting is a priority and time is tight, but I find it really hard to talk about personal issues when someone is facing away from me.
Secondly, it's helpful to avoid standing over a patient in a way that might make them feel cornered or trapped eg: towering over them and making a barrier between them and the door. This can make a real difference in creating a feeling of comfort and safety.
When it comes to the verbal, I believe language in healthcare should be as non-judgemental as possible. Words are not just words— language shapes how we treat others and how we feel about ourselves. Look at the difference between 'treatment avoidant' and 'struggles to attend appointments', 'failure to comply' and 'needs more support to do her exercises', 'neglects self-care' and 'finds it hard to take care of her health'. People with BPD tend to be really hard on themselves and the last thing we need is health professionals to be cold, critical or blaming. It could (and for a lot of people probably would) cause a spiral of shame which could lead to avoiding healthcare in the future.
3. Give as much control to the patient as possible
Often trauma involves a loss of control. Even traumatic memories themselves repeat, uninvited, as if a broken cinema screen is on loop in the mind— replaying and replaying in an effort to be understood. It's worth acknowledging the loss of control (or fear of losing control, if not actually losing it) that happens in certain aspects of healthcare. Think of being anaesthetised, unable to move. Being reclined with someone looking at (or into) your body. Experiencing pain and not being able to make it stop.
A helpful question can be: what can I, the professional, do to help my patient feel as much control as possible? It could be something simple like telling them they can say stop and you will stop (only promising them if it's possible), giving them a choice of pain relief options or asking them where they would like to begin (if there is an option for this and it's fine clinically to do that of course). Consent is whole subject in itself, but there is always a place for the polite words 'may I look? may I touch?'.
4. Give as much privacy to the patient as possible
There is a level of scrutiny and sometimes invasion that can be incredibly unsettling. Even if a health professional needs to see a private body part of a patient, there is no need for them to see the whole body. There is no need to get up close and personal more than is needed. Allow a patient to dress and undress in private, even if you need to see what's underneath their clothes. The act of dressing and undressing feels very personal to many (most?) people. Choosing body language and body positioning carefully can minimise discomfort and help the patient feel more comfortable. Make sure other professionals don't enter during the consultation unless they has been pre-agreed with the patient as it can increase uncomfortable feelings of exposure.
There is sooo much more I could say on this topic, but for now I urge health professionals to spend a little time reflecting on these things and how people, including those with BPD and/or with a history of trauma may feel in clinical encounters.
Of course, you may not always know that your patient has a trauma history— it's hardly likely to be written on their T shirt! If you are aware you may not know the details given how (understandably) private it may be for them. The potential invisibility of trauma therefore makes it all the more important that healthcare professions treat every single person that walks through their door with the utmost with care and gentleness. I know some professionals take this side of their practice very seriously and that heartens me immensely! Thank you!
I would like to say a big thank you for reading and I would love to hear from you if you have any thoughts or comments.
Rosie x
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