I was relieved last month when I saw that my fellow Psychologists in LTC member, Lisa Lind, Ph.D., had written an article for McKnight’s about Preparing for trauma-informed care in LTC. As McKnight’s resident behavioral health expert, I was feeling like I should write something on the subject, but I was struggling with how to do so given my apprehensions about it.
Now that Dr. Lind has provided a practical guideline, let us turn to what’s kept me up at night.
While I think it’s a good thing to pay more attention to the emotional experience of residents, I’m worried about how asking them about their traumas will be implemented in the field.
As a psychologist, residents talk to me about their painful past experiences every day. I’ve heard about children born of rapes, hidden abortions, violent childhood homes and all manner of intensely personal information, to which I was often the only one told after a lifetime of carrying a secret. It is a sacred honor to be the listener to a late-life unburdening and it comes after trust has been established over time.
Traumas are sensitive emotional wounds and I’m concerned that in their well-meaning efforts to comply with the new F-tag directives, staff members and surveyors will be poking these emotional wounds with a big stick.
There are many aspects of the situation which contribute to my uneasiness:
- Nursing homes are medically focused institutions. An in-service training or two won’t make up for the general lack of psychological training of the staff.
- Teams are still having difficulty identifying major triggers for psychological evaluation in the present day, such as an amputation or the death of a roommate.
- There are cultural and generational differences in comfort in discussing one’s personal life.
- There’s very little privacy in nursing homes. Roommates and residents seated near nursing stations and team rooms frequently overhear discussions of their peers’ personal information despite staff efforts at discretion.
- Extremely personal, trauma-related questions may be asked in areas that are not completely private due to practical considerations such as time and a lack of secluded space.
- Extremely personal, trauma-related questions are likely to be asked by people with whom no foundation of trust has been established.
- Re-traumatization related to the above.
- The charting of very personal details.
- The sharing of medical records with other facilities or organizations that may not have had basic training in protocols for trauma-informed care.
- Medical records security breaches.
- Levels of turnover that are traumatizing in and of themselves.
- Small towns, where a resident’s past trauma might have implications for the workers who learn of it.
- The triggering of past traumas in staff without adequate supports.
In addition to all of this, I operate from a belief that virtually every resident coming into long-term care has been traumatized to at least some extent by the health event that precipitated their admission, the medical procedures they’ve undergone, being away from home and other losses. While not every resident has post-traumatic stress disorder (PTSD), for most people this experience brings up past times when aspects of their lives were out of control.
In my opinion, the good intention of increasing awareness of mental health issues would be better served by evaluating every resident for psychological services upon admission, the way each resident is assessed by rehab, recreation and other departments, while simultaneously improving the training of staff to refer residents after events such as a decline in physical functioning, a loss of a loved one or a change in behavior.
Better yet, as the field moves away from the fee-for-service model, funding could be directed toward staff positions for psychologists so we can focus not only on individual residents, but on psychoeducational groups, addressing family needs, training staff members so that they don’t add to resident distress, minimizing staff stress, improving team functioning and other critical issues that psychologists are trained for but not paid to perform in long-term care. We could also do research in these areas to see what is and isn’t effective and cost-efficient.
Meanwhile, since trauma-informed care regulations are coming in November, I hope that staff and surveyor training emphasizes above all the extremely personal nature of this information and the importance of handling it in as private and sensitive a manner as possible.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.