Trauma Informed Care for the At-Risk Client

Working with the at-risk client

Fortunately, not everyone that experiences a traumatic event will develop post-traumatic stress disorder. There are often certain risk factors that make some individuals more susceptible. As a trauma informed professional you can enhance those skills that build resilience and wellness in your clients.

Prior sexual violation is a significant risk factor for birth trauma. Although the reported incidence of sexual assault is about 1 in 4 for female-presenting individuals, we know that this is grossly underreported and that far many more have been the victims of harassment, objectification, molestation, marginalisation, and more. The likelihood is that most of your clients have already been subject to some form of sexual violation, including medical services. And if they are part of a marginalised group, then they are even more likely to have experienced sexual violation. That means that how they interpret routine clinical care may be quite different than you intend. In fact, for some rape survivors, their births feel like they are “back in the rape“ (Halvorsen, Nerum, Øian, & Sørlie, 2013). Professional care that is trauma informed  can make the difference in how your pregnant and birthing clients emerge from the experience.

Adverse childhood experiences (ACEs) are those traumatic events that occur before an individual’s 18th birthday. These adverse experiences may be the result of childhood abuse or neglect, or experiences that were part of household dysfunction, such as domestic violence, substance abuse, or mental illness. Clients that have a high score for ACEs are more likely to have accompanying health concerns (Felittii et al., 1998). The corollary to that is that a client with altered coping strategies, such as substance abuse, impaired cognition, dysfunctional relationships, poor decision-making skills, etc., is more likely dealing with the effects of ACEs. The birth suite could be one of the first places where this individual is regarded with respect in a resilience-based paradigm where their existing coping strategies are acknowledged and built upon. You can review the WHO’s Adverse Childhood Experiences International Questionnaire here.

Professional Empathy

Most practitioners start their medical training with the same or higher levels of empathy than a control group. However, the practitioner’s empathy declines over the course of their medical school training as they are taught to objectify the patient, are overloaded with work, experience mistreatment from supervisors, and are not given emotional support. It’s not the individual, but how they learn to survive their training (Decity Smith, Norman, & Halpern, 2014).

Empathy for the client is at the core of trauma-informed care. Empathy is client-centred and benefits both the practitioner and the client. It not only reduces burnout, but it increases clinical accuracy and patient wellness (Halpern, 2003; Shanafelt et al., 2005; Rakel et al., 2009; Neumann et al., 2011; Mercer, Jani, Maxwell, Wong, & Watt, 2012).

Care providers often wonder if they’ve got they’ve got more time in the day or anything left to give to offer empathy to their clients. Empathy is a learned skill that not only reaps significant clinical and professional benefits, but also takes no more time in their day (Krasner et al., 2009). 

Cognitive empathy is how most practitioners are taught to approach their clients. This is an emotionally detached concern for the client where the practitioner recognises and understands the client’s experience. However, affective empathy is achieving emotional resonance with the client and improves cognitive accuracy, improves client disclosure, improves the effectiveness of a treatment, and improves both the client’s and the practitioner’s well-being. A client that perceives that their care provider has empathy for them is much less likely to experience trauma. (Post, 2014)

You can do a self-assessment on your level of empathy here.


Burnout in a care provider is a risk factor for trauma in the at-risk client.

Burnout is defined by these three characteristics:

  1. Emotional exhaustion and a lack of enthusiasm for work
  2. Depersonalisation of the patient and cynicism towards patients and peers
  3. Low sense of accomplishment at work

Just over half of obstetricians report burnout (Pekham, 2016; Avery, 2017). Midwives and nurses report burnout, sometimes called compassion fatigue, at about the same rate (Nolte, Downing, Temane, & Hastings‐Tolsma, 2017; Sheen, Spiby, & Slade, 2015). It's noteworthy that burnout decreases empathy in the caregiver (Mollart, Skinner, Newing, & Foureur, 2013).

When a care provider is dealing with burnout, they employ depersonalisation as a coping strategy. It’s a means of not becoming too invested in the person they’re treating, however, it’s a significant risk factor for a traumatic experience for the client, as the most significant risk factor for a traumatic birth is perceived lack of support from the care provider (Ayers, 2016; Harris & Ayers, 2012). Burnout and compassion fatigue also make the care provider less effective and it contributes to poorer quality of care (Shanafelt & Noseworthy, 2017). 

When doulas burns out, they generally leave the profession, meaning that few doulas are able to work long enough to become highly skilled in their profession. It’s a lose-lose situation for professionals and clients.

Burnout isn’t just a personal issue, it’s a facility-based issue. How the hospital runs their units is highly predictive of provider burnout. And while it’s great when a practitioner can engage in mindfulness and self-care to lessen personal burnout, without a facility-wide approach to trauma-informed care, the patient is still at risk. Fortunately institutions can employ effective strategies to further reduce burnout and improve patient care.

You can do a self-assessment for possible burnout here.

Pregnant woman sitting on table beside doctor

Pregnant woman sitting on table beside doctor