Trauma-Informed Engagement, Part 3: Safety and Trustworthiness
By Carolyn Shimmin
Previous posts on trauma-informed engagement have addressed what trauma is and its effects, particularly in the context of patient and public engagement in health research. In this post, we discuss two important concepts of trauma-informed engagement ― safety and trustworthiness ― and ways to work towards establishing them in research partnerships.
Patient and public partners come to engagement with a variety of life experiences that shape how they feel, what they think, and how they respond when interacting with health researchers. Some patient and public partners have previously experienced boundary violations and abuses of power including interpersonal trauma (e.g. domestic violence, childhood sexual abuse) or other forms of oppression and violence within healthcare systems (e.g. systemic racism, transphobia). Recognizing this can be powerful for both health researchers and patient partners.
Why are Safety & Trustworthiness Important to Patient and Public Engagement?
Physical, emotional, psychological and cultural safety are integral aspects of trauma-informed engagement. It is important to understand that people who have experienced and survived trauma may feel unsafe in new environments and have difficulty trusting health researchers and their intentions. Health researchers need to recognize that a patient or public partner’s reactions are not necessarily personal, and don’t necessarily reflect the researcher’s skills or abilities. Instead, these reactions may be influenced by what has come before, or expectations of what is to come next, including the fear of being let down by the healthcare system again ― which health researchers are frequently (and often unknowingly) perceived as representing. Understanding this gives permission to patient and public partners to experience their natural reactions without feeling that they are disrespecting the health system or the health researcher. This is why safety and trustworthiness need to be established from the very first encounter, and continually addressed throughout the research project.
Creating Guiding Principles for Safety in Research Partnerships
Physical Safety
Oftentimes when health researchers and patient/public partners come together, we have a discussion around safety that includes questions like:\
- What does physical safety mean to me?
- What does physical safety look like to me?
- What does physical safety feel like to me?
Examples might include: meeting in spaces within the community and not in healthcare settings or university settings (which may be re-triggering to some); not crossing arms, leaning in, standing behind someone who is sitting, or rolling eyes.
Emotional or Psychological Safety
- What does emotional/psychological safety mean to me?
- What does emotional/psychological safety look like to me?
- What does emotional/psychological safety feel like to me?
Examples might include: empathetic/active listening, not raising voices, and no judgement.
Cultural Safety
- What does cultural safety mean to me?
- What does cultural safety look like to me?
- What does cultural safety feel like to me?
Examples might include: an understanding of white privilege and historical and present-day colonialism, a commitment to anti-racist practice, and an environment that is spiritually, socially, emotionally and physically safe for people, where there is no assault, challenge or denial of people’s identity, of who they are and what they need.
Writing down these examples and using them as guiding principles for the whole team that can be revisited and discussed at the beginning of each team meeting is important.
Other Methods of Establishing Safety & Trustworthiness in Research Partnerships
Other ways safety and trustworthiness can be established within engagement practice include:
Welcoming Introductions
First and foremost, take time to build relationships. In research, there is often a desire to move through a meeting agenda quickly, whether it’s co-development of the terms of reference or consensus building around a research question. But taking the time to slow down, get to know all of the partners who make up your research team, and allowing flexibility/adaptability in order to ensure space for storytelling (and laughter) is essential. This may mean taking an entire meeting (or more) to get to know each other, and scheduling follow-up meetings to discuss the research.
Adapting the Physical Space to be Warm and Welcoming
Just like choosing a meeting space that is not re-traumatizing for patient partners (e.g. meeting in the community vs. at a hospital or university), it’s also important to create an inclusive and welcoming space. In discussing safety needs, this might mean sitting in a circle (to remove hierarchy), dimming the lights, and allowing space to move around.
Providing Clear and Accessible Information
Safety also includes empowering people with information, provided in a way that is accessible for them (such as lay summaries of the project, one-on-one conversations, videos, illustrations, infographics, etc.). It is important to meet people where they are at, rather than forcing patient partners to conform to a research setting they may not know how to navigate.
Ensuring Everyone Understands Confidentiality
One of our colleagues has a great way of introducing the concept of confidentiality to a group by saying “Things we learn together can be shared, stories we tell one another must stay here.” This means that general information about research processes and decision-making can be shared outside of the group, but the experiential knowledge and stories shared within the group must stay within the group (unless otherwise stated explicitly).
Creating a Crisis Plan if a Research Team Member is in Distress
Ensure you have a readily available list of supports and resources that are easily accessible by patient and public partners and researchers within their community (including free, walk-in, and in-person, phone, and online supports). You can offer to sit with the partner if they want some support when phoning to make an appointment or reaching out to a crisis line. It is also important to have an understanding of grounding techniques, which help those in distress reorient themselves to the present. Grounding skills can be helpful in managing overwhelming feelings or intense anxiety, and can include taking deep breaths, sipping a glass of water slowly, and/or focusing on an object in front of you.
Demonstrating Predictable Expectations and Scheduling Meetings Consistently
In building trusting relationships and establishing safe spaces, let the patient partners set the pace and tone of meetings, and model very consistent behaviours so that there is a feeling of ongoing reliability and support.
Vicarious Trauma
It’s also important to consider the safety and needs of health researchers themselves. Trauma-informed engagement creates an awareness of vicarious trauma (i.e. a transformation of self in a health researcher resulting from empathic engagement, including bearing witness to recounts of traumatic experiences), as well as researcher burnout. Whether or not health researchers have experienced trauma themselves, they may be triggered by a patient partner’s responses or behaviours. The impact of vicarious trauma occurs on a continuum and is influenced by a number of factors, including:
- How much traumatic information a health researcher as well as other patient and public partners are exposed to;
- The degree of support within a research team’s work environment; and
- Personal life supports and personal experiences of trauma.
Utilizing a trauma-informed engagement approach is not contingent on a patient or public partner’s or health researcher’s disclosure of trauma. It is a way of doing engagement that recognizes the need for physical and emotional safety, as well as empowerment, choice and control in decisions. Trauma-informed engagement is a way of being in relationship or partnership and can be cultivated in every research interaction. By utilizing a trauma-informed approach in all of your patient engagement activities, you are looking to create larger and more inclusive spaces for diverse perspectives and voices to be heard.
Continue Reading Part 3: Safety & Trustworthiness
Need Help?
- Please refer to the Canadian Association for Suicide Prevention’s list of crisis centres across Canada.
- First Nations and Inuit Hope for Wellness Help Line: 1–855–242–3310. It is toll-free and open 24 hours a day, 7 days a week.
About the Author
Carolyn Shimmin (@CarolynShimmin) is the Patient and Public Engagement Lead at the George & Fay Yee Centre for Healthcare Innovation (CHI). Her experience includes stakeholder engagement, research, writing and reporting on various health policy issues including mental health, addictions, trauma and the sexual exploitation of children and youth. Areas of interest include patient engagement, lived experience research, knowledge translation, trauma-informed approaches, intersectional analysis, and post-structuralist queer theory.
