This is part two of a three-part series on self-care and preventing practitioner burnout from faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC. Part One is available here. Jennafer is the co-author and co-instructor of the along with Nari Clemons, PT, PRPC.
Augh, I was so frustrated with myself. I fell for it again. Here’s the scenario: a patient came in suffering excruciating pain. She had been to see a pelvic health professional as well as various medical professionals and was unable to get relief and answers for her rectal pain. She was desperate and called me “her last hope.” Phrases used included, “I need you! Fix me! I hear you are a miracle worker! If you can’t help me no one can!” And just like that I took on the role of Rescuer.
In 1968 a psychiatrist named Stephen Karpman developed a model of personal interaction that he called the Conflict Triangle. It has also become known as the Karpman Triangle, The Drama triangle or the Victim triangle. Per Wikipedia:
The Victim: The Victim's stance is "Poor me!" The Victim feels oppressed, helpless, hopeless, powerless and ashamed. They seem unable to make decisions, solve problems, take pleasure in life or achieve insight. The Victim, if not being persecuted, will seek out a Persecutor and also a Rescuer who may save the day, but may also perpetuate the Victim's negative feelings.
The Rescuer: The Rescuer's line is "Let me help you." A classic enabler, the Rescuer feels guilty if they don't rush to the rescue. Yet their rescuing has negative effects: It keeps the Victim dependent and gives the Victim permission to fail. The rewards derived from this rescue role are that the focus is taken off of the Rescuer. When they focus their energy on someone else, it enables them to ignore their own anxiety and issues. This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.
The Persecutor: (a.k.a. Villain) The Persecutor insists, "It's your fault." The Persecutor is controlling, blaming, critical, oppressive, angry, authoritative, rigid, and superior.
What is interesting about this triangle is that the roles are constantly shifting. In full rescuer mode, I gladly took on this patient, intent on solving her problems. Over time, I saw that my consistent coaching for lifestyle change and self-care was falling on deaf ears. My patient was not following through with anything I asked of her; therefore my treatment plan was not working. The patient began to get frustrated with me. I then cast myself as the victim. She became my persecutor! While perhaps in her mind, I had failed as the rescuer, she was still the victim and I had become her persecutor. At the time, I did not have the skills to know how to navigate this situation in a positive or helpful way. Finally I sought the advice of my supervisor and my therapist to draw up a contract with this patient. The contract outlined each of our responsibilities. If either of us didn’t fulfill our responsibilities, the consequence would be ending our professional relationship. When she persisted, unwilling to do her part, I discharged her per our agreement.
I learned so much from this experience. Here are some things that I have implemented and may be helpful in your practice if you have similar challenges.
- In an initial visit with a new patient I explain that the patient and I make a team and we each have a role to play in reaching the patient’s goals.
- If someone says, “Fix me!” I say, “Think of me as your coach, I can show you how to help your body heal, but it’s your job to do the work.”
- When I hear, “Everyone says you are a miracle worker.” I say, “That is so kind, but it doesn’t work that way. Healing is complicated and everyone has their own journey.”
- In this way, with baby steps, we can get OUT of the drama triangle and into healthy relationships with our patients and the people in our lives.
- Consider the Winner's Triangle published by Acey Choy in 1990.
In her blog NextMeCoaching, Jessica Vader coaches on turning Drama and Control into a Winning situation.
The three roles in the Winner’s Triangle.
Vulnerable – a victim should be encouraged to accept their vulnerability, problem solve, and be more self-aware.
Assertive – a persecutor should be encouraged to ask for what they want, be assertive, but not punishing.
Caring – a rescuer should be encouraged to show concern and be caring, but not over reach and problem solve for others.
If you struggle with professional and personal boundaries, you are not alone, and you can get support. Consider talking with your supervisor, a counselor, reading a good book on the subject, and or taking Boundaries, Mediation and Self Care, a course offering through Herman and Wallace that was designed to help pelvic health professionals stay healthy and inspired while equipping therapists with new tools to share with their patients.
We hope you will join us for Boundaries, Mediation and Self Care this November 9-11, 2019 in San Diego, CA.
Look forward to my next blog where saying no takes an unexpected turn.
The number of individuals who identify as transgender is growing each year. The Williams Institute estimated in 2016 that 0.6% of the U.S. population or roughly 1.4 million people identified as transgender (Flores, 2016). This was a 50% increase from a 2011 survey which estimated only 0.3% or 700,000 people identified as transgender (Gates, 2011). Though these numbers are growing each year, due to increased visibility and social acceptance, it is presumed that these numbers are underreported due to inadequate survey methods, stigma/fear associated with “coming out” and deficient definitions of the multitude of options for gender identity (Flores, 2016).
With the rise of individuals who identify as transgender, gender non-binary and intersex, healthcare professionals have equally seen an influx of patients who require care throughout their discovery and transition. Though medical intervention for these individuals is not new, the first documented surgery was in 1922 to Dora Richter, it has often been segmented and lacking in evidence-based treatment strategies (“Dora Richter,”2019). In 1979 The World Professional Association for Transgender Health (WPATH) was founded and published their first version of the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People (“WPATH,” 2019). Currently, WPATH is on their seventh version of the SOC which is opening doors for the treatment of this population.
Though organizations such as WPATH have attempted to standardized care, the patient experience and reception of quality care are significantly lacking. In 2015 the National Center for Transgender Equality performed a groundbreaking survey of 27,215 respondents with the aim to “understand the lives and experiences of transgender people in the United States and the disparities that many transgender people face” (“About,”n.d., para. 1). This survey revealed that 33% of individuals who saw a health care provider had at least one negative experience related to being transgender (National Center for Transgender Equality, 2015). Negative experiences included; being refused treatment, verbal harassment, physically or sexually assault, and teaching the provider about transgender people in order to get appropriate care (National Center for Transgender Equality, 2015). Alternatively, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person (National Center for Transgender Equality, 2015). Though these statistics are staggering and affronting there is hope for a better future.
Research for the care of these patients, specifically related to pelvic floor physical therapy, is on the rise. In the Annals of Plastic Surgery, an article was published with the purpose to capture incidence and severity of pelvic floor dysfunction pre-surgery, monitor any progression of symptoms with standardized outcome measures and highlight the role of physical therapy in the treatment of patients undergoing vaginoplasty (Manrique, et al., 2019). While in the Journal of Obstetrics & Gynecology a retrospective case series similarly focused on physical therapy pre and post-operatively highlighting dilator selection and success, pelvic floor dysfunction including bowel and bladder as well as reported abuse history (Jiang, Gallagher, Burchill, Berli, & Dugi, 2019). Through articles such as these clinicians can expect an uptick in calls questioning if they treat these patients. This begs the question of, "How can you best prepare?"
The answer is simple, attend continuing education. It is where you can not only learn evidence-based evaluation and treatment but also connect with other providers and mentors that care for these patients. In 2020 Herman & Wallace will be offering a continuing education course that serves this exact purpose. Keep your eyes on next years offerings, as spaces will surely fill quickly.
About. (n.d.). Retrieved May 15, 2019, from http://www.ustranssurvey.org/about
Dora Richter. (2019, May 09). Retrieved May 15, 2019, from https://en.wikipedia.org/wiki/Dora_Richter
Jiang, D. D., Gallagher, S., Burchill, L., Berli, J., & Dugi, D. (2019). Implementation of a Pelvic Floor Physical Therapy Program for Transgender Women Undergoing Gender-Affirming Vaginoplasty. Obstetrics & Gynecology,133(5), 1003-1011. doi:10.1097/aog.0000000000003236
Manrique, O. J., Adabi, K., Huang, T. C., Jorge-Martinez, J., Meihofer, L. E., Brassard, P., & Galan, R. (2019). Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes. Annals of Plastic Surgery,82(6), 661-666. doi:10.1097/sap.0000000000001680
National Center for Transgender Equality. (2015). Annual report of the U.S. Transgender Survey. Retrieved May 15, 2019, from https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
Wpath. (n.d.). Standards of Care version 7. Retrieved May 15, 2019, from https://www.wpath.org/publications/soc
In July of this year, I was invited to present in Christchurch, New Zealand as part of a teaching tour that took in Singapore, Australia and Tasmania. The topic of my class was female pelvic pain, so we discussed Endometriosis, Vulvodynia, Sexual Health and many other sub-topics but we had several discussions about the effects of trauma on pelvic pain. For those who have visited Christchurch, it is a beautiful city but it is still reeling from a series of massive earthquakes, that started in September 2010. The most devastating was in February 2011, when 185 people were killed and 6600 people were injured. Everywhere you go in Christchurch, there are reminders – from the constant buzz of ongoing construction, to structures that are waiting demolition, like the beautiful old cathedral that was beside our hotel. Usually, when I teach, we do some ‘housekeeping’ announcements about fire drills and exits; in Christchurch it was ‘In the event of an earthquake…’. I wondered how the near constant reminders were affecting the inhabitants, so I read of how ‘…people called living with continual shaking, damaged infrastructure, insurance battles and unrelenting psychological stress ‘the new normal’. There are several ongoing research studies, looking at the effects of this trauma and how it is still having an effect on the people of Christchurch.
If you’ve attended Pelvic Floor Level 1 with Herman & Wallace, you’ll remember we quote a study from Van der Welde about the effects of perceived danger on muscle activity in the upper trapezius and pelvic floor muscles. We also discuss the work of Levine, of ‘Waking the Tiger’ fame, who explores the somatic effects of trauma in our bodies – and how trauma, much like pain, is whatever we say it is.
I became intrigued with the topic, so I was delighted to hear that Lauren Mansell has created a course to deal exactly with this topic. I was even more delighted when she sat down for a chat with me to explore the nuances of trauma awareness, boundary setting and self-care for therapists, especially pelvic therapists, who work with those who have experienced trauma of any kind.
I hope you find this conversation as interesting as I did! Here is our conversation:
1. ‘Vaginismus, a Component of a General Defensive Reaction. An Investigation of Pelvic Floor Muscle Activity during Exposure to Emotion-Inducing Film Excerpts in Women with and without Vaginismus’ van der Velde, J & Laan, Ellen & Everaerd, W. (2001)
2. ‘Waking The Tiger’ by Peter A. Levine (1997)
In a previous post on The Pelvic Rehab Report Sagira Vora, PT, MPT, WCS, PRPC told us how "women with sexually adverse experiences tend to have impaired genital response when in consensual sexual situations, however, women who do not have sexual abuse histories and but have sexual pain tend to have appropriate genital response." Today Sagira helps us understand how the pelvic floor responds to consensual sexual activity in women with a history of sexual trauma.
Today we try to look for answers for questions that came up during the last blogs.
How does the cohort that has had adverse sexual experiences present? How do women with history of sexual trauma process sexual experiences? How does the pelvic floor present or respond to consensual sexual situations when a woman has been abused in the past?
To answer these questions, it’s important to understand two facts about the pelvic floor. 1) the pelvic floor plays a role in emotional processing1, and 2) muscle activity in all muscles, including the pelvic floor, increases with exposure to stress and during anxiety evoking experiences2.
We explored in the last blog that women with sexual abuse histories responded with increased pelvic floor overactivity when watching movie clips with sexually threatening and consensual sexual content. Apparently, for women with sexual abuse history even consensual sexual situations can be experienced as threatening1.
Lehrer et. al. found overactivity in the neuronal and hormonal circuits that increase sexual arousal and activity. These circuits are already overactive in individuals who have Post Traumatic Stress Disorder (PTSD), and increased activity can increase anxiety, fear and other symptoms of PTSD instead of normal sexual arousal and excitement during a sexual experience2. For the woman with PTSD this means that sexual arousal signals impending threat rather than pleasure1. And as we already learned in previous blogs and above that when humans feel threatened they respond by tightening muscles and most notably the pelvic floor muscle.
Significant co-relation is found between sexual abuse, subsequent PTSD and chronic pelvic pain3. Hooker et. al, found irritable bowel syndrome, pelvic pain, and physical and sexual abuse to be the most commonly diagnosed together4. More importantly, when patients were successfully treated for PTSD they continued to be 2.7 times more likely to have pelvic floor dysfunction and 2.4 times more likely to have sexual dysfunction. This builds the case for interventions that are multidisciplinary to help patients of abuse and sexual assault, with the pelvic floor therapist playing a significant role.
In the next blog, lets explore how the pelvic floor therapist can work with a counselor and a sex therapist to help the woman with sexual pain dysfunction.
Anna Padoa and Talli Rosenbaum. The overactive pelvic floor. Springer. 1st ed. 2016
Yehuda R, Lehrner A, Rosenbaum TY. PTSD and sexual dysfunction in men and women. J Sex Med. 2015:12(5):1107-19
Blok BF. Holstege G. The neuronal control of micturition and its relation to the emotional motor system. Prog Brain Res. 1996; 107:113-26
Para ML, Chen LP, Goranson EN, Sattler AL, Colbenson KM, Seime RJ, Et. al. Sexual abuse and lifetime diagnoses of somatic disorders. JAMA. 2013; 302:550-61
Hooker AB, van Moorst BR, van Haarst EP, Van Ootegehem NAM, van Dijken DKE, Heres MHB, Chronic pelvic pain: evaluation of the epidemiology, baseline characteristics, and clinical variables via a prospective and multidisciplinary approach. Clin Exp Obstet Gynecol. 2013; 40:492-8
In a previous post on The Pelvic Rehab Report Sagira Vora, PT, MPT, WCS, PRPC shared that "cognitive-behavioral therapy appears to play a significant role in improving sexual function in women". Today, in part three of her ongoing series on sex and pelvic health, Sagira explores how sexual pain affects sexual dysfunction in women.
After having explored what allows for women to have pleasurable sexual experiences including pain-free sex and mind-blowing orgasms, we now turn towards our cohort that have pain with sex and intimacy. How does this group differ from women who do not have pain with sex? Are there some common factors with this group of women, and perhaps understanding these factors may help the pelvic floor therapist render more effective and successful treatment?
There are few studies exploring sexual arousal in women with sexual pain disorders. However, their findings are remarkable. Brauer and colleagues found that genital response, as measured by vaginal photoplethysmography and subjective reports, was found to be equal in women with sexual pain vs. women who did not have pain, when they were shown oral sex and intercourse movie clips. This and other studies have shown that genital response in women with dyspareunia is not impaired. Genital response in women with dyspareunia is however, effected by fear of pain. When Brauer and colleagues subjected women with dyspareunia to threat of electrical shock (not actual shock) while watching an erotic movie clip they found that women with dyspareunia had much diminished sexual response including diminished genital arousal. But Spano and Lamont found that genital response was diminished by fear of pain equally in women with sexual pain and women without sexual pain.
Fear of pain also resulted in increased muscle activity in the pelvic floor. However, this increase was noted in women with pain and women without sexual pain equally and was noted with exposure to sexually threatening film clips as well as threatening film clips without sexual content. The conclusion, then, from these results is that the pelvic floor plays a role in emotional processing and tightening, or overactivity is a protective response noted in all women regardless of sexual pain history.
The one difference that was noted was with women who had the experience of sexual abuse. For them, pelvic floor overactivity was noted when watching sexually threatening as well consensual sexual content. Women without sexual abuse history did not have increased pelvic floor activity when watching consensual sexual content.
In summary, evidence supports the hypothesis that women with sexually adverse experiences tend to have impaired genital response when in consensual sexual situations, however, women who do not have sexual abuse histories and but have sexual pain tend to have appropriate genital response. Both groups, however, have increased pelvic floor muscle activity in consensual sexual situations. This increase in pelvic floor muscle activity leads to muscle pain, reduced blood flow, reduced lubrication, increased friction between penis and vulvar skin and hence leads to pain.
This brings us to our next questions, how does the cohort that has had adverse sexual experiences present? How do women with history of sexual trauma process sexual experiences? How does the pelvic floor present or respond to consensual sexual situations when a woman has been abused in the past? Please tune in to the next blog for answers…
Blok BF, Holstege G. The neuronal control of micturition and its relation to the emotional motor system. Prog Brain Res. 1996; 107:113-26
Brauer M, Laan E, ter Kuile MM. Sexual arousal in women with superficial dyspareunia. Arch Sex Behav. 2006; 35:191-200
Brauer M, ter Kuile MM, Janssen S, Lann E. The effect of pain-related fear on sexual arousal in women with superficial dyspareunia. Eur J Pain: 2007; 11:788-98
Spano L, Lamont JA. Dyspareunia: a symptom of female sexual dysfunction. Can Nurse 1975;71:22-5
When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.
Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).
This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.
Cushing et al., (2018) recently published online a study testing the impact of yoga on post-9/11 veterans diagnosed with PTSD. The participants were >18 years old and scored at least 30 on the PTSD Checklist-Military version (PCL-M). They participated in weekly 60-minute yoga sessions for 6 weeks including Vinyasa-style yoga and a trauma-sensitive, military-culture based approach taught by a yoga instructor and post-9/11 veteran. Pre- and post-intervention scores were obtained by 18 veterans. Their PTSD symptoms decreased, and statistical and clinical improvements in the PCL-M scores were noted. They also had improved mindfulness scores and decreased insomnia, depression, and anxiety. The authors concluded a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms.
Domestic violence, sexual assault, and unimaginable military experiences can all result in PTSD. People in our profession and even more likely, the patients we treat, may live with these horrors in the deepest recesses of their minds. Yoga is gaining acceptance as an adjunctive therapy to improving the symptoms of PTSD. The Trauma Awareness for the Physical Therapist course may assist in shedding light on a dark subject.
Walker, J., & Pacik, D. (2017). Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Medical Acupuncture, 29(4), 232–238.
Cushing, RE, Braun, KL, Alden C-Iayt, SW, Katz ,AR. (2018). Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Military Medicine. doi:org/10.1093/milmed/usx071
I work at University of Chicago and we are in the throes of preparing for a (big T) Trauma Center. But I am physical therapist who works with (little t) traumatized patients- as I treat only pelvic or oncology patients (and usually both).
From the online dictionary: Trauma is 1. A deeply distressing or disturbing experience (little t trauma) or 2. Physical injury (injury, damage, wound) yes- big T Trauma. In my experience, the Trauma creates the trauma and the body responds in characteristically uncharacteristic ways (more on this later).
People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal and caring manner. Always. Every time. To the best of my ability, and without shame or blame.
Let’s talk briefly about Trauma Informed Approach
This is a (person), program, institution or system that:
The Tenets of Trauma Informed Approach
Trauma Specific Interventions
Types of trauma are varied but I usually treat survivors of emotional, verbal, sexual and medical trauma. I have even treated patients who felt traumatized by other pelvic floor physical therapists (again, no judgement). Since most of my clinical experience include sexual and medical trauma survivorship, I try to reframe these experiences as potential Post Traumatic Growth, especially when working with my oncology patients. For my pelvic patients who divulge sexual trauma, I don’t dictate or name anything. I allow the survivor to make the rules and definitions. Survivors of sexual trauma need extra care when treating pelvic floor dysfunction.
First, when treating survivors of sexual trauma: expect ‘characteristically uncharacteristic’ events to occur. These include the psychological/somatic effects of passing out, flashbacks, seizures, tremors, dissociation and other mechanisms of coping with the trauma. Have a plan ready for these patients.
Triaging the survivor to assess their needs, when trauma has been verbalized/disclosed:
After assisting the survivor in their journey towards healing, it is imperative that you take care of yourself. Making healthy boundaries (with patients and others), taking time to decompress, creating healthy ritualistic behaviors, mindfulness/relaxation and somatic release (like yoga, massage or working out) is crucial to successfully treating patients who have experienced trauma and who have shared that trauma experience with you.
Because I use gentle yoga for both my trauma survivors’ treatment and for my own self-care, my new course implements evidenced based trauma sensitive yoga. Additionally, modifications for manual therapy are explored. The class is designed to be informative and experiential while integrating the Trauma Informed Approaches of Safety, Trustworthiness and transparency, Peer support, Collaboration and mutuality, Empowerment, voice and choice and Cultural, historical and gender issues.
Join me in Trauma Awareness for the Pelvic Therapist, next available this March in Albany, NY.