Emotion in the Clinical Encounter >A Trauma-Informed Approach to Emotion Communication in the
Clinical Encounter
Rachel Schwartz, Judith A. Hall, Lars G. Osterberg+
TABLE 10-3Summary of Communication Strategies and Sample Phrases by Principle of Trauma-Informed Care
Principle
Safety: Ensure and convey physical and emotional safety for
patients, staff, and clinicians.
Trustworthiness and Transparency: Maximize transparency in as
many clinical and administrative processes as possible, with the
goal of building and maintaining trust with patients, family
members, and staff.
Peer Support and Mutual Self-help: Value the lived experiences
and perspectives of people with trauma histories; encourage these
patients to connect with others who share similar experiences, to
harness resilience and promote healing.
Communication strategies
•Observe the Four Cs:
•Calm: Minimize extra stimuli; speak in a calm, even tone; maintain
nonthreatening body language; clear path to exits.
•Contain: Offer private room; ensure confidentiality; only discuss
what patient is comfortable discussing; respect patients’ personal
space and minimize unnecessary physical touch (unless patient
consents to use of therapeutic touch).
•Care: Share verbal messages of support and acknowledgment;
use signage, pins, brochures, and other visual cues to convey
support for a diverse array of identity groups (e.g., a “Black Lives
Matter” sign, or gender-inclusive “pronoun pins” for staff).
•Cope: Offer a centering exercise, e.g., mindful deep breathing;
work with patient to develop a safety/well-being plan.
•Trustworthiness: State and ensure confidentiality; welcome
supportive friends/family if applicable.
•Transparency: Clearly disclose any state- or institution-specific
limits to confidentiality; clarify professional role; explain steps and
procedures in advance.
•Provide information on local peer support groups and other
organizations that support those who have experienced trauma;
discuss and normalize the traumatic response; provide printed
educational materials at the patient’s educational level and in their
preferred language.
Sample phrases
•“This [ER / hospital / clinic] is one of the safest places you can be
right now, even if it can look a bit chaotic at times.”
•“We don’t have to discuss any details you’re not comfortable
sharing.”
•“I’m sorry ___ has happened,. ___ is not your fault. My team and I
are here to help you.”
•“I hear you.”
•“Shall we take some slow, deep breaths together?
•“In the event that something bad were to happen to you, or you
were in danger, do you have a plan for who you would contact
and a safe place to go?”
•“Everything you tell me today is confidential.” [Clearly state any
exceptions related to patient safety such as mandated reporting]
•(after assessing for safety) “Is there anyone here with you today?
Would you like them to join us?”
•“People respond to trauma in different ways. Many people may
experience flashbacks, nightmares, sleep changes, feelings of
decreased interest, isolation, and other short- or long-term
symptoms. These are an expected part of the response to trauma.
We can talk more about them whenever you’d like.”
•“Would you like some printed information on trauma that you can
read later on? If that feels less safe you can also keep this safety
card in your phone case”
•“[Name of organization] is a great local organization that connects
people who have experienced trauma through group meetings
and other resources. Would you like their contact information?
You can reach out to them whenever you choose.”

Collaboration and Mutuality: Promote shared decision-making and
mutual collaboration with patients, employees, and students who
have a history of trauma.
Empowerment, Voice, and Choice: Ensure that patients retain
choice and control during decision making, while promoting patient
empowerment with an emphasis on skill building.
Combatting Structural Violence: Institutions and individuals
recognize and mitigate the traumatic effects of structural violence
on patients, employees, and students, using behaviors, policies,
protocols, and processes that are responsive to their racial, ethnic,
cultural, and gender needs.
Source: Adapted from “Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care,” National Council for Behavioral Health, 2020, and Ref. 38.
Date of download: 12/29/22 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved.
•“Before we talk more, would you like to do a quick mindfulness
exercise to help us center our thoughts together? This is totally
•For individuals: Use body language to convey attentiveness (sit at
optional.”
eye level, maintain eye contact, lean slightly forward); minimize
distractions in clinical space; offer shared “centering exercise”;
•“There are a number of different steps we could take next.”
verbally emphasize the importance of shared decision making.
•“I want us to work together to come up with a plan that works best
•For institutions: Actively solicit anonymous feedback from
for you.”
patients, employees, and trainees regarding necessary changes,
as well as confidential reporting of bias or mistreatment.
•“How does this plan sound to you?”
•“What are your priorities for today’s visit? I want to make sure we
address what’s important to you.”
•“You are in control of everything we do and talk about here today.”
•Empowerment: Clarify patient’s goals; acknowledge resilience
•“Please tell me if anything I do or say makes you uncomfortable.”
and bravery; offer self-administration of sensitive exams; offer
positive coping strategies.
•“That sounds very frustrating / painful.”
•Voice: Pause frequently to allow patient to speak; use empathic
•“You are very brave for sharing your story with me. Thank you.”
statements.
•“Is there anything I can do to help make this experience more
•Choice: Provide options for care; obtain consent and assent as
comfortable for you?”
appropriate for each component of the visit and physical exam.
•“A physical exam would help me better understand what
treatment you need, if any. Is it OK if I [describe specific
maneuvers and rationale] today?”
•“Experiencing [racism / sexism / homophobia / xenophobia, etc.]
•For individuals: Sensitively inquire about experiences of structural
can be very stressful, and even traumatic. Do you feel like any of
violence in patients with higher risk of these experiences (e.g.,
these have been affecting you?”
patients of racial/ethnic minority identities); inquire about and
respect religious/cultural preferences regarding care to the extent
•Even though I can’t know everything about your experiences of
possible.
[racism / sexism / homophobia / xenophobia, etc.], I want you to
know that I am sorry that you have gone through [racism / sexism
•For institutions: Hire and support a diverse clinical staff that
/ homophobia / xenophobia, etc.], and want to be your ally to help
represents the many identities and experiences of their patient
in any way that I can.
population; provide mandatory training on diversity, equity, and
inclusion (DEI), bias/mistreatment, and trauma-informed care for
•“Do you have any religious or cultural beliefs that might affect your
all employees and students; provide welcoming signage and
care today? I want to make sure I am accommodating your
signals such as pronoun pins; offer interpreters at all steps of the
specific needs as best I can.”
clinical process, including scheduling and checkout.