Following a miscarriage, Sara (not her real name) experienced significant guilt and self-blame. She began having intrusive and uncontrollable thoughts and memories of the miscarriage, which caused heightened fear and stress. She avoided hospitals, and panicked and cried uncontrollably whenever she saw babies or pregnant women in public. Sara’s relationships with her family, spouse and friends became strained – she stopped going out and was withdrawn because it was distressing to talk about how she was doing.

A year passed – Sara remained avoidant of anything that could trigger memories and feelings of fear and distress. Her family and relatives struggled to understand why she could not “move on” from the loss. Recently, Sara’s husband urged her to seek professional support, as her sleep had worsened with her mood spiralling into fleeting suicidal thoughts.

Traumatic losses or perinatal trauma such as pregnancy loss or difficult birthing experiences, is one of the most common types of psychological trauma seen in women at KK Women’s and Children’s Hospital (KKH).

Other types of psychological trauma commonly seen at KKH arise from interpersonal traumatic experiences, such as relationship violence, sexual abuse or sexual assault. These experiences may threaten an individual’s existing worldviews, such as causing them to believe that people are generally dangerous.


Timely psychological support is crucial for recovery

After a traumatic experience, it is normal for a person to experience any of the following stress reactions for up to a month:
  • Having upsetting thoughts, memories or nightmares about the event
  • Feeling as though the event was happening again
  • Changes in mood and/or beliefs about themselves, others or the world
  • Changes in sleep and/or appetite
  • Feeling irritable
  • Difficulty in concentrating
  • Heightened awareness of potential signs of danger
  • Being easily startled by unexpected occurrences, such as loud noises
  • Avoiding places, people, things, thoughts, memories and feelings that remind them of the event

Many individuals recover from the stress reactions once they have been removed from the traumatic situation and are provided with appropriate emotional and practical support.

However, some may continue to experience these reactions for a prolonged period, posing a longer-lasting impact on their day-to-day functioning, relationships, and sense of safety and self. They may also feel isolated and alienated, and develop self-harm or suicide ideation.

Timely psychological and psychiatric review and intervention are essential to reduce symptoms and prevent long-term health implications. With support, the person has stronger chance to regain or improve their quality of life.


Five steps for trauma-informed care

Community healthcare professionals can provide timely support using the checklist below:

  1. Provide a sense of psychological safety: Be empathic and mindful of your body language, tone of voice and choice of words, as these can help build rapport with and instil a sense of safety in the patient.

For example, be mindful not to inadvertently communicate blame to a person who had experienced a traumatic event.

DON’T: Ask a question that implies responsibility for the traumatic event, such as “Why didn’t you ____?”
DO: Ask an open-ended and neutral question, such as “What happened that made it challenging to ____?” This normalises the person’s response during the traumatic event.

  1. Empower patients to make informed choices: Keep your patient informed during the history taking process, such as explaining the required procedures, symptoms to look out for, and treatment options.

  2. Screen for traumatic stress symptoms: Routinely administer trauma screening tools with trained providers to interpret the screening results. These include:

  1. Be aware of cultural, gender or historical issues: A person’s past experiences, culture, and other identities may influence how they respond to difficult experiences or to healthcare providers. Remaining non-judgemental and taking a curious stance about these reactions can build rapport and help your patient feel safe.

  2. Provide referrals depending on patient’s needs:
    • Signs of traumatic stress: Make a referral to a psychiatrist in a public hospital (e.g. KKH or Changi General Hospital) for subsidised psychological therapy.

    • Signs of acute risk issues requiring immediate psychiatric treatment: First refer the patient to the Institute of Mental Health (IMH) via 6389 2222 (available 24 hours). An assessment of traumatic stress symptoms can follow after the acute risk issues have been managed.

    • Other signs of emotional distress with no risk issues: Encourage the patient to seek help at

Psychosocial and trauma support for women

At KKH, the Psychosocial and Trauma Support Services (PTSS) provides evidence-based psychological therapy for women to reduce their distress and improve their quality of life. This can include reducing avoidant behaviours, resuming engagement in activities and relationships, and increasing their self-efficacy to better manage traumatic stress.

PTSS also educates family members, where needed, to help them better understand and address assumptions about psychological trauma. This empowers them to support their loved ones in managing their symptoms and re-engage with life.


​Resources for healthcare professionals

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​Ho Yiling, Principal Psychologist, Psychosocial Trauma Support Service, KKH
 
A principal psychologist with the PTSS Women’s Service team, Yiling supports adults, youths and families who had experienced psychological trauma from adverse events. Her clinical experience extends to providing trainings and implementing trauma-informed practices for healthcare and community stakeholders, with her interests centred around clinical supervision, public health education and mental health literacy. Yiling received a Doctor of Psychology (Clinical) from The University of Queensland, Australia.
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​Isobel Tan, Senior Psychologist, Psychosocial Trauma Support Service, KKH
 
Isobel is a senior psychologist with the PTSS Women’s Service team, and has been working with adults, youths, children and families with psychological trauma arising from abusive situations and other life-altering events. She is also involved in the training and implementation of trauma-informed care. Her interests include raising awareness about trauma, complex trauma presentations in high functioning individuals and dynamic therapeutic processes. Isobel has a Masters in Psychology (Clinical) from the National University of Singapore.