Communication and Consent in Trauma-Informed Care
How to listen, ask, and respond in ways that build safety for survivors
Communication Can Heal or Harm
For a survivor of childhood sexual abuse, every interaction with a care provider carries weight. The words a provider uses, whether they ask before touching, how they respond to a request, all of these either build safety or reinforce old patterns of powerlessness. This article covers the communication skills that make the difference between a birth that re-traumatizes and one that heals. While written with support people in mind, the skills here are equally valuable for care providers who want to offer trauma-informed care.
Directive versus Non-Directive Communication
Directive communication is giving information, directing someone how to do something, and giving advice. It implies the caregiver is the expert. There are times when directive communication is necessary, during a medical emergency, when giving clear instructions for pushing, or when explaining a procedure. Non-directive communication encourages the other person to explore their own feelings and find their own solutions. It creates equality and helps the survivor feel valid as a person. Non-directive communication is what builds trust. It includes active listening, reflecting feelings, paraphrasing, clarifying, asking open-ended questions, and using I-messages for feedback. For survivors, the normal ups and downs of pregnancy and birth are more complex. They need space to express their feelings, not quick solutions.
Active Listening
Active listening means listening with empathy (understanding the true content and feelings being expressed), openness (without interruption, judgment, or evaluation), and awareness (noticing congruence between words and body language). It also means unconditional regard: open posture, comfort with silence or crying, a warm tone of voice, nodding, and avoiding distractions like looking at a watch or answering the phone. When a survivor feels truly heard, their body begins to relax. When they feel rushed or dismissed, their defenses go up.
Reflecting Feelings and Paraphrasing
These two techniques are powerful in building trust. Reflecting feelings means naming the emotion you hear: \"You sound worried about the exam.\" \"You feel dismissed because no one explained what was happening.\" Paraphrasing means restating the content in your own words: \"So you want to try laboring without an epidural first, but you want to know it is available if you change your mind.\" Both techniques tell the survivor: I hear you. I understand. You matter.
Open-Ended Questions
Open-ended questions cannot be answered with yes or no. They invite the survivor to share their experience. Compare: \"Are you going to breastfeed?\" (closed) with \"What are your thoughts about feeding the baby?\" (open). The closed question stops conversation. The open question invites it. For survivors who have learned to give the answer authority figures want to hear, open-ended questions signal that their actual experience is what matters.
Barriers to Effective Communication
Three categories of communication routinely shut down trust with survivors. Judgment: Evaluating, approving or disapproving, criticizing, labeling, blaming, asking why, interpreting, or psychoanalyzing. When survivors feel judged, they feel inadequate, angry, or guilty. They become defensive. Giving solutions: Advising, ordering, directing, warning, moralizing, or recommending. This is a common trap for authority figures. It does not allow the survivor to fully explore what is concerning them. Avoidance: Becoming distracted, dismissing concerns, joking, interrupting, minimizing with false reassurance, or changing the subject. When a survivor has strong feelings, these behaviors leave them feeling unheard, discounted, or angry.
Good and Bad Communication: Three Examples
The book \"When Survivors Give Birth\" illustrates how communication can go wrong or right between a survivor and her care provider. The pattern is consistent: when the provider listens to the meaning behind the words rather than reacting to the surface content, the relationship deepens and the survivor feels safe. When the provider dismisses, judges, or minimizes, the survivor shuts down or becomes defensive. Below are three common scenarios.
Scenario One: The Birth Plan
A survivor brings up her birth plan and expresses concern about episiotomy. A poor response: \"I do not do them unless necessary, but you have to understand we cannot promise you exactly what your birth will be like.\" The survivor hears dismissal and feels she cannot trust her provider. A good response: \"I am glad to hear you are working on that. Can you tell me what concerns you most about episiotomy?\" The survivor says it feels like mutilation. The provider responds: \"I can understand why you would feel that way. Let me explain the situations where I would recommend one, and we can work together to minimize the chance.\" The difference is listening before responding and validating the feeling before addressing the clinical reality.
Scenario Two: The Distressed Teen
A young survivor becomes distressed and unable to proceed with a vaginal exam. A poor response: the provider holds her legs apart and tells her to relax while her mother holds her hand. The survivor feels re-traumatized. A good response: the provider stops, names what she sees: \"This seems very upsetting to you. I will not force you to have the exam.\" Then she asks gently: \"In my experience, many young women who have had unpleasant sexual experiences have trouble with vaginal exams. Has anything like that ever happened to you?\" This question, asked with genuine care, opens the door to disclosure without pressure. If the survivor confirms, the provider can proceed at the survivor's pace, with her directing each step.
Scenario Three: The Previous Traumatic Birth
A survivor with a previous traumatic birth wants a planned cesarean. A poor response: the provider lists reasons why VBAC is safer and dismisses her fear. The survivor feels unheard and trapped. A good response: \"Tell me about your first birth. What was the hardest part?\" After listening, the provider acknowledges: \"It makes sense that you would want to avoid going through that again. Let me explain what would be different this time if you chose to labor, and then you can decide what feels right.\" The survivor may still choose cesarean, but she will feel heard and respected either way.
Informed Consent versus Informed Decision-Making
Informed consent is the minimum standard: the provider describes the procedure, alternatives, and risks, and the patient agrees. Informed decision-making is a higher standard. It includes seven elements: discussion of the patient's role in decision-making, discussion of the clinical issue, discussion of alternatives, discussion of potential benefits and risks of alternatives, discussion of uncertainties, assessment of the patient's understanding, and exploration of patient preference. For survivors, informed decision-making is essential because it restores the sense of agency that abuse took away. When a provider truly engages in shared decision-making, the survivor experiences something new: a powerful person treating her as an equal rather than an object. This alone can be healing.
Responding to Disclosure
If a survivor discloses their abuse history to you, how you respond matters enormously. Helpful responses: calm concern (\"I am glad you told me. This helps me understand how to care for you better\"), acknowledgment of the difficulty of disclosure (\"That takes a lot of courage\"), and reinforcement of control (\"I do not need more detail than you are comfortable sharing, but please let me know if something I do or say brings up those memories\"). Unhelpful responses: shock or disgust, intrusive curiosity about details, minimizing (\"That was a long time ago\"), blaming (\"Why did not you tell someone?\"), or rescuing (\"I will make sure this does not cause you any more problems\"). If you respond with calm, steady presence, the survivor learns that their story is safe with you.