Someone who is a survivor of childhood abuse has written this article, which was first published on Dental Fear Central. Although this article refers to childhood abuse, the same responses and fears may be experienced by people who have been assaulted or raped as adults.
When I looked at other web pages for people who are frightened of dental treatments, I found they mostly talked about fear of needles or fear of pain.
Abuse survivors may feel fears similar to other people, such as fear of needles, fear of pain etc., but if you are like me, you won’t be frightened of those things.
For many abuse survivors, there are other issues such as:
- Having to lie down for treatment
- Having objects put into your mouth
- Dentist’s hand(s) over your mouth / nose
- Fear of not being able to breathe
- Fear of not being able to swallow
- Fear of severe gagging / being sick
- Worried that the dentist may get “cross”
For me personally, the things I find difficult, if not impossible, at the dentist are:
- Lying down (impossible)
- Having a rubber dam placed in my mouth (impossible)
- Having impressions taken (very difficult)
- In-the-mouth x-rays (difficult)
- Fingers / hand(s) over my nose (difficult)
And, I worry a lot that I might lose it and become/behave like a frightened small child, and what will my dentist and nurse then think of me.
You may not wish to tell your dentist that you were abused as a child, and there is no need for them to know. A reasonable dentist will respect their patient’s wishes, will be led by their needs without needing to know how and why these arose.
However, dentists are not mind-readers, and it is reasonable for them to think patients are afraid of needles and pain. So, if you need to sit up and not lie down, then let your dentist know. If he cannot treat you unless you’re lying down, look for someone who can.
When choosing a dentist, you may also want to think about whether you’ll be more comfortable with a male or a female dentist.
If you read through the other pages on this website, you will find many useful suggestions that I will not re-iterate here. Just remember that you are not unique or peculiar – and that most dentists are genuinely kind and caring and want to help.
With regards to embarrassing behaviour…, if you read on, you’ll find in the following section I’ve included examples of times when I’ve felt embarrassed, wished the ground would open up and swallow me, felt that I can’t ever go back – but I did go back and it’s been o.k.
If you’re reading this as a dentist, your patient is unlikely to disclose that they were abused as a child (there may be a few exceptions to this – and I will say more about this later). Therefore, from your perspective you only know that you have a patient who seems to be especially fearful, may have some “puzzling” fears and exhibit some “unusual” behaviour.
The following tips are therefore helpful when dealing with any patient who seems fearful. Time may be an issue, especially if you work within the NHS (or a similar public health service outside the UK). But you may be able to implement the suggestions in the “Quick fix” paragraph (near the end of this section). Remember that every patient is different, and what may work for one patient may be wrong for someone else.
Many dentists tell their patients to raise a hand/finger if they want the dentist to stop. Agreeing a pre-arranged signal can be re-assuring for patients. However, many abuse survivors find it impossible to give any kind of “stop” signal. They may then come across as an exceptionally compliant patient, sitting or lying completely still and not moving a muscle.
One useful clue will be your patient’s breathing: quick shallow breaths, irregular breathing, stop/start breathing are all signs that your patient needs you to stop and take a break, even if they have not raised their hand/finger.
Similarly, your patient may make a small movement or a small sound, but when you ask them if they are alright, they do not respond. You ask them again if they are o.k., but there is still no reply. You may then feel tempted to carry on. However, your patient is not responding because they are so frightened that they have literally lost the ability to speak, and they can’t nod nor shake their head.
In both situations, it is better for your patient if you can stop and calm them down before you continue.
Calming the patient
Your patient may have been able to tell you before you started treatment what helps them to calm down. If that was not the case, then it’s a question of “trial and error” to see what works.
In my case, I like it if my dentist puts his hand on my shoulder or gently rubs my arm, keeps eye contact and tells me to “take deep breaths with sighs on the end” (and then tells me when to breathe in and out). Three or four deep breaths later, and I can speak again and don’t feel frightened any more. (This works for me – as a patient, think about what would work for you.)
Other things to watch out for:
- Spontaneous tears (no accompanying sobs or sounds, just tears leaking from your patient’s eyes).
- Your patient may be unable to tell you if the treatment becomes painful (but their breathing may become irregular – see above).
- Observe if your patient keeps eye contact. For some patients this is very important. They will “stare” at you throughout, and follow you with their eyes, and may become distressed and fearful, if you move and eye contact is broken. In those instances when you have to move out of your patient’s field of vision, or for some reason you have your back to them, you could talk to them so they don’t become distressed by not seeing you anymore. Some patients close their eyes, or look away during treatment. It is then especially important to keep talking to tell them what you’ll be doing next.
- Dissociation (see article by Dr Carmen Santos)
- Extreme startle response
Extreme startle response
Many abuse survivors exhibit an extreme startle response to sudden noises and movements. Growing up, it would have been vital for your patient to be extremely alert. The startle response is an instinctive response to a perceived danger signal and therefore very difficult to “unlearn”.
There are three main systems in our brain: cortex, limbic, and brain stem. The highest level is the cortex, which is our “thinking” part. The limbic system deals with feelings, and the brain stem handles survival instincts, such as the startle response. Brain functions are linked to stress levels. When we are relaxed, we can think more clearly. The more stressed we are, the more likely it is that we respond from our brain stem, which is triggered by anything we perceive as a “danger” signal. The brain stem reacts more quickly to stimuli than the cortex. So, if your patient suddenly “jumps”, use your calming down techniques (talking gently, making sure they are breathing, reassuring them) and give them a few seconds so that the “thinking” part of their brain can catch up.
Your patient may also “jump” and become distressed if someone suddenly enters the room. When someone entered their room as a child, it may have well been a “danger” signal. In a large dental practice, it may be quite common for someone to come into your room to drop something off, or ask you or your nurse a quick question. This can be very upsetting for abuse survivors, who will be fearful of a stranger coming in, when they are in a very vulnerable position in the chair. Whilst it may not be possible to stop people from coming into your room, you can make this less upsetting for your patient, by explaining who the stranger is: “Don’t worry; this is just Lucy dropping off the post.” It may also be helpful if you can stop whatever you are doing until the stranger has left the room.
Being hyper-alert means that chemicals such as adrenaline and noradrenaline are released in your patient’s body. These can interfere with any anaesthetic you are giving your patient. You may find that you need to give more anaesthetic than usual. But when your patient leaves your surgery and then calms down, they may experience increased numbness.
It has been the case for me that I’ve been able to feel the dentist drilling into my tooth, but shortly after leaving the surgery found half the side of my face going numb, spreading up and around my right eye, and including my nose and my tongue, making swallowing uncomfortable.
It may be helpful if you warn your patient that this may happen so that they don’t feel too alarmed on the way home.
It can also be difficult for abuse survivors to give straight answers to even simple questions. When growing up, your patient would have had to try and anticipate the “correct” answer to any question posed by their abuser, because giving the “wrong” answer would have had painful repercussions.
Being in the dentist’s chair may bring back powerful memories and emotions of the abuse and your patient may slip into their “child-self”. If you then ask a question, your patient may automatically fall back into trying to anticipate the “right” answer.
To give you an example: When a check-up revealed that several of my teeth needed treatment, my current dentist asked me if I preferred long or short appointments. Feeling very much like a small child at the time, I automatically thought that my dentist must hate me and would therefore prefer to see as little of me as possible, and hence the “correct” answer to the question had to be to ask for long appointments. (That way, he would have to see me less often, than if I asked for short appointments.)
When I left the surgery and was able to think clearly again, I could not believe I had said that, because I much prefer short appointments! It took three days before I plucked up the courage to telephone and ask if I could leave a message for my dentist to say I’d changed my mind and could I please have short appointments. Unfortunately, my dentist didn’t get the message, and when the treatment plan arrived in the post, it listed long appointments. It took another week before I felt able to write a short letter asking if the appointments could be changed. And the next time I saw my dentist, I was absolutely convinced that he’d be cross with me for changing my mind.
When you ask your patient a question, you can’t be expected to be a mind-reader, and somehow know if they are giving you a straight answer. But whatever answer you are getting, you may be able to make an additional comment along the lines that it’ll be o.k. if your patient changes their mind later, and all they have to do is to let you know. That way, if your patient gets home, and realises they behaved like a child and didn’t actually say what they needed, they will feel reassured that they can contact you to get things straightened out. Otherwise, in extreme cases, your patient may feel that matters have now got into such a muddle, that they can’t come back.
It may be your usual practice to have your nurse or receptionist/secretary respond to letters or telephone messages. If your workload permits it, it can be very helpful for patients who are abuse survivors if you reply personally to them rather than delegating this. It takes a great deal of courage to “ask” for anything; subsequently they may feel “stupid” and worried that their dentist will now be cross with them. If you can find the time to respond personally, this can be very reassuring that all is well.
Talking to your patient
Abuse survivors are rarely great conversationalists (for a number of reasons – but there is no space here to go into this). Therefore you may find it hard work to keep a conversation going with your patient as you wait for the anaesthetic to start working or for the x-rays to come back, and you may feel sorely tempted to do something else or chat with your nurse.
Can I suggest that you persevere? If you ignore your patient, they may start to worry again that you don’t like them, wish that they weren’t there, are cross with them – you get the idea. So, try out a few topics to see what works – and it’ll get easier over time, as your patient gets to know you more. In my case, I don’t like to talk about family, holidays, hobbies, as this feels too personal. But I can talk quite happily for hours about my job (which I think is terribly interesting and fascinating, but which probably puts others to sleep).
Being empathetic and understanding
As I wrote above, being in the dentist’s chair may bring back powerful memories and emotions of the abuse and your patient may slip into their “child-self”. Behaving like a small, frightened child, your patient may try to hold onto your hand or even lean against you. (I did this once when my previous dentist had to take impressions.) Understanding this will enable you to be gently reassuring, as you would be with any actual child patient.
Whatever behaviour your patient has exhibited, once the treatment session is ended, and your patient recovers their “adult self”, they may feel very shamed and embarrassed by their previous behaviour. This may include feeling that they can’t possibly come back for further treatment, because they can’t look you and your nurse in the eye again. It can therefore be very helpful if you can be as matter-of-fact and reassuring as possible, and at the end of the session tell your patient that you look forward to seeing them again.
If your patient behaves “oddly” and your response to this is not respectful and understanding, they will feel stupid and shamed. Patients who are abuse survivors still want you to talk to them and discuss their treatment with them.
In the example I gave above, my previous dentist convinced me that she had to hold patients leaning against her pretty much every day of the week, and this was entirely normal and nothing out of the ordinary. Whilst I did not fully believe this, her matter-of-fact reaction helped me to return for further treatment.
If you did all of the above with all of your patients just in case one of them was an abuse survivor, you wouldn’t be able to see many patients. Clearly, it isn’t possible to do all of the above all of the time.
However, I’d like to think that the following are fairly simple and can be fitted in even if your schedule is very busy:
- Asking your patient if they want to sit up or lie down for treatment (and telling them they can change their mind later if they want to…)
- Having a soft blanket handy that you can offer to your patient each time before you start treatment is also easy to do. (You can probably imagine how extremely difficult it will be for a patient to tell you that they were sexually abused as a child and now feel naked whenever they sit in the dental chair, and then ask you if they can please have a blanket). Where cross-infection control regulations don’t allow this, let your patient know that they can bring a blanket along if they like.
- Keeping an eye on your patient’s breathing is also fairly simple. Offering reassurance and helping someone to breathe properly again also does not take a great deal of time.
- Praising your patient, especially at the end of the session, is also quick and simple, and goes a long way to reassure your patient that you are not cross, annoyed and irritated with them and that they can come back.
Making a difference
If, every now and then, you are able to take a bit more time with a patient when you think you recognise the signs that someone is an abuse survivor, you are likely to make a HUGE difference in someone’s life – not just to their oral health but also in contributing to healing the whole person.
At my first appointment with my current dentist, he gave me a special card with his home telephone number on it. He said that knowing how difficult dentist visits are for me, he didn’t want me to have to deal with an unfamiliar dentist in an emergency. I was completely amazed at this act of kindness.
My current dentist also cleans my teeth, so that I don’t have to see the hygienist, and I greatly appreciate this.
At my previous dentist, I once had to undergo a complicated procedure. When I arrived, the dentist told me that today neither she nor the nurse would be able to hold my hand or touch me in any way because they couldn’t risk transferring germs to my mouth. However, she had arranged for a second nurse to be present, whose only job that day was to hold my hands. I was immensely touched that my dentist had clearly thought very hard how to make me comfortable and had gone to so much trouble.
Abuse survivors often feel full of shame, believe that they are dirty and disgusting, and can’t imagine that someone would be prepared to bother with them. Coming across someone – you – who genuinely wants to help and is kind, gentle and non-judgmental can make an enormous difference.
Why tell me?
I mentioned at the start of this section that your patient is unlikely to disclose that they were sexually abused as a child, but that there may be a few exceptions to this.
If one of your patients does tell you that they were sexually abused, you may not know how to respond and wonder why they are telling you of all people; after all, you barely know them and only see them a few times a year at most.
This may be precisely why they chose you as someone to tell! Many abuse survivors go through life fearful that anyone finds out their secret. As a child, it is likely that their abuser told them never to tell. If they did tell someone, it is likely that they were not believed, and that “telling” had disastrous repercussions. As adults, many abuse survivors feel full of shame, often guilty, believing that the abuse was somehow their fault, and that anyone who finds out will be repulsed. Therefore, those closest to them, such as a spouse, may not know that their partner was abused as a child. Past abuse can affect many aspects of your patient’s life today, and they may have made a decision that they want to change that. This may include being (more) open about their past, i.e. talking about it.
If they talk to you about it, they are obviously hoping that you react positively. But they have probably also chosen you, because – no offense – you are not very important. If you react badly to what they are telling you, it is not that difficult to replace you and find another dentist. If they tell someone close to them, and that person reacts badly, that’s much harder to deal with. In telling you, they may simply be trying to see what happens if they tell someone now.
You may still be left wondering what to say to your patient in those circumstances. It’s probably best not to interrupt while they are speaking. Your patient will be very nervous, and they have probably “practised” this at home and just want to get to the end of whatever they have decided to say. You may want to respond with something along the lines of: “I am very sorry that happened to you. And I am very glad that you felt able to tell me. Is there any way I can help now?”
I hope this section has answered some of the questions you may have asked yourself about some of your patients. Understanding the particular difficulties and needs of a patient who was abused as a child, and knowing how to respond to these, will make visits to the dentist as comfortable as possible for both patient and dentist.
If you found this article interesting, you might also like to read: Sexual Abuse and Dental Fears: An Interview with Dr Carmen Santos