Sense of safety: a whole person approach to distress in primary care

Abstract

Listen

Translate article

Distress is an everyday experience of both clinicians and patients in the primary care setting. At present, assessment of distress is constrained by disciplinary symptom-based approaches that fragment care, spawn confusing comorbid diagnostic categories and promote cure-focussed use of medication. This approach ignores the complex primary care priority of caring for the whole person and the robust research confirming the interconnections between mind, body, community and environment. Primary care assessment of undifferentiated distress requires an understanding of the whole person, their inner experiences, relationships and context.In this thesis, I investigate the concept of Sense of Safety as transdisciplinary whole person experience that may help both clinician and patient to appraise distress in primary care. The term distress focusses clinical reasoning on the complex task of understanding the experience of the whole person, rather than on disciplinary or symptom-based diagnostic categories. The term Sense of Safety emerged from clinical intuition and insights from the trauma and attachment literature about the modulating effect of safety on child development and adult experience of distress. In this thesis I propose that Sense of Safety is fundamental to understanding both the aetiology of distress, the logic of defences against threat and danger, and to understanding innovative ways to care for people in distress.Transdisciplinary methodology used in this research includes respect for both observed and experienced knowledge of stakeholders and academics. Alignment of transdisciplinary and generalist philosophy and practice is explored and contributes to research design and focus on translation of these ideas into practice. Research included a transdisciplinary conceptual literature review, stakeholder consultation and iterative reflexive academic review. Key stakeholders included patients, indigenous academics, experienced general practitioners and multidisciplinary mental health clinicians. Consultation included semi-structured interviews, and focus groups using written and verbal feedback mechanisms. Academic review included formal consultation with an international multidisciplinary advisory panel, as well as presentation to international research groups and discussions with a subset of international advisors.The conceptualisation of Sense of Safety developed from integration of analysis of these consultations and iterative feedback with transdisciplinary literature. This led to an understanding of Sense of Safety as a process of appraisal that includes concurrent and interconnected awareness of self, other, and context. This included awareness of both processes (that have become known as Sense of Safety Dynamics) and content (that have been defined as Sense of Safety Whole Person Domains) that build, maintain, and reveal an experience of Sense of Safety. This understanding also included an awareness of the contribution of both appraisal and coping systems to the whole person experience of Sense of Safety. The transdisciplinary literature also confirmed the physiological impact of experiences of safety or threat on health. These insights broadened understanding and offer innovative ways forward to care for the whole person in distress in primary care.Appraisal of Sense of Safety has the potential to become a shared language, a collaborative goal, and a broad map for whole person care of distress. It could be developed into alternative outcome measures grounded in the whole person experience of safety. It could raise awareness of accuracy of appraisal systems, and increase focus on coping resources for living. The concept of Sense of Safety could help primary care clinicians to offer congruent care that does not fragment understanding of the whole person in distress. Future research could focus on practical translation of these ideas into the primary care setting.