Correcting Misconceptions of Trauma-informed Care with Survivor Perspectives

Trauma-informed approaches have the potential to promote recovery but must involve survivors and service-users to prevent the experience of retraumatization within psychiatric and mental health services

Zenobia Morrill
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Researcher and survivor Dr. Angela Sweeney collaborated with Dr. Danny Taggart on a new editorial, published in the Journal of Mental Health, outlining both the misconceptions and central principles of trauma-informed care. They draw attention to the primary drivers of trauma-informed approaches and the necessity of integrating survivor perspectives and systemic social justice considerations into this movement.

“Despite growing international interest, trauma-informed approaches can seem fuzzy, complex, something that service providers already do, or a theorised call for practitioners to ‘be nicer,’ Sweeney and Taggart write. “However, writing as trauma survivors and academics/clinician, the more we learn about trauma-informed approaches, the more we argue that these approaches have the potential to lead to a fundamental shift in how mental health services are organised and delivered, meaning that they are better able to meet the needs of service users.”

Photo Credit: news.stlpublicradio.org

Sweeney and Taggart highlight recent research that connects mental distress and suffering to trauma. A large body of literature documents this connection and finds that many people receiving mental health services have experienced traumatic events. Research supports the theory that traumatic experiences are causal in the subsequent development of distress and that the manifestation of distress can be contingent upon the severity, frequency, and range of adverse events experienced. For instance, recent studies have called attention to the strong relationship between childhood trauma and the later development of psychosis symptoms.

In addition, those in socially disadvantaged groups, such as racial and ethnic minority groups, more commonly experience traumatic events. Social factors, such as poverty and racism, are also considered to be forms of trauma. Therefore, minority group members are not only more susceptible to experiencing traditional forms of trauma, they are exposed to daily forms of social trauma, the authors explain.

Sweeney and Taggart outline the three key drivers of trauma-informed approaches. The first is that childhood trauma has been so closely linked to later psychological distress. The greater the number of adverse experiences one is exposed to, the worse the prognosis, researchers have found. Traumatic events have been seen to correspond to higher levels of engagement in self-harm and suicidality as well as a greater likelihood that one will later access mental health services.

Sweeney and Taggart write on the prevalence and significance of trauma experienced by service-users and cite a systematic review that estimated that around half of mental health service users have experienced physical abuse, and more than one-third have experienced sexual abuse. “Although these rates are not surprising from a biopsychosocial perspective,” they write, “the rates of trauma and abuse experienced by people who go on to use mental health services are worthy of attention at a service development level.”

The second driver speaks to the harm incurred by service-users within psychiatric systems. Iatrogenic harm, or the harm caused by treatment, has been observed in psychiatric systems that feature practices described as “predicated on coercion and control,” the authors write. Such power abuses often replicate a “parallel process” to the trauma that originally contributed to service-users’ distress.

Sweeney and Taggart write that “evidence for the (re)traumatising effects of mental health services include: increased use of coercion among black and minority ethnic groups, the effects of restraint and seclusion in inpatient settings, and exposure of inpatients to violence, invalidation and disrespect.”

“By recreating abuse through ‘power over’ relationships, services can revictimise service users, preventing recovery,” they write. “This highlights the need for psychiatric services to do the opposite of trauma: from fear to safety, from control to empowerment, and from abuse of power to accountability and transparency.”

The third driver of trauma-informed approaches has arisen out of the knowledge and organizations led by trauma survivors. Their contributions have pushed for psychiatry to reexamine the ways in which it may be obstructing recovery through retraumatization. Sweeney and Taggart feature the writing of trauma survivor, Beth Filson who wrote of her experiences:

“I knew that what I was experiencing made sense given what had taken place in my life. Even then I understood my reactions as sane responses to an insane world. I was told, whatever else might be going on with you is not relevant – it’s your mental illness that matters. This drove me into a frenzy, for now, help was just another perpetrator saying, you liked it, you know you did; that wasn’t so bad; it’s for your own good.”

Trauma-informed approaches, however, are services organized around preventing re-traumatization, the authors contend. The authors outline the following eight principles that underscore trauma-informed care:

  1. “Seeing through a trauma lens, meaning that there is an understanding and acknowledgment of the links between trauma and mental health.
  2. Adopting a broad definition of trauma extending beyond PTSD, including recognizing social trauma and the intersectionality of multiple traumas.’
  3. Making trauma enquiries sensitively and with knowledge about how to respond.
  4. Referring people to evidence-based, trauma-specific support, where indicated.
  5. Addressing vicarious trauma and retraumatisation (e.g., through a reduction in the use of control and restraint).
  6. Prioritizing trustworthiness and transparency in communications, such as limiting the number of professionals to whom a person has to repeat their traumatic history.
  7. Moving towards collaborative relationships and away from helper– helpee roles based on trust, collaboration, respect and hope.
  8. Adopting strengths-based approaches that reframe symptoms as coping adaptations, e.g., dissociation as an adaptive strategy to escape unbearable experiences.”

The authors address numerous misconceptions and misunderstandings that remain about trauma-informed approaches. For example, some believe that trauma-informed approaches put forth the notion that all service-users have experienced trauma. Sweeney and Taggart clarify that trauma is not understood to be at the root of all mental distress. However, employing trauma-informed interventions, they argue, ensures appropriate care for the majority of service-users who have experienced trauma while also providing gold standard care to service-users for whom this is not the case.

Similarly, trauma-informed approaches are not specifically and exclusively oriented toward people who have experienced trauma, Sweeney and Taggart write. For some trauma treatments such as EMDR, this may be true. Trauma-informed approaches, however, “are a whole-systems approach within which staff would be knowledgeable in referring on to trauma-specific services, where this is wanted,” the authors write.

Sweeney and Taggart also address the misconception that a shift from the biomedical approach which asks: “What’s wrong with you?” to a trauma-informed stance which asks: “What’s happened to you?” is not a literal shift. Instead, “this is intended as an orienting shift,” they write “rather than a literal one; it is not intended to suggest that everyone should always be asked what happened to them, or that no-one is currently asked their life history.”

The authors emphasize that trauma-informed approaches operate at a whole systems level and therefore ought to be implemented by organizations and individual practitioners alike in order to function optimally. Finally, they address what they believe may be the most harmful misconception:

“Perhaps the most damaging misconception is the belief that this is what practitioners do already. Although many practitioners do work in trauma-informed ways, and a number of organizations are implementing trauma-informed approaches, we know that within the UK for instance, people are often not equitably involved in decisions about their care that Community Treatment Orders are used extensively, with a year on year increase of 10%; that the use of restraint in inpatient settings is widespread, with adverse outcomes including risk of death; and that people voluntarily on inpatient wards are subject to the same loss of autonomy as those under section.”

Sweeney and Taggart do not fail to also address the pitfalls of trauma-informed approaches. For example, they warn that these approaches cannot simply be used to replace the medical model dogma with another universal dogma offering trauma-only explanations.

“Although the notion that all service users have experienced trauma is a misconception, there nonetheless remains some concern that an overly determined emphasis on the relationship between trauma and mental health could position service users primarily as victims, limiting our access to other, less vulnerable identities,” they explain.

Service-users must be given the opportunity to develop their own narrative rather than having one imposed by practitioners. Additionally, recent literature highlights the neurological underpinnings of trauma. Sweeney and Taggart caution against the co-opting of already-existing, one-size-fits-all treatments that are repackaged under the guise of trauma-informed treatments. This outcome would not demonstrate a bonafide effort to reduce power abuses, but would simply recreate them.

“In attempting to do differently, trauma-informed approaches have the task of providing reparative healthcare in times of economic austerity, responsibilisation and time-limited treatments. The responsiveness and patient control in trauma-informed approaches requires negotiated and flexible service design, which at the same time cannot equate to limitless care.”

It is important, the authors maintain, that trauma-informed approaches are driven by social justice considerations and include the implications of social discourses beyond psychiatric knowledge.

“‘Trauma’ as a category, therefore, has political and social implications, as well as psychiatric ones, and mental health services not only need to change their practices, but to engage with communities where trauma occurs and groups identifying as trauma survivors.”

Centering survivor knowledge in the future development, research, and implementation of trauma-informed approaches is critical, they write, because with their lived experiences, survivors intimately understand the importance of reversing power abuses. Furthermore, they do so through the process of grassroots efforts organized to change services and promote recovery.

 

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Sweeney, A., & Taggart, D. (2018). (Mis) understanding trauma-informed approaches in mental health. Journal of Mental Health. DOI: 10.1080/09638237.2018.1520973 (Link)

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28 COMMENTS

  1. It’s too bad that “Mad in America” isn’t trauma informed. Sure, they post *British* articles like this one. But America is NOT England, nor is it the United Kingdom. NOBODY in America has EVER been “sectioned”. But “sectioning” happens every day in the British Isles. “Sectioning” is most severe in England. English “sectioning” always results in either re-traumatizing trauma victims, or initiating first trauma in the trauma naive. Here in America, where “Mad in America” sometimes traumatizes those who comment, we say “court ordered”, or “involuntary”, or “forced”, and use euphemisms such as “ACT”. “ACT” is a buzzword dog-whistle whose letters stand for “Assertive Community Treatment”….
    But the larger take-away from this article is that so-called “mental health treatment” in general, and psychiatry and psych drugs in general, too often do more harm than good to already traumatized, so-called “mental patients”
    I know that *I* sure feel re-traumatized just from reading this article.
    But that’s also partly because my incest-trauma inflicted friend has been thrown in the State loony bin again by the local “Community Mental Health Center”, and forced to take brain damaging drugs because that’s what “they” think she needs. “They” are NOT trauma-informed!
    Psychiatry has done, and continues to do, far more harm than good.
    The above article simply proves that point.

  2. a shift from the biomedical approach which asks: “What’s wrong with you?” to a trauma-informed stance which asks: “What’s happened to you?” …

    Why don’t they take one more step by asking “How can we help you?” ?

    These hospitals claim their intended goal is to stabilize people and send them on their way so why do they continue to circumvent a patients right to undisturbed rest with the early morning blood pressure checks ?

    Lack of sleep is the common denominator amongst almost everyone who enters inpatient psychiatry, why in the world would you rudely wake up “manic” and “psychotic” people who are finally getting the sleep they need stabilize and recover why would you rudely have the goons come in an wake them up early in the morning when they are finally sleeping soundly ?

    “If you get up early at night you will be tired” Says the clueless simpleton morons. It doesn’t work that way, the stress of sleep disruption and artificial and rude wake up only prolongs the mania and psychosis by exacerbating the anxiety and insomnia that causes it. As Illogical as it sounds the stress of sleep deprivation makes insomnia worse as you become ‘to tired to rest’. That’s how the snowballing bad feedback loop that causes what they call mania works.

    That BS they do waking everyone up is like the best proof they don’t know a damn thing about the brain, mind and mental illnesses. Or maybe just don’t care as long as the money making wheels of their institution keep turning.

    “What’s happened to you?” I had a total nervous breakdown over ______ and haven’t slept in days. “How can we help you?” Leave me the hell alone in the morning with your goons and blood pressure checks designed intentionally to circumvent a patients right to undisturbed rest because until I get some long undisturbed REM sleep my mind wont work right.

    How is that from a survivor prospective ?

    • Yeah, that’s why that BS about “Anosognosia” or whatever really steams me! The basic attitude is, “We know what you need, and even if you say it’s not helpful, it’s because you don’t understand yourself. So just do what I say and shut up.” About as arrogant and authoritarian as you can get.

    • I’m so amused by this because I recall how the nurses never actually took an accurate pressure from me anyway because my blood pressure is usually low enough to scare the bejeezes out of them. Totally normal for someone who’s had very low bp my whole life, it runs in the family. But they’d never accept the first pressure, always saying I had to walk around for a few minutes and drink some juice or soda to increase my pressure. One nurse flat out said she’d be fired for not calling a medical emergency if she reported a pressure that low in my chart. To be fair, it was like 55/42. But with a normal pressure of 80/60, it can dip quite low when I’m resting. But there is no rest after they get a reading like that… And the funniest part about it is the higher pressure they then get as a result of completely stressing me out are not in the slightest bit accurate. And they know that. But it’s far more important to them to cover their ass than report accurate readings. And of course, it made me look like an idiot when I finally ended up needing a regular cardiologist – he looked back through my hospital records and assumed the low readings they got in his office were a new issue because what has been recorded in my charts has routinely been a second or third reading. Actually, having typed this all out, I’m convinced this is malpractice but experience tells me no one cares.

    • One more thing, Cat, this wake up routine is common practice in prisons as well. Supposedly for control and security, but it no surprise that the prison environment has so many people drugged and in treatment regardless of whether they had mental distress before imprisonment.

    • @”the_cat”:
      Yes, what we have now is a process-centered process, and a system-centered system.
      What we NEED is a person-centered process, and a services-centered system.
      Only then can we ask, “What can we do for you?”….
      But I still say that the trauma-informed “What happened to you?”, is a good first step.
      Psychiatry and psych drugs can NEVER get beyond “what’s wrong with you?”, because they will NEVER ask or answer any other questions….
      And as for psychiatry’s “answer” of potent, neuro-toxic psych drugs? Well, *WE* know….

  3. Sorry but I think this is important.

    “causal” not “casual”

    “traumatic experiences are casual in the subsequent development of distress”

    I’m not a grammar nazi – but I kept re-reading the sentence and it took me awhile to figure out that’s what (I believe) you meant.

    • Good point JanCarol. This is a good article but I also did a double take and re-read regarding “casual”. Dictionary defines “casual” in terms of ‘by chance, unexpected or unforeseen’ so I wondered about this. This is important so hopefully if it was meant to be “causal” instead of “casual” it can be corrected.

  4. I want to feel some hope that trauma-informed care might make some difference, but my personal experience of several admissions to a medium-term trauma disorders unit suggests otherwise. I have found little difference between regular psychiatric units and the prestigious trauma unit I went to – more art therapy, same blaming the victim tactics. I put in 12 72-hour notices in 7 weeks, begged them to let me go home. Finally they let me go a few days after I attempted suicide on the unit, but only after the director of the unit personally screamed at me for several minutes in his office. I recently came across the Medicare Lifetime Reserve Days Waiver form I had to sign to get in and the $55,000 bill for the stay. Trauma-informed or not, it’s still the Hotel California until either your insurance runs out or you become a liability.

  5. I feel that this kind of research errs on the side of being too kind to psychiatry. That may be strategic, a kind of “soft reply turneth away wrath” People who are too defensive wont listen etc., so I don’t know if these researchers have really not grasped how damaging psychiatry is.

    I was a traumatised child in tremendous pain. The “branch of medicine” that supposedly helps people in my situation was not just insensitive but more abusive than the situation that caused me to be suffering. The only appropriate kind of analogy would be something like going to a hospital with a broken leg and having the staff jump on it – some of them smiling and enjoying the opportunity to inflict more pain on someone who could not fight back, others oblivious to the humanity of the patient, and thinking that such sub-humans are incapable of feeling pain and that it is important to not be fooled into thinking that anything this object says has any validity.

    So you get worse, which means that leg hasn’t been jumped on enough. Once you are unable to walk, you have proven the pre-existing hypothesis that the leg was inherently useless and you will need crutches for life. (If only psych treatments were as benign as crutches) In addition you have learned to fawn in response to abuse. To say thankyou and otherwise shut up about suffering forever, and to never expect compassion. This was my experience. An alternative route is to learn to play the system, which is adaptive but even more disastrous. It means that rather than crawling away, the individual is more likely to keep going back. There is no blame here, people manage such abuse however they can. It is the nature of being abused and powerless that no response can ever ‘work’ for the person on the receiving end.

    It is traditional to see the original abuse as the only substantial injury and I think this is where many subsequent non-psychiatric helpers get stuck. It is too challenging to confront the fact that a person in distress being punished with abuse is the primary harm, and they’d rather hear about almost anything else. How can anyone be helpful if they are too personally confronted by the fact of psychiatric abuse to be able to hear about it and respond appropriately?

    • As soon as I see language which talks about “approaches” my instinct is to go to the next article, as the implication is that there is a “mental health” power relationship involved, and that the situation has been medicalized from the start. After all, what is “it” that we are “approaching”?

      It is also problematic when “survivors” are considered adjuncts to “treatment.” If one is a “survivor” why would he/she agree to be dragged back into the same paradigm that has supposedly been “survived”? Is “survivor” the new term for “consumer”?

      • I don’t believe psychiatry can be reformed into something non-abusive. I don’t believe the way things are is accidental – this is social control – a gulag for “patients” and a dire warning to everyone else. One of the most telling facts is that the same profoundly abusive cultures are found between regions and between countries. This is independent of the drugs and other “treatments”.

        Fact is though, there are people in there. God knows how many world-wide, so it still matters to me what happens to those people. those people aren’t just grist to some revolution mill.

        I don’t want there to be more kindness. Adding random bits of faux- kindness to abuse leads to trauma-bonding, a specially pernicious form of compulsive attachment to a source of abuse. I want those who are pushing for trauma-informed approaches to concentrate on removing harms, so that those who get out are less damaged by their time in.

      • I believe that survivor came first and now we’re “consumers”. I suspect that we ourselves chose the word survivor and I know for sure that the system chose “consumer”; I don’t think that they liked the idea that when you survive it’s usually something awful or horrible or difficult. “Consumer” is so much more bland and acceptable and it makes it seem as if we’re truly participating in the system out of free choice. I’m not a “consumer” when I’m forced to buy or use something. I never have used the word and never intend to. I’m a survivor, plain and simple.

        • Actually “psychiatric inmate” came first historically speaking, then “consumer” (of “mental health services”) was substituted when opportunistic people from within our ranks sold out the movement to the psychiatric industry. Some also called themselves “victims” or “survivors” of psychiatry, but at the height of the movement “psychiatric inmate” was the predominant term.

          I was under the impression that we had all finally dispensed with the term “consumer” as a vestige of a very dark period for the movement. If you haven’t I highly suggest it!

    • “The ‘branch of medicine’ that supposedly helps people in my situation was not just insensitive but more abusive than the situation that caused me to be suffering.”

      The big “fiction” is that the “mental health profession” even has a right to help child abuse survivors. Today’s DSM believing “mental health professionals” have ZERO ability to EVER bill ANY insurance company for EVER helping ANY child abuse survivor EVER. Unless they first misdiagnose ALL child abuse survivors with the billable DSM disorders.

      https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

      Child abuse is listed as a “V Code” in the DSM, and the “V Codes” are NOT insurance billable disorders. So the “mental health professionals” have deluded the world into believing they are the people who are supposed to help legitimately distressed people, when in reality, they are merely there to misdiagnose legitimately distressed people.

      The entire “mental health” system is satanic. And I agree with you, the psychiatric/”mental health” system is “more abusive than” a single abusive person or several abusive people. Because, of course, a “system” that abuses people will always be worse than just a few people who abuse a person.

      As to the comment, “recent studies have called attention to the strong relationship between childhood trauma and the later development of psychosis symptoms.” This likely relates to the above mentioned flaw in the DSM, which causes “mental health professionals” to incorrectly declare everyone who is legitimately distressed about any form of child abuse, either to oneself or one’s child, as “psychotic.”

      And the prevalence of adverse childhood experiences within those stigmatized as “depressed,” “anxious,” “bipolar,” or “schizophrenic” is 82%, and it’s 92% for those stigmatized as “borderline.”

      https://www.madinamerica.com/2016/04/heal-for-life/

      Today’s “mental health system” is a child abuse covering up industry, not an industry which is there to help legitimately distressed people. The “mental health professionals” cannot even bill to help legitimately distressed people who’d dealt with adverse childhood experiences, like child abuse.

      Perhaps this flaw in the DSM should be corrected by those who profiteer off of working within that currently satanic, iatrogenic illness creating, child abuse covering up, psychiatric system?

  6. Psychosis is a banned style o thinking, that has nothing to do with trauma. Psychosis is a main function of psyche and normalcy is a really strong fixation. From psychological point of view, apollonian ego is psychological denaturalization. Psychosis is the greatest enemy of apollonian antipsychological shallowness. They think they can control psyche, this archetype is so blind and psychopatic.
    Arrest them.They need dehumanisation, drugs and control….

    There is a need of psychosis, and this is very strange that PSYCHiastrists are able to see only the need of normalcy. Maybe they should change their job. Show me a gardener who sets a fire in his garden and then, he called that, a concern or profession. This is psychopathy. And still, they are concern about mental health asssumptions, so who will protects the psychological minorities? No one. For example, homosexuals have always been a minority so psychiatry destroyed homosexuals, because of theological thinking about the psyche. They won’t kill you themselves, because god supossed to be good. So they will leave it to psychiatry to “cure” you.

    Mental health is mainly a theological permission to kill those who resemble satan. And psyche is satan for theology.
    But this is hidden truth. This is not science, thisis ideology. And theology condemned humans for their psychology, so to create a spiritual easy utopian reality with money and material things as a greatest value. It is not my hate, it is your fault, inquisition. God is not a killer, but theologians are.

    Dear Luise – Luise and her mother
    Re – visioning psychology – James Hillman
    Manufacture of madness – Thomas Szasz

  7. It was so liberating to be discharged from acute services here in the UK. No more sleepless nights before being yanked in for massive meetings with the psychiatrist, full of bogus claims and who would never take no for an answer. Lol recall that fantastic quote “we don’t have to agree about everything”. Threats of imprisonment, contentious accusations of disordered thoughts and family problems. Huge CPA meetings about nothing because He had decided what “he was going to do”. Magic day when we left that behind.

  9. I want to see the psychiatric institution that actually does real trauma work with the people in it’s grasp. Can anyone give me the name of such an institution? I don’t think that there is one. If you did true trauma work you wouldn’t hold people against their will, nor would you force neuroleptic drugs on them. The “mental health system” does not practice trauma care. Some institutions can claim to be trauma-informed but this doesn’t mean that they do actual trauma work. What it does mean is that they try to inform staff and raise their consciousness to the point that the staff understands that the people they’re supposedly caring for are trauma survivors. The intent in this consciousness raising attempt is to keep staff from triggering and re-traumatizing people all over again. all over again in the name of “good treatment”.