On March 4, 2020, Rethinking Psychiatry (in Portland, Oregon) met for our monthly meeting. The topic was “Beyond the Buzzwords: What Does Trauma-informed Care Really Mean?” This subject turned out to be even more relevant, as we are now facing a global pandemic that is causing massive trauma.
This was to be our last in-person meeting for the foreseeable future. We are continuing to meet online. Both our April and May meetings were held via Zoom and both were well-attended and generated great discussion. Our facilitators and participants did a great job adapting to the online format.
March’s meeting was a rich discussion of what trauma-informed care means. It is an important idea but can be an empty buzzword. Our goal was to have a deeper, more meaningful conversation on what this term really means. A diverse group from the local community attended and we had a really interesting, thoughtful discussion.
The talk was recorded and posted on our YouTube channel, but we edited out the comments of the participants, other than Rethinking Psychiatry’s core members, to protect their privacy. We started with a discussion of the official definition of trauma-informed care, and then talked about what the term meant to us. We also talked about the “four R’s” of trauma-informed care: Realize, Recognize, Respond, and Resist retraumatization. Here are the highlights of the participants’ comments on how these principles can be applied.
Trauma-informed care realizes the widespread impact of trauma and understands potential paths for recovery.
Trauma-informed care takes into account how terrifying it can be to face trauma. People with trauma are often frozen, stunted, in survival mode, and unable to verbalize what happened to them. They may do things that might not make sense to other people, but that are adaptive survival strategies. The idea of holding multiple truths is important. Trauma is complex and there are no simple “one-size-fits-all” strategies.
Trauma-informed care recognizes that trauma can take many forms. Some are not generally recognized or acknowledged as being traumatic—for example, medical issues are often overlooked as a source of trauma. It is important to recognize there are many different kinds of trauma, and that there is variation in what different people consider traumatic. It is up to an individual to say what was traumatic for them.
We discussed the groundbreaking study on Adverse Childhood Experiences, which showed how incredibly common childhood trauma is and the strong correlation between ACE scores and a wide variety of problems in adulthood.
One participant said they wonder, “What are the ACE scores of people who rape the earth [and do other terrible and abusive things]?” We talked about how many people who do harmful and abusive things have their own trauma. In the acclaimed, groundbreaking book on trauma, “The Body Keeps the Score,” Dr. Bessel Van der Kolk talks about people who do terrible things after being traumatized themselves. Trauma is a complicated thing. Despite being considered an expert on trauma-informed care, Dr. Van der Kolk was asked to step down from a leadership position in the center he founded after multiple employees alleged that he had bullied them. It can be hard to wrap our heads around how complex and contradictory people can be.
True trauma-informed care shows an understanding of the nervous system and the body’s response to trauma. Trauma-informed care does not ask the question, “What’s wrong with you?” but instead asks, “What happened to you?”
A trauma-informed care provider takes things slowly, has humility, approaches care with gentleness and without judgment, and allows people to be vulnerable. A trauma-informed care provider understands that trauma is complicated and painful.
Trauma-informed care recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system.
Trauma-informed care recognizes the impact of historical and intergenerational trauma. In recent years, more attention has been paid to how trauma is passed through generations. For example, Jewish psychiatrist Dr. Rachel Yahuda pioneered the field of intergenerational transmission of trauma by studying how children of Holocaust survivors were affected by their parents’ trauma. Native American social worker Dr. Maria Yellowhorse Braveheart studied similar patterns in indigenous communities, and African-American social worker Dr. Joy DeGruy expanded on this work and coined the term “Post Traumatic Slave Syndrome.” Adaptive responses to trauma that are passed down are often pathologized by people of privilege. Trauma-informed care recognizes trauma on many levels.
Trauma-informed care responds by fully integrating knowledge about trauma into policies, procedures, and practices.
Trauma-informed care should be about power with, not power over. We live in a trauma-filled society that is based on domination, and power and control. That in itself is traumatizing. Trauma-informed care is about collaboration, not control.
All too often people in positions of power are the gatekeepers of what kind of help trauma survivors can access. Sometimes insurance will only pay for “evidence-based treatment” such as CBT (Cognitive Behavioral Therapy), even if that is not a very effective treatment for survivors of severe trauma. There is often a lot of circular reasoning in this approach—agencies won’t study treatment that is not “evidence-based,” so then they can say that there is no evidence of a particular approach working. Truly trauma-informed care provides a variety of options and respects people’s rights to self-determination.
Trauma-informed care resists retraumatization.
Our system often involves professionals making decisions for other adults in a way that is disempowering and invalidating, especially for marginalized people. It is retraumatizing when people are treated as a problem rather than treated as being capable of healing and making progress. Not having one’s trauma acknowledged is traumatizing on the most basic level.
We discussed how our society and the systems in place are not built to be trauma-informed. Systemic oppression creates trauma. Due to systemic oppression, people seeking help are often forced to choose between one traumatizing position or another. This is especially true for unhoused folks and other people who are oppressed and marginalized.
Systems often use the term “trauma-informed” without substance. Being forced into treatment but then told it’s “trauma-informed” is a form of gaslighting (gaslighting is also a subject that Rethinking Psychiatry has previously covered). Trauma-informed care must respect people’s opinions and choices and avoid gaslighting.
Sometimes our mental health and medical systems are extremely retraumatizing for these reasons—especially when police or other authorities become involved. For example, people who felt powerless from childhood abuse are often retraumatized when police show up and have all the power. Contacting police should be treated as a very last resort, and true trauma-informed care is built on collaboration and trust. Police can do some things to reduce retraumatizing people—for example, by taking a respectful and helpful approach instead of an aggressive and domineering approach. A social worker can be retraumatizing by using a dismissive and invalidating approach.
Training can be contradictory and an agency’s culture can be not at all trauma-informed. Mental health and social services can often give mixed messages, don’t always provide true informed consent. and claim to be far more progressive, client-centered, and culturally sensitive than they actually are. (One participant referred to the phenomenon as “Portland nice,” though this phenomenon is certainly not isolated to Portland.)
We discussed how creating a safe environment for both workers and care providers is vital. This includes both physical safety and emotional safety. However, the idea of emotional safety can be complicated. It should not mean assuming fragility or avoiding difficult but necessary topics. Care providers should be able to hear difficult feedback. Several group members pointed out that sometimes providers can be close-minded and unaware of their own privilege.
We discussed how trauma-informed care needs to extend to providers. Many people who work in the mental health or medical field have their own trauma, and the work in itself can be traumatizing. Sometimes there are many barriers to care providers seeking their own treatment. Providers sometimes are not even aware of what they are struggling with, which leads to burnout and retraumatizing clients. There is a lot of stigma around providers struggling and seeking their own treatment.
There is a lot of classism built into the mental health system, which is also retraumatizing. Social work has gotten away from its roots and has become more professionalized, which can lead to being out of touch. Frontline workers often deal with poor wages and unsafe, exhausting working conditions, and this is traumatizing instead of trauma-informed. Our medical and mental health system is so focused on liability, which often leads to practices that are counter to being trauma-informed.
Trauma-informed care acknowledges people’s pain, as well as their capacity for growth and resilience. We discussed how some people heal and grow after major trauma. We talked about the idea of post-traumatic growth. This is a controversial idea and participants expressed mixed feelings. It is important to foster an environment of healing and resilience but also to avoid “Toxic Positivity,” which can be retraumatizing.
Trauma-informed care is complicated, and our system is filled with obstacles. Being trauma-informed does not mean having to be perfect. This goes for care providers and care recipients.
For more about the work of Rethinking Psychiatry, visit: http://www.rethinkingpsychiatry.org/
For more about trauma-informed care, visit: https://traumainformedoregon.org/resources/resources-individuals-families
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.