The Role of Trauma-informed Care

IMG_1055Time to revisit and review trauma. Trauma-informed care is health care provided within the framework of an understanding of the various neurocognitive, psychological, physiological, and social effects of trauma on individuals. People who are homeless have particularly high rates of trauma—both before and during their experience of homelessness. And, of course, homelessness itself is a type of trauma, a type of deep illness, as sociologist Arthur Frank refers to an illness that casts a shadow over your life.

Trauma is an event that is life threatening or “self” threatening. Serious accidents and medical mishaps. Drug and alcohol addictions. Natural and manmade disasters. Wars. Rape. Intimate partner violence. Childhood neglect, physical, and sexual abuse. Complex trauma is trauma that occurs within key caretaker relationships and that is pervasive and enduring. Complex trauma is, well, more complex to live with and to treat.

We use the phrase scared speechless to describe fear that overwhelms and suppresses the speech and language area of our brain while we’re in the midst of a traumatic event. As Bessel Van Der Kolk, a physician and expert on trauma puts it, “All trauma is preverbal.” (p 43) Trauma bypasses these higher order areas of the brain and goes straight to the more primitive fight and flight fear area—the amygdala, two almond-shaped areas deep inside our brains in the primitive limbic system. Trauma is not stored as a storied memory with a clear-cut beginning, middle, and end, but rather as fragments of experience, images, smells, sounds, and other bodily sensations. That is why people who have survived a significant traumatic event—even years and decades after the trauma is over—struggle to tell the story of what happened. Yet their bodies bear witness to the event through terrors, flashbacks, numbing, and stress-mediated physical problems like migraines and auto-immune diseases—diseases in which the body turns on itself, as if in slow suicide. If the trauma happened to the person as a child before the firm development of a sense of self, that person’s memories of the event can remain visceral and largely inaccessible to verbal processing.

Van der Kolk states, “Almost every brain-imaging study of trauma patients finds abnormal activation of the insula. This part of the brain integrates and interprets the input from the internal organs—including our muscles, joints, and balance (proprioceptive) system—to generate the sense of being embodied.” (p 249) He points out that the flood of activating neurochemicals from the fight or flight response to trauma effectively cuts people off from the real origin of their bodily sensations; the fight or flight flood numbs people, and is the reason for dissociation and out-of-body experiences many trauma patients deal with. Van der Kolk goes on to declare, “In other words trauma makes people feel like some body else, or like no body. In order to overcome trauma, you need help to get back in touch with your body and your Self.” (p 249)

Art, music, and dance are often used as treatments for trauma patients because these expressive modalities do not depend on language. They do not depend on—indeed, they are better off without—the use of our rational minds both to create and to experience. As psychiatrist Laurence J. Kirmayer writes, “And if the text stands for a hard-won rational order, imposed on thought through the careful composition of writing, the body provides a structure to thought that is, in part, extra-rational and disorderly. This extra-rational dimension to thought carries important information about emotional, aesthetic, and moral value.” (pp. 324-325)

In the late 1990s, in a Seattle area community health clinic where I worked as a nurse practitioner, many of my patients were Bosnian and Ukrainian refugees. One of my more heart-wrenching patients was a 4-year old Bosnian girl whose teeth were rotted to the gum line because her mother had given her a sugar-soaked rag to suck to keep her silent as they tried to escape the civil war. The language interpreter told me that the child’s older brother had ben killed, and that her mother had been raped. I referred the child to our children’s hospital where they surgically removed all her baby teeth and then fitted her with child dentures until her adult teeth appeared. I was hoping to refer the mother for talk therapy to deal with her traumas, but soon realized it was best to refer her for massage therapy with a trauma-informed female therapist. I worked with our clinic social worker to petition the patient’s health insurance (which happened to be the state Medicaid office) to pay for this—what we typically consider slightly frivolous and self-indulgent treatment. Medicaid paid for the massage therapy and it seemed to lighten her depression. This wasn’t art, music, or dance therapy, but it was body-based therapy.

The body remembers. Maddy Coy, a UK-based researcher who works with survivors of prostitution, maintains that especially for women who experienced childhood sexual abuse (a startlingly high percentage of prostitutes worldwide), the use of appropriate body work such as yoga and massage is oftentimes crucial for recovery. Body work helps traumatized people reestablish a focus on what the body can do instead of what is done to the body.

Early in my career as a nurse I worked for a year in a safe house emergency shelter for women who were escaping intimate partner violence. Before my work there I did not understand the concept of trauma mastery and how this played out in the lives of women caught up in the cycle of abuse. I sided with the common misperception that the reason so many women return to their abusive partners is because they are psychologically damaged and weak. There is the not insignificant role of addiction to the thrill of trauma and danger—to the effects of the activating yet numbing fight or flight neurochemicals—which can bring at least temporary relief to the bouts of fatiguing depression that often accompany trauma. Then there is the unconscious attempt to return to the site of previous trauma to get it right this time, to do what we wish we could have done the first time, to master our trauma.

As social worker Laura van Dernoot Lipsky points out, these unconscious attempts to master our traumas often backfire and simply reinforce our old traumas. Lipsky goes on to say that many of us in health care and other helping professions often are using our work as a type of trauma mastery, and that by doing so we may set expectations for ourselves and others that are “untenable and destructive.” She advocates ongoing efforts aimed at self-discovery and self-empathy, and points to the many positive examples of “people who have been effective in repairing the world while still in the process of repairing their own hearts.“ (p 159) Eve Ensler and her personal, combined with world repair, work that she describes in her powerful book In the Body of the World, is one of my personal favorite role models for this sort of balanced approach.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s