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.

Beyond Endurance Test

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Untitled, oil on canvas. Erika Kahn. Photo credit: Josephine Ensign/2017.

These dark, uncertain times demand our full attention, compassion, and capacity to endure beyond what we previously thought we could endure. And by this I do not mean passive suffering or some sick, masochistic hair-shirt sort of endurance. Nor do I mean resilience, the saccharine notion that the human body, the human psyche, and even entire communities (or countries) can be like heated metal—stressed and stretched but not broken—that they can bounce back, return to steady state, and perhaps be stronger and wiser for the experience?

Paul Farmer, physician and global health expert, reminds us that,  “The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.” (1)

Trauma never happens in isolation. An individual trauma ripples outwards as well as inwards. Suffering from trauma is always a social process; recovering from trauma is always a social process.

Resilience, either from an individual or a community (or country as we are now facing), even if it were possible, would it be desirable? If most traumas, most disasters, are at least partially caused by and certainly compounded by social (in)justice issues, do we want to return to normal, to the status quo after our worlds, our bodies, our communities have been shaken to the foundations, have been seared by fire, have been permanently altered and scarred? Skirting close to the danger of glorifying trauma, of feeding an addiction to the pain and suffering so overly abundant in our world, is the recognition that individual and community healing “means repair but it also means transformation—transformation to a different moral state.” (2) And it means enduring, going on, doing what we can individually and collectively to transform the world for the better.

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Adapted from my book manuscript for Soul Stories: Voices from the Margins.

Sources for quotes:

  1. Paul Farmer. “On suffering and structural violence: a view from below.” In: Violence in War and Peace. Edited by Nancy Scheper-Hughes and Philippe Bourgois. (New York: Blackwell Publishing, 2004). pp 281-289. Quote is from p. 288.

 

  1. Veena Das and Arthur Kleinman, “Introduction,” in Remaking a World: Violence, Social Suffering, and Recovery, ed., Veena Das, Arthur Kleinman, Margaret Lock, Mamphela Ramphele, and Pamela Reynolds (Berkeley: University of California Press, 2001), 23. (Quote is from “Introduction” pp. 1-30. Quote is from p. 23)

See also: Arthur Kleinman, “The art of medicine: how we endure” The Lancet. January 11, 2014. Vol 383. pp 119-120.

Past Forgiveness: Part II

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The following is an excerpt from my book manuscript titled Soul Stories: Voices from the Margins (under review). I’m sharing it here—and now—because I know of at least one young woman and several older women out there in the world who probably need to hear these words. (“Past Forgiveness: Part I” was posted on August 3, 2016 and linked here.)

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I have spent my entire life—or at least my entire life from when I first became fully aware of myself—trying to find a way to forgive my dysfunctional family. Mainly my father, the charismatic narcissist minister who liked to grope my budding breasts and then pretend he had only been trying to show me fatherly affection. Or, that he was only sponging my chest when I was ill in bed with a high fever from Red Measles when I was fourteen. “What kind of Freudian psychological hang-ups do you have about your father?” he asked, when I grew old enough to confront him on his groping behavior. As if.

And my mother, my strikingly artistically gifted and intelligent mother who preferred to live in a surrealistic, made-up world of her own, trying to be my friend instead of my mother. She chose to believe my father and not me. As if. She told me that my panic attacks, which developed in the immediate aftermath of my father’s first groping episode, were really sent by God as a dark night of the soul, and meant I just needed to pray harder. As if.

And even my three older siblings, and especially my oldest sister who had been like a second mother to me, who believed my father even after his death as he partially disinherited me. My siblings who continue to admonish me to get over my anger, to forgive and forget, to leave it all in the past. As if.

As if anger is a bad thing. As if anger isn’t protective, propelling, and proper in unjust situations.

As if I was right all along: I had been adopted. I firmly believed this as a child. I was born long after my siblings. My two childhood best friends were both adopted and their parents didn’t tell them this fact until they were older. I held a deep conviction that I was not of this family.

As if I was right all along: in order to survive, to heal, to thrive, I needed to sever ties, become un-homed, move far away to the Western frontier of Wallace Stegner’s “native home of hope” and make my own way, my own family, my own home. What does it mean to be homeless when home was never a safe place? In such cases, it is not possible for young people to runaway from home; they can only run towards home.

As if family secrets were legitimate heirlooms to pass down to future generations, squirreled away in cedar chests along with crocheted bedspreads and starched baby clothes.

My father never acknowledged his wrongdoing, never confessed his sins of groping me, of groping my maternal aunt when she was young, of groping at least one of his granddaughters. How can I begin to forgive him?

As if.

I spent many years of my adult life swinging wildly between minimizing the trauma, “it could have been worse,” to full-body catastrophizing, drowning in the role of victim, “I am scarred and damaged beyond repair,” before realizing that is how our psyches cope with such trauma, and that the window of opportunity—of strength and hope and healing—lies in the space between those two extremes. It requires embracing the white-hot contradiction of the two truths. As if that were possible.

Until it is possible. Through a combination of fatigue, fortitude, and sheer inexplicable grace, it becomes possible.

Past Forgiveness: Part 1

DSC02140The following is an excerpt from my book manuscript titled Soul Stories: Voices from the Margins (under review). I’m sharing it here—and now—because I know of at least one young woman out there in the world who probably needs to hear these words. I’ll post a a “Part II” soon.

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In Regarding the Pain of Others Susan Sontag writes of the meaning of images depicting tragedies and traumas. Towards the end of the book she contends, “There is simply too much injustice in the world. And too much remembering (of ancient grievances: Serbs, Irish) embitters. To make peace is to forget. To reconcile, it is necessary that memory be faulty and limited.”

But I wonder if reconciling, if forgiving, is always predicated on forgetting. And, is forgiving always a good thing?

As I began writing this essay, a young white supremacist shot and killed nine black people during a prayer service in a historic black church in Charleston, South Carolina. The day after this hate crime atrocity, the relatives of those murdered came together and gave a public declaration in which they called on the shooter to confess his crime and repent. He was not admitting to any wrongdoing or crime, yet they forgave him for murdering their loved ones. They said that they called on their deeply held Christian convictions to guide them in this matter.

Was their quick and very public forgiveness a form of Christian witnessing, a rebuke to the Devil, to evil in the world? Or was it something else? I realize I am treading on difficult ground here, that being within my white privilege I can never know what the family members of those victims experienced. Of course, there is something admirable and noble in turning anger and vengeance into love and forgiveness. But then that becomes the standard and what if there are relatives of victims who can’t or do not want to forgive the white supremacist murderer?

Forgiveness is a peculiarly Christian thing to do.  Having been raised within an exclusively Christian worldview—with its turn the other cheek, forgive a person seventy times seven, forgive us our debts as we forgive our debtors—I hadn’t realized that other major world religions like Judaism have different views on forgiveness. In Judaism, forgiveness can only be granted by the aggrieved person, and only after the perpetrator has asked for forgiveness and has made both atonement and restitution.

Forgiveness is also a peculiarly female thing to do; it is emphasized in traditional gender roles in Eastern and Western societies. Women are conditioned to be the family and community peacemakers, and forgiving is viewed as an essential part of that role. People who forgive are supposed to “soften their hearts,” release their anger and sense of revenge in nonviolent, nonliteral ways.

Robert Enright, a Catholic psychologist at the University of Wisconsin—Madison, has developed a 60-item Forgiveness Inventory to measure forgiveness, and an 8-step program leading to forgiveness. He has been dubbed “Dr. Forgiveness.” Through his research, he contends that people who forgive lead healthier and longer lives than those who “stay stuck” or “hold on to” resentment and a lack of forgiveness. He advocates the use of the “two chair technique” in counseling someone to forgive. The person sits in one chair facing an empty chair representing the person who wronged them. They tell that person—that chair—how they feel. Then they sit in the second chair, try to see things from the other person’s perspective, and talk things through with the imaginary person until they achieve forgiveness.

There is even an International Forgiveness Day, the first Sunday of August, established by the World Wide Forgiveness Alliance. (It has been changed to October 7th for 2016 for some reason.) The 2015 Forgiveness Day was on August 2nd, and at 2pm on that day people were called “to take two minutes to forgive someone and join over 2 million people in the Wave of Forgiveness.” On their website, they featured photographs and testimonials of the 2015 Heroes and Champions of Forgiveness. Most were women and it seems that most were women of color, a fact I find ironic given the power dynamics inherent in forgiveness.  I took the online 33-item Forgiveness Quiz with questions such as “Forgiveness is a sign of weakness,” and “I believe that revenge is devilish and forgiveness is saintly”—an echo of Alexander Pope’s famous line of poetry “To err is human; to forgive, divine.”

Most of my answers to the quiz questions using their Likert scale were neutral because my real answers to these questions were “it depends.” Nevertheless, my composite score told me I tend towards being a more forgiving person. Even though I think it is a rather silly and oversimplified test—and I question our society’s insistence on forgiveness, especially gendered forgiveness—I find my test result to be comforting. I also find that comfort disquieting.