You Can't Be Trauma-Informed If You Can't See the Trauma

 

Trauma-informed care should be like universal precautions – in the same way you wouldn’t clean up a blood spill without wearing gloves, you should always assume that someone has experienced trauma and treat them accordingly.

Only it doesn’t happen that way. Once our indignation or any other parts of our wounded selves come into play, that usually goes out of the window unless you have been conditioned to wear a trauma-informed lens. And even then, there will be times we fail.

Let me give you an illustration. A domestic violence shelter resident who was attending our parenting classes called me and wanted help.  She wanted help, but how she actually went about it was to embark on a long rant, full of cussing and accusations, which almost burnt my ear off. Fortunately, I have been teaching about trauma for a long time and have learned to populate the theory with the faces of my nearest and dearest. “Ah, I know you, you’re [name of good friend]!” I said to myself. You get big to get what you want because that’s what you learned from your abusive parent. You were terrified half to death as a child, but when you are under stress, that is the pattern of communication that resurfaces.

I managed to calm the mother down and empathize with her situation. She was in danger of losing her housing and she and her 10-year-old boy would be back on the street. I pointed out her strength in being able to advocate for herself and even managed to help her see that she would lose the battle if she went into a meeting with the shelter director and lost her cool. She asked me to give the shelter director a call on her behalf and I agreed.

Me: She’s really afraid she’s going to lose her housing.

Shelter Director: But she’s loud and rude and gets in your face and she upsets the other residents!

Me (to self): Have you never actually met a trauma survivor?!

I don’t know this shelter director but I imagine the mother activated him in all kinds of ways. Maybe the story in his head is that she should be grateful and show that by being meek and compliant. Maybe he imagined helping defenseless women when he took this job and a potty-mouthed street fighter did not fit that image. Maybe he was offended because he had been brought up to believe that angry outbursts were unacceptable and should be punished. Maybe he came from a family where he was never allowed to show his anger.

I will never know his story but I do know that a lot was going on for him, so much so that all his training about the triune brain, Adverse Childhood Experiences, the resiliency zone and all the other staples of trauma training did not get applied. You have to recognize trauma in order to be able to apply trauma-informed care.

That is why a large part of Echo’s trauma trainings is dedicated to ‘how trauma shows up.’ We have so many labels, biases, and reactions stemming from our own trauma histories, that we slap on other people’s behavior and miss the trauma. Passive aggressive? Control freak? Trauma. Lack of hygiene? Emotional manipulation? Trauma. Defensiveness? Punitive? Trauma.

When we don’t recognize the underlying trauma we tend to punish people who offend against our sense of what is ‘right’ or we stigmatize and exclude them. The mother was in danger of being ‘exited’ from the shelter. Fortunately, she used all the resources available to her and showed up at the meeting with professionals (school teachers, her son’s therapist) to help her. My kind of girl! But so easy to dismiss as a ranting, abusive, hysterical woman.

I would be feeling really good about my role in all this if it weren’t for the fact that yesterday I had a phone call with someone who pushed all my buttons. It was only later than I was able to find my compassion for her because I realized [name of that very useful friend] would probably have approached the conversation the same way. I mourned my caller’s lack of skills and my lack of skills in responding. I had compassion for myself that in the thick of it, it is really hard to remember those darned trauma-informed lenses.

Here are some questions we’ve developed to help you (and me) learn from these activating situations:

  1. Without judgment, what was my reaction (physical, emotional, mental) and how did I then respond?
  2. Did the behavior offend against my personal values?
  3. Did it offend against my learned social values?
  4. Was it triggering my trauma?
  5. Was I witnessing a trauma response in the other person?
  6. Am I able to find compassion for myself and the other person?
  7. Did I respond by punishing, shaming, shunning or badgering?

You’ll notice that only one of those questions relates to the other person. Our ability to tune into someone else’s needs or trauma relies on how well we are able to regulate our own emotions. I failed miserably yesterday and my attempt to make a repair (okay, half-hearted and still indignant attempt) was not well received. But I get to brush myself off and try on those trauma-informed lenses again. With a big mirror and my portrait gallery of friends and family, how can I not succeed!

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Thanks for posting this, Lou. Being able to hesitate, take a breath and respond kindly is a muscle that needs to be exercised often. And even then, we slip. At least I'm at the point where I know almost right away that "I shouldn't have said that!" But I'm still not at the point where I don't slip. Maybe that's just part of being human.

Wonderful article. Louise. Love how you have put it across

Once our indignation or any other parts of our wounded selves come into play, that usually goes out of the window unless you have been conditioned to wear a trauma-informed lens.

The importance of developing a compassionate heart.

When we stop reacting and instead act with wisdom and understanding.

Every moment of our day can be a practice of 'Loving Kindness Meditation.'

 

Great post! I did a workshop on ACEs and Trauma-Informed Care for home health professionals yesterday and just forwarded this as a follow-up. Thank you for your ongoing important work; we are all learning, growing, and healing!

Thank you for this oh-so-real peek at the challenges of interacting with people who "push our buttons." Even the most skillful among us can wind up in conversations that become unpleasant and unproductive. Clearly, the first and most important step toward interrupting that cycle is self-awareness and reflection. Next, come specific skills for reframing the situation, tapping compassion and conveying empathy. The Institute for Healthcare Communication has created a communication skills development workshop, THE EMPATHY EFFECT: COUNTERING BIAS TO IMPROVE HEALTH OUTCOMES, to bolster these essential skills, and make them more universally applied. For information about bringing THE EMPATHY EFFECT to your organization, please see: http://healthcarecomm.org/trai...ove-health-outcomes/ or call us, toll-free: Tel: (800) 800-5907

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The Empathy Effect Workshop

Hi Louise, Great post on seeing through a trauma informed lens!   Question: once you pause, reflect that the person in front of you acting out of trauma, and that you then approach them with compassion and understanding, if the person still continues to be disruptive and or abusive to you or others, how or when do you suggest setting appropriate boundaries?

Hi Louise, I think you put it so well when you said that providers should always assume that someone has experienced trauma. Those are great questions/tips you provided about what to think about if someone is reactive in an encounter. A webinar acesconnection presented earlier this week shows how peers can help providers and health sciences students understand the ACEs and trauma they've experienced through role playing. Here's a link to the blog post about it, which includes links to the video recording. 

Oh Louise:

I LOVE reading your posts and learning from you! Thank you for being so real and honest. This part about how trauma shows up is often missing. The clinical stuff may be described but the actual ways it shows up are often not that. 

That is why a large part of Echo’s trauma trainings is dedicated to ‘how trauma shows up.’ We have so many labels, biases, and reactions stemming from our own trauma histories, that we slap on other people’s behavior and miss the trauma. Passive aggressive? Control freak? Trauma. Lack of hygiene? Emotional manipulation? Trauma. Defensiveness? Punitive? Trauma.

Also, the glasses remind me that an art teacher and I did an interactive art installation and asked trauma survivors to SHOW how trauma feels and in what ways to show what trauma looks like to the one behind the glasses and seeing the world through trauma (and maybe also a trauma-informed lens). 

Some talked dissociation and some talked feeling shattered, some felt like all they could see was fear and others talked about how they could see so little at all because they were shut down. It was SO COOL and the unexpected part was those without trauma TRIED ON the glasses and for a moment, got to see the world others did. Some glasses were covered in dirt. Some were painted. Some were cracked. Some had wonky prescriptions and words like RAGE all over them. I wish I had more pictures to share and that someone would run with it and do it again. 

It was cool because it was a way to show how those living trauma feel it and too often that piece of education is missing. How people think about trauma and understand research is important. How people live, feel and experience the world, is not always a direct line up as you know. I wish I lived in CA so I could go to every workshop AND meet you in person!
Cis

Hi Mary!

 

That's a good question. Just because we empathize doesn't mean that its okay for someone else to act in a way that is harmful to us or others. At Echo, we talk about setting limits with empathy.

For example, with the mother who was yelling at me down the phone. I made sympathetic noises and offered her empathy ("I would feel the same way too!") and gave her some space to tell her story. After it became obvious she was not going to slow down, I told her in a prosodic voice that I really wanted to hear what she had to say but it was hard when she was yelling at me. I would repeat that each time she got amped up. When she veered off into a rant I would say, "I have an idea. Do you want to hear it?" Then she would stop and listen to me. At one point, I did actually say that being yelled and cussed at didn't feel good and that it was beginning to feel abusive. 

That's where accountability comes in - letting the trauma survivor know that their actions are hurting someone else and that's not okay.

We prefer to talk about 'setting limits with empathy' because some people bandy about the word accountability and they don't mean that at all - they mean the trauma survivor should darn well get a clue and quit acting that way!

 

Aw, Cissy! I wish you lived in CA too! 

I love your art project idea. I hope other people take that and run with it. What a marvelous visual reminder. 

I often quote you: "Nothing about us without us." It is why we take a survivor-driven approach. And let's be real - most of us are survivors. 67% of us have at least one ACE and that rises to 83% if you are from a community of color. I would hazard a guess it's more like 100% in the 'caring' professions! However, you'd never know it from clinical trainings. I get it - it's nice and safe behind the clinical language and pretending it's all about 'those people over there.' 

It takes courage to speak from your personal experience and you are out there doing just that, Cissy. The more we speak from a survivor perspective the more we can remove stigma and judgment, and the more we can coax people to come out of their hidey holes of shame to find healing. 

 I've been reading these comments to this great blog post (thanks Louise for posting!).  In  reading the last thread, it reminded me of lovingkindness meditations which I am working on in my practice.  Love for ourselves (setting boundaries, etc) is as much a part of the practice as love for other beings and often so hard to remember to prioritize!

Louise Godbold posted:

Hi Mary!

 

That's a good question. Just because we empathize doesn't mean that its okay for someone else to act in a way that is harmful to us or others. At Echo, we talk about setting limits with empathy.

For example, with the mother who was yelling at me down the phone. I made sympathetic noises and offered her empathy ("I would feel the same way too!") and gave her some space to tell her story. After it became obvious she was not going to slow down, I told her in a prosodic voice that I really wanted to hear what she had to say but it was hard when she was yelling at me. I would repeat that each time she got amped up. When she veered off into a rant I would say, "I have an idea. Do you want to hear it?" Then she would stop and listen to me. At one point, I did actually say that being yelled and cussed at didn't feel good and that it was beginning to feel abusive. 

That's where accountability comes in - letting the trauma survivor know that their actions are hurting someone else and that's not okay.

We prefer to talk about 'setting limits with empathy' because some people bandy about the word accountability and they don't mean that at all - they mean the trauma survivor should darn well get a clue and quit acting that way!

 

Hi Louise,  thanks for your responding to my comment.  I love how you balance seeing through a trauma informed lens with asking to share your ideas for solutions, as well as speaking your truth about the clients behavior as feeling abusive, and then setting healthy boundaries with empathy.  Great example.  Thanks for sharing. Mary

 

What a great post! It reminds me of one of my favorite quotes, by the surgeon Sherwin Nuland, who also wrote the fabulous books How We Die and How We Live:

"When you recognize that pain — and response to pain — is a universal thing, it helps explain so many things about others, just as it explains so much about yourself. It teaches you forbearance. It teaches you a moderation in your responses to other people’s behavior. It teaches you a sort of understanding. It essentially tells you what everybody needs. You know what everybody needs? You want to put it in a single word?

Everybody needs to be understood.

And out of that comes every form of love.

If someone truly feels that you understand them, an awful lot of neurotic behavior just disappears — disappears on your part, disappears on their part."

I've seen this firsthand with the homeless youth with which I work (certainly a traumatized group). Thanks for sharing Louise! Jill

Wonderful post, Louise.  Thanks for being so real.  This isn't easy and we all need compassion, since, as you say, we're all in it together. 

Every behavior carries a message and that is as true for us in the helping professions as it is for those we work with.  Thanks for the reminder always to stop, take a breath, and listen to our own body and emotions.

Thank you for this...it is so very true.  I seem to rant every other day that being ttrauma-informed is not enough; it isn’t a tool to carry around in a toolkit.  It has to become part of what we see and how we respond every single day to folks we encounter personally and professionally.

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