We began understanding the trauma-based nature of our adult patients’ problems in the early 1980’s and from about 1986 to 2001 we specialized in treating adults who had been abused as children. When we looked back at what we had each learned in our training and our early experience as mental health professionals we had some striking realizations. Before we understood the complex biopsychosocial impact of traumatic experience we didn’t really understand what we were doing, why sometimes it worked and sometimes it didn’t work. When someone failed, we could not have explained why our strategies with them failed and likewise, when they succeeded we did not know how that had happened so it was hard to repeat it. We didn’t understand what had happened to them and the multiplicity of ways that their life trajectories had been changed by trauma so we were unable to set clear goals that could alter those trajectories in the future. We failed to grasp how their symptoms in the present had evolved from adaptations to extremely negative events in the past, so we were more likely to overtly or subtly ridicule them for their symptoms.
Since so much of our patients’ reality was shrouded in these mysteries, we had no real idea about what “recovery” was other than a diminution in symptoms. As a result, there was no framework for what a truly collaborative therapeutic relationship would look like. Since their symptoms were often dangerous and scary, and there was always a legal system looming over us, threatening us with any behavior that we did not control, we tried to control our patients in ways that that felt to them like a reenactment of the oppressive experiences they had experienced as children. Sometimes we set too few limits and sometimes too many because we had no real way of judging what we were doing and we did not know how to read the feedback our patients gave us, often behaviorally. Sometimes we treated people as if they were helpless, sometimes we didn’t give them the solicitous care they needed. We denied our own violence and failed to take into account the fact that many of us had endured experiences not dissimilar to the ones our patients struggled with. We failed to comprehend, even while experiencing it, the ways in which trauma impacts systems as well as individuals, producing the reverberating cycles of dysfunction that we have been describing earlier in this book.
A few years ago, we began asking a number of experienced trauma therapists from a variety of different kinds of programs how their growing recognition of the impact of trauma on their clients was affecting them. The answers they reported were very consistent with the changes we had encountered in changing our own understanding about the underlying causes for most of the psychopathology we had been seeing for decades. These are at least some of the sources of resistance that programs attempting to adopt the Sanctuary Model are likely to encounter in their staff, administrators, and other stakeholders. The experiences of these clinicians can be broken down loosely into four overlapping domains: the impact of recognizing the traumatic origins of human problem on mental models of the world; on one’s own emotional life; on one’s roles; and on one’s sense of justice.
Trauma-Informed Change: Challenging Personal Mental Models
Service providers universally agreed that becoming “trauma-informed” means changing your mental model of how the world works and that this requires a major intrapsychic adjustment around common everyday assumptions, although the specific assumptions varied from person to person. We interviewed people who had made this shift in their basic assumptions and asked them to reflect back on what this shift had meant to them.
- It’s all so complicated - trauma has an impact on all systems – it all interacts and there is no simple cause and effect connection.
- You can no longer sustain the notion that there is a clear line of differentiation between good and bad – good people do very bad things to themselves and others and bad people often have reserves of goodness if we can figure out how to mobilize it.
- You can no longer believe that the past is the past, or that history doesn’t matter - it clearly does and it is not nearly as easy as I thought it should be to put the past behind you.
- I thought this was all going to boil down to biology and genes, but it’s not.
- I thought I could really get people to change if I just learned the right therapy and got really good at it – but that isn’t enough at all.
- I always kept politics out of things at work, but I found out that is impossible, that all of these traumatic events occur in a political and social context and that unless we change that context, we are just putting our finger in a dike – and maybe even enabling a really sick system to stay sick.
- You have to accept that sometimes people decide to go on doing things that are wrong and that it is their choice and they have a right to make that choice – the only way I can have power over them is if I lock them up and tie them down.
- I used to think that the DSM diagnostic system was my Bible and that gave me an odd sort of comfort. Now I have had to give up the notion that DSMIV diagnoses – at least a lot of them - matter very much as far as whether someone can be helped or not – that’s more up to me than I like to believe.
- I was taught that you tried to stay away from the issue of past trauma because it was like “like opening up Pandora’s box”– asking for trouble without getting any positive benefit. That was almost completely wrong – I have discovered that unless I help someone deal with the past, they cannot move forward.
- I never really learned about the close and interactive connection between mind and body, even though I went to medical school. In our training it was totally separate and people in medicine didn’t even talk to people in psychiatry unless you absolutely had to, mostly to get a patient moved. I had to learn to accept that the mind alters the body and the body alters the mind in ways we are only beginning to understand.
- When I started listening – really listening – to what happened to people as children, I got triggered myself and had to get some help to deal with my own history of sexual abuse. I am sure this happens to lots of therapists, only they don’t always do anything about it and just deny the importance of childhood adversity instead, so their patients don’t do as well as they could.
- It’s too inclusive, too overwhelming. I mean, I guess I like to pigeon-hole information and this trauma stuff is hard to put into a category – is it about medicine? Psychiatry? Religion? Philosophy? Sociology? Politics? So does that mean I have to have expertise in everything in order to adequately treat people?
The emotional impact on the helper of supporting people in their recovery from the impact of trauma has received a significant amount of attention over the last decade largely because of the toll that emotional changes can take on the individual and on the workplace. There are various terms used to describe this impact including: vicarious trauma , secondary traumatic stress , and compassion fatigue . When we asked experienced therapists about the impact of coming to terms with the traumatic origins of a wide variety of problems presented by their patients they shared with us some of their own emotional responses:
- You have to empathize with people who do awful things – and sometimes they do awful things to you.
- You have to come face-to-face with the most profound ugliness and perversity
- You have to deal with how depressing it is that people do these things to other people, especially to children.
- You have to listen to and feel with horrible stories, images, and experiences.
- It’s been hard for me to believe that trauma could have anything to do with symptoms when patients are psychotic, or have mood swings, or are violent but when I discovered that trauma is often involved, I had to remember all of the times I had ignored that with other people I had worked with.
- You have to remember things you don’t want to remember about things that happened to you.
- You have to be willing to make people uncomfortable and feel pain.
- It’s been really hard to look back and realize that that there are many people that I probably didn’t help, or maybe even hurt, because I didn’t know what I was doing.
- Other people I have to deal with can be so pessimistic about change and I get angry hearing their pessimism and knowing it’s because they are still as ignorant as I once was.
- If you work with trauma survivors – and everyone does – there is no way to avoid the idea that feelings matter and that a lot goes on completely outside of conscious awareness – and I was never really taught much of anything useful about any of that – I learned it was all about just changing behavior – now I don’t know what that means anymore.
- I don’t have the training to take care of these problems – I don’t know what to say when someone talks about the traumas they have experienced – I used to be able to just focus on the “here and now” and think I was doing something – now I am not so sure and it makes me feel so bad that there are not adequate resources to help people when they could be helped.
Shifts in Roles
Having a well-defined role is part of what helps us feel secure and safe. We know what we are supposed to do and not do. Similarly, understanding where other people fit in and putting them into neat categories helps reduce uncertainty and keeps us out of unnecessary, time-consuming, and potentially dangerous conflicts. As clinicians told us, acquiring a working knowledge about the impact of trauma also impacts they way they work and that can be very disconcerting.
- I realize that I used to sort of, look down at people who had been victimized as weak and ineffective and sometimes even that they must have been ‘asking for it’. I was identifying with the perpetrator because it was more comfortable for me.
- I am very task oriented and in my role I would just keep people’s attention fixed on the task at hand. Now I have had to take more time than I really have to deeply listen to what people say and what they don’t say.
- My whole life has been built around being a helper and I always thought I needed a lot of feedback about what a good job I do and how grateful people are for my help but in working with trauma survivors I have had to get used to the fact that they may never thank me for helping them because to help them it has to come from them not me.
- I don’t think this is such a problem now since trauma theory is more accepted than it used to be but when I first started seeing all this past trauma in people, I felt like I was an alien and I really identified with the fact that the patients felt that way too, that victimization had made them feel like outsiders. Because I had been on a upward spiraling career path but as soon as I started seeing all this childhood abuse, I too became an outsider.
- I went through a period when I totally bought into the concept that all therapy could be done quickly and that a managed care environment was what the profession really needs, but I was wrong. Sometimes, brief therapeutic approaches can be all the person needs but with people who have been through years of abuse at the hands of other people, so much work has to go into rebuilding the capacity to relate, that brief visits just give the illusion of doing something when it may just make things worse.
- You have to learn to keep your mouth shut at parties with people who are not trauma specialists because the stories you tell freak out regular people.
- As a therapist, I always felt kind of invulnerable, above the bad things that can happen to people. I guess it was the illusion of control but it made me feel good. Once I started really listening to my patients’ stories and was open to hearing them, I knew that danger could be around us all the time, that I could possibly be quite capable of killing another person and that I could possibly be killed by another person.
- You realize that you are only the driving instructor not the driver – and you have no control over the wheel.
- You have to be more willing to take risks and no that no one will protect you if things turn out badly.
Justice and Tragedy
Our culture is grounded in a belief that justice should exist and where the world is not just, it’s simply a matter of time before that situation will be created. There is comfort in believing that people get what they deserve because then we can control the bad things that happen to us by just being good Once that belief is in place and supported by vast cultural assumptions, it’s very destabilizing to have that fundamental belief overturned.
- I have had to come to terms with the reality of just how unjust the world really is and that has been extremely upsetting.
- Is there really any justice when these terrible things can happen to so many children who are utterly incapable of protecting themselves?
- It’s become clear to me that it is totally true that “hurt people hurt people”.
- I work in the criminal justice system and it was so easy to see these people as just bad. Now life has gotten more complicated because I find myself having a much broader understanding and even some sympathy, for how they got to be the way they are. It doesn’t excuse their behavior but it does explain it.
- Why are we punishing these kids, like it’s going to help them to just do more of what has already been done to them that got them in the condition they are? It doesn’t make a lot of sense.
- This cycle of violence stuff is so clear and so sad, once you get close to it and open up your mind to what you are seeing and why people do the things they do.
So, when we truly grapple with what it means to create a “trauma-informed” system it is a much more challenging change then most people realize when they are just beginning. It’s why the Sanctuary Model has evolved as a total system change that takes time, dedication, commitment, perseverance, courage, and fortitude. To grapple with the challenge of transforming a system, it is vital to have a firm grasp of the extent and nature of the existing problems. In the next chapter we are going to focus on the issue of workplace stress and how it manifests in the human service delivery sector.