Reflecting on Who We Are and How It Impacts Survivors

When providing trauma- informed services to survivors of domestic and sexual violence it important we ensure that we are doing whatever we can to keep from re-victimizing the survivor or engaging in behaviors that may be reminiscent of past abuse.  Through actively engaging in a reflective practice on our own and during supervision we may be able to recognize those conditions within ourselves that get in the way of being able to provide safe, empathetic, and empowering assistance.

We often talk about the experiences of survivors in a way that takes into account the trauma in their lives.  We ask “how do the effects of trauma get in the way or impact the person’s ability to be able to move forward?”  This practice of reflecting on the experience of the survivor can move an advocate from focusing on what is “wrong” with a person to recognizing the impact of trauma and finding ways to reduce the impact and/or engaging with the person in a way that empowers them to be able to move beyond the trauma.

Terri Pease, Ph.D., of the National Center on Domestic Violence, Trauma and Mental Health talks about reflective practice.  She quotes Jeree Pawl, past board president of Zero to Three, to remind us that “who we are is as important as what we do” in our relationships with survivors.  She stresses the importance of reflecting on the impact that survivors have on our lives and the history that we bring into our relationships with them. 

I am often called to provide insight into the actions of a woman in shelter or a woman who is seeking services from a court advocate.  The advocate wants me to explain what is happening with the woman from a trauma-informed standpoint and help her find something different to do to help.  Another step I like to take, though, is to ask “how is this interaction affecting you?”  In other words, can you take a moment to reflect on what may be coming up for you as you work with this survivor?  Many times the challenges of working with survivors can stir up some emotions that we may find difficult to keep from being reflected in our actions.

If the victim is particularly challenging and expresses herself with anger, an advocate may find that she resists working with the victim.  The victim may be engaging in some survival skills that are often labeled as lying, manipulating or attention seeking.  If an advocate can take a few moments on her own or in supervision to reflect on what this is bringing up for the advocate, then it may help to improve the relationship with the survivor.  For example, I know that due to my own past I have difficulty when I am in the presence of extreme anger that feels like it may be directed toward me.  Over the years I have learned to recognize when my own history is starting to blur my interactions and I, hopefully, am able to breathe my way through and not take the survivor’s anger personally.  Additionally, many advocates, including myself, feel helpless when they are unable to meet all the needs of the survivors.  This may feel like frustration with the survivor and it will be reflected in our interactions with her unless we realize that our helplessness has to do with the greater picture and our own fear of not being able to do enough. 

Advocates, in the face of tapped out services within their communities, often feel overwhelmed by the needs of the survivors and feel if they cannot meet them all then they are not good advocates.  Yes, it is hard when the needed services are not available, but we cannot do it all.  We do all that we can and at the end of the day we need to be able to take care of ourselves so that we don’t burn out and become frustrated with the women who are reaching out to us.  An awareness of who we are and what we bring to our work is critical to being able to sustain our relationships with survivors and to being able to be trauma-responsive.    

Painting by Richard Edward Miller

Moving Beyond Being Trauma-Informed

I have never really felt comfortable with the term “trauma-informed.”  It seems passive and too open to interpretation.  Anyone can pick up a book, read an article, or even a blog post and become informed about trauma.  At its most basic, it implies some knowledge of what trauma is and what it does.  It can also be expanded to be a philosophical underpinning of the work that we do to assist victim/survivors of domestic and sexual violence, an understanding that the effects of trauma are because of what was done to a person rather than there being something wrong with her/him.  However, what we really want to be is “trauma-responsive.”  This moves our programs from the basic understanding of trauma to not only having knowledge of the effects of trauma, but also incorporating activities, policies, and interactions that value the experience of the survivor, assist in finding ways to mitigate the impact of trauma, and reduce the possibility of triggering or re-victimizing.

In order to have a definition of trauma-informed services that addresses the needs of domestic violence survivors, the National Center on Domestic Violence, Trauma and Mental Health created the following working definition of “trauma-informed” that moves beyond passive knowledge to a genuine active response. 

”A trauma-informed program, organization, system, or community is one that has undergone a transformation in awareness about the traumatic effects of abuse and violence and incorporates that understanding into every aspect of its practice or program. In such settings, understanding about trauma is reflected in the knowledge, attitudes, and skills of individuals as well as in organizational structures such as policies, procedures, language, and supports for staff.  This includes attending to culturally specific experiences of trauma and providing culturally relevant and linguistically appropriate services. Any person, system, or setting can be trauma-informed. A DV program that is trauma-informed recognizes that survivors, staff, and others they interact with may be affected by trauma they have experienced at some point in their lives. Central to this perspective is viewing trauma-related responses from the vantage point of “what happened to you” rather than “what’s wrong with you,” recognizing these responses as survival strategies, and focusing on survivors’ individual and collective strengths. Trauma-informed programs are welcoming and inclusive and based on principles of respect, dignity, inclusiveness, trustworthiness, empowerment, choice, connection, and hope. They are designed to attend to both physical and emotional safety, to avoid retraumatizing those who seek assistance, to support healing and recovery, and to facilitate meaningful participation of survivors in the design, implementation, and evaluation of services. Supervision and support for staff to safely reflect on and attend to their own responses and to learn and grow from their experiences is another critical aspect of trauma-informed work.” (Training the Trainers Curriculum, NCDVTMH, 2011)

If your program meets this definition, then it is meeting the needs of survivors in a more active, responsive way.

How to Tell if a Therapist is Trauma-Informed

The growing knowledge of the effects of trauma on people's lives has increased the need for trauma-informed services.  In addition, a number of treatment models have arisen that address the needs of trauma survivors.  In response to this increased need a number of therapists have started identifying themselves as trauma-informed or providing trauma treatment when they are basing this solely on the fact that they have a number of clients who have identified themselves as trauma survivors.  It is important to be able to sort out which therapist are actually trauma-informed and are knowledgeable in treatment modes that meet the needs of survivors and do not inflict further re-victimization.

The Sidran Institute at http://www.sidran.org/  as excellent information on what to look for in a therapist and the type of questions you should ask a therapist before engaging in therapy.  Clink here to access their web page on What to Look For and How to Choose a Therapist.

The Pennsylvania Coalition Against Rape  has an excellent document on locating a trauma therapist.

For a list of current treatment models click here.

Taking a Different View - Trauma-Informed Services

Working with survivors of domestic violence can sometimes be challenging.  At times it seems as if they are working against us and sabotaging our efforts to help.  They don’t always fit the ideal description of a victim.  We may expect them to be timid, dis-empowered, fearful, and willing to accept any help we offer them to feel safe.  When they don’t respond to us in the way that we would like we may even feel manipulated, attacked, used, or we may even begin to doubt their stories or label their actions as symptoms of a mental illness.

When working with survivors of domestic or sexual assault who are challenging it is very important that we stand back and take a different point of view.  Instead of talking about a person’s behaviors or symptoms that are getting in the way of her being able to move forward, it is more helpful to ask “how are the effects of trauma impacting her ability to make changes, engage in services and move forward and how can we help to alleviate effects?”  In addition, it is helpful to ask ourselves what we are doing that may be re-victimizing or increasing the impact of trauma triggers.  This is the goal of being a trauma-informed organization.

One definition of trauma-informed services is:

When a program is trauma-informed, every part of its organization, management and service delivery system is assessed and potentially modified to include a basic understanding of how trauma impacts the life of an individual who is seeking services.  Trauma-informed organizations are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that their services and programs can be more supportive and avoid re-traumatization.

In able to provide trauma-informed services, advocates may sometimes need to take a breath and recognize their own trauma responses in order to be able to respond in a trauma informed way.  By thoughtfully working with someone to recognize when she has become activated emotionally and then assisting her in reducing her responses we are of more value as an advocate than if we become resistant or activated in return. 

This may be particularly challenging in working with shelter guests.  A guest can feel powerless in the face of living in a strange place with people she doesn’t know and feeling controlled by staff or other systems.  This will increase trauma responses and a domino effect may occur among the shelter guests, one or more guests’ actions creating a possible activating situation.  Ongoing discussion amongst staff and guests about the effects of trauma and regular activities to relieve stress are vital in being able to help everyone feel emotionally safe.

It can also be helpful to take time out from looking at the non-productive behaviors (trauma responses) that you may see in a survivor and start to actively seek and point out any positive actions the person may make.  We can often fall into the habit of focusing only on the negative and fail to recognize the efforts and strength it takes for a woman to move forward after years of abuse.  Each time we point out something someone does wrong only validates what she may have heard from an abuser or parent.  We can help change patterns by focusing our efforts on a person’s strengths.

Insidious Trauma – Why Anti-Oppression and Social Justice Work are Critical for Trauma-Informed Programs

While many of us working in the field of domestic violence and sexual assault address the needs of survivors of interpersonal violence and recognize the impact of oppression on the lives of victims, we may, at times, fail to realize the overlapping impact of the insidious trauma that is experienced by many groups, including women, LGBT, disabled persons, and the elderly.  Psychologist Maria Root (in a number of articles) describes insidious trauma as the impact of living in societies where stigma, discrimination, and violence against women are still very much part of the fabric of their everyday lives.  We can expand this definition to include other marginalized populations and imagine the impact on a survivor with whom we may be working.

Those of us who work in ending violence against women are well versed in understanding oppression and social injustice in regards to women.  Let’s take that same construct and move on to recognize the impact that a person’s race and/or ethnic background has on their life experience and how it sets a person up for insidious trauma.  A person of color or a different ethnicity experiencing interpersonal violence is most likely also experiencing insidious trauma that occurs from the awareness that their race/ethnicity makes them a target just by their being present in the world.  This is increased when the person is isolated in the community, separated from family and cultural supports, and recognizes their own vulnerability.  Given the messages they may be receiving from the media regarding hate crimes or how they are being treated in public, they may be experiencing some traumatic effects due to insidious trauma. 

This also applies to people with different abilities or the elderly.  In a chapter in Laura S. Brown’s book Cultural Competence in Trauma Therapy – Beyond the Flashback, Dr. Brown tells the story of a young woman with a congenital disorder that had required increased amounts of assistance from others.  This young woman developed the belief that most people who were disabled wished they were dead.  She had developed this from hearing stories of people with disabilities who were seeking physician assistant suicide and finding that there was a pervasive attitude among the non-disabled population that people with disabilities were brave to continue living and felt it was understandable that someone would want to commit suicide.  It is easy to imagine that this attitude by mainstream society could affect a person’s image of his/her self as a valuable member of society. This woman was eventually able to find a movement that protests against this attitude and supports the dignity and affirms the lives of those livings with physical challenges. 

In addition, insidious trauma occurs within the LGBT community as they hear ministers, politicians, and social network trolls make comments about hate crimes or blaming them for natural or manmade disasters such as in Hurricane Sandy or the Sandy Hook school shooting. 

Laura Brown also states that in order to be culturally competent in providing trauma-informed services we should also consider how insidious trauma may be present even if the particular person has not identified having had an experience of overt trauma.  “Everyday racism, sexism, heterosexism, ableism, and other forms of institutionalized oppression may seem so familiar to people as the background noise of their lives that they have no cognitive construct into which to place these encounters; they simply have the post trauma distress and dysfunction arising from doing battle every day against an army of small toxic agents.” Often the historical violence that has been done to a group of people such as Native Americans, Black Americans, Jews, and a large number of immigrant populations has an impact that lasts beyond the generation during which the greatest violation occurred. 

Understanding what we do about complex trauma’s impact on a survivor’s ability to trust and feel safe in the world, we now need to add the understanding that the person we are working with may also be experiencing the effects of insidious trauma.  A person may come into shelter or for other services with lack of trust and an increased sensitivity due to oppression and stigma she may have experienced or seen others of her particular group experiencing.  In the past I have heard people refer to the person as having a chip on her shoulder.  By understanding the effects of insidious trauma, we can now understand that this distrust, hypervigilance, and protective stance are a part of the effects of the trauma experienced by their particular group and should be addressed in the same way we do with other trauma survivors. 

Knowing this, it also calls us to action in regards to addressing oppression and social injustices in society.  We can do this on individual, agency, community, and national levels.  If we are to call ourselves “trauma-informed” we need to also be aware of and address those institutions, attitudes, laws, and beliefs that contribute to insidious trauma.

Looking Through the Trauma Lens with Self- Reflection

Understanding trauma and its impact on survivors of domestic violence and sexual assault is not only a theoretical approach but has become an important component of the way we work.  When looking at our work through the trauma lens it is critical that we look both ways.

A lot of work has been done on understanding the impact of trauma on the survivor.  We know that trauma is going to affect her willingness to reach out and engage when trust has been broken on many levels.  We also have become aware of how concentration and focus can be negatively impacted, reducing her ability to make productive decisions and use resources effectively.  Trauma responses may make it difficult for her to follow-through with appointments or she may avoid circumstances that trigger her or make her feel disempowered.  

It is also important to look through the trauma lens at ourselves and understand how trauma impacts the way that we do our work.  If we are unaware of our own responses to trauma, our own personal experiences and our responses to others’ trauma, we may find ourselves being less than who we wish to be in our interactions with survivors.  Being judgmental and critical of the choices of others, distancing ourselves, or trying to fix rather than support may be signs that we are not managing our own feelings that have arisen due to the impact of trauma. 

As advocates, we have to work with staying present and supportive of survivors even when we feel uncomfortable with their way of being in the world.  It may also be necessary to step back at times to self-reflect on what we bring to the relationship.  Even though we are encouraged to maintain boundaries in our work with survivors, we are also developing a relationship with a survivor that can either help or hinder their healing process.  The following questions from Carole Warshaw at the National Center on Domestic Violence, Trauma and Mental Health can be used in supervision or as a self-tool in order to stretch ourselves and engage more fully in our relationship with the survivor. 

What is particularly challenging for you about this person or interaction? i.e. she never shows up, she is sarcastic, she may be lying to me, I don’t like the way she makes me feel.

What are you aware of feeling?  I get angry, I try to avoid contact with her, I find I want to take her and her child home with me, I feel manipulated, and I am overwhelmed

What are you feeling underneath? i.e. I feel incompetent, I am not a good advocate, I don’t like being angry, I feel special, I feel like I am being set up

What do you think she might be feeling? Is she trying to protect herself? Is she being triggered? Are there feelings coming up in our interactions that she is having trouble tolerating?

What do you find yourself wanting to say?  What is that inner voice saying that you would not want to hear yourself say aloud?

What could you say that might be more helpful?  What would be more a more empathic or empowering, trauma-responsive approach? 

What if this is not signed up for? This may mean that you need more self-care and supervision in order to determine what steps you need to take for yourself.

Taking a look at ourselves through the trauma lens may be difficult at first, but can lead to more meaningful interactions with survivors and others in our lives.  

Introduction to Excellent Website on Providing Trauma Informed Services to Women and Girls

Coalescing on Women and Substance Abuse – Linking Research, Practice and Policy


http://www.coalescing-vc.org/index.htm

This site captures material from historical and ongoing projects related to women’s substance use in Canada. The projects described here have been sponsored by the British Columbia Centre of Excellence for Women’s Health with the involvement of many partners. The site was first mounted to share the findings of the Coalescing on Women and Substance Use: Linking Research Practice and Policy project (2003-2008) a project that sparked short-term virtual communities of practice (vCoP) on six key topics related to women's substance use in Canada. Now material continues to be added from both virtual and F2F projects, for example on projects related to girls and heavy alcohol use, and on applying a gender lens to work on the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.

The aim of this site to share and promote action on promising approaches to responding to substance use by girls and women, on the part of service providers, researchers, health system planners and decision makers.

The following discussion questions found on the site can be used by direct services providers to reflect on their current practices and policies in providing trauma-informed services.

1. What have you noticed about the links among trauma, mental illness and substance use problems from your experience of supporting women with these and related challenges?

2. Does your service assume that violence has played some role in the woman’s/girl’s life, even if she has not identified abuse as a source of difficulty?

3. How does your service currently address the needs of girls and women experiencing trauma, substance use and mental health concerns?

4. Does your service provide training to women accessing services in skills useful to healing from trauma as well as substance use and mental health concerns - such as self-soothing, self-esteem, self-trust and assertiveness?

5. Has education (basic information about trauma and its impact) been offered to all staff at your service? Have clinical staff received training on specific modifications of existing services for trauma survivors?

6. What opportunities are there for building awareness/taking action to improve the response for girls and women with substance use problems and related trauma and mental health concerns?

7. Notice the language used within your context. What would happen if ‘symptoms’ were reframed as ‘adaptations’? How would things change at a practice and policy level if ‘disorders’ were considered ‘responses’?

8. Improving the system of care for girls and women requires a paradigm shift from “what is wrong with her?” to “what happened to her?” Consider what this shift might mean for your services or system.

9. How does your organization support efforts to minimize the possibility of re-traumatization?

10. In what ways are girls and women involved in the development of service policies and protocols?

11. How is diversity, such as one’s cultural background, considered in the trauma-specific services you offer?