Early in my career, I worked on an adult inpatient mental health unit. I also evaluated individuals in the emergency room that presented with mental health crises. I saw a clear connection between certain diagnoses, primarily borderline personality disorder, mood disorders, substance abuse and PTSD, and those who experienced childhood abuse – particularly sexual abuse. Awareness of this connection came only from listening and talking with patients, not from reading their charts or discussing what brought them to the ER that day.
Whether it was in the ER or on the mental health unit, it wasn’t uncommon for me, a fresh out of college 23-year-old, to hear a person tell me about the traumas that she, her parents, and her parent’s parents have experienced, rather than telling the attending psychiatrist, nurse, or social worker.
It was apparent to the patients and to me that the 10 minutes a person’s treatment team spent with them was only intended to treat what was “wrong” with them, not evaluate how what had happened to them had a hand in signing admission papers. There was something lacking in most conversations about patients, whether it was casual talk among staff in the nurse’s station or discussing treatment around an expensive table. I felt an absence of something, always, but couldn’t name it.
My frustrations with common practices continued as I moved into Intensive Care Management (ICM) and then Health Home Care Manager, providing support and coordination of care for individuals living with chronic mental, medical, emotional, and social illness in the community. My teammates and I managed caseloads of 30+ individuals on average. We were the voices for our clients and the eyes and ears for:
• probation and parole officers
• housing program counselors
• department of social services caseworkers
• homeless shelter case managers
• social security administration caseworkers
• emergency department social workers
• representative payees
• addiction recover counselors
• employment support service counselor
• inpatient mental health unit treatment teams
• inpatient medical nursing care managers
• mobile crisis teams
• natural supports
Care Managers communicate with nearly every one of those 15 providers on a weekly basis, for 30+ people. They work closely with resources in our communities and the individuals they serve. This puts care managers in a unique position to witness firsthand the systemic cracks, in multiple systems, that contribute to re-traumatization of the people they serve.
A primary function of care management is to link individuals to providers and community support services. Prior to connecting the client, an assessment is completed to identify what services are needed and other treatment/history information is obtained. The standard assessment forms used may or may not ask about trauma, but even when it does, the “trauma question” is usually squished in between unrelated demographic or financial questions, with no preparation or support wrapped around it for the client or staff. Care managers are often anxious and uncomfortable asking someone they just met to tell them about their traumatic experiences, because they are not trained how to ask, or why such a question is even important. The client is often left feeling like a band aid has been ripped off with no one to help re-bandage the wound afterwards.
Once the assessment is completed, that form is filed away. It is not standard practice to take into consideration a person’s trauma histories when referring to providers, whether the person disclosed trauma during the assessment or not. There is no direction or support for care managers to find trauma-informed community providers. A referral is made based on insurance and who is taking new patients, not on who is capable of best serving the client. A care manager linking a trauma survivor to a doctor, therapist, or other provider with no experience in treating trauma happens every day. This type of care coordination is standard; the acknowledgement of damage done is not.
I often found that while discussing a person’s care with mental health and medical treatment teams, I am informing them of the client’s traumatic histories. How does this important information not come up in therapy or after repetitive doctor visits with no results? How is no one recognizing and addressing the connection between trauma and chronic fatigue, depression, pain, headaches, suicidal ideation, GI issues, distractibility, self-medicating, anxiety, insomnia, irritability, or self-sabotaging behaviors? And why don’t therapists, primary care physicians, and psychiatrists talk to each other?! These individual practitioners are each treating what are really symptoms and maladaptive behaviors of an underlying disease, the disease being trauma. But that disease is rarely if ever at the forefront of treatment planning. It’s infuriating.
I’ve been in situations where I recognize that a client is a clear danger to herself or others. Protocol leads me to initiate a “pick-up order” if they are not willing to go for a mental health evaluation voluntarily. A pick-up order involves the police showing up, usually with little time, patience, or information that I stressed be passed on, and handcuffing the person anyway necessary to be transported to the hospital for a mental health evaluation. I’ve seen too many wrestling matches ending with someone getting injured, and situations where a woman is screaming and fighting off three men in uniform trying to hold her down to “help” her. It’s a scene I’ll never be desensitized to, nor do I ever wish to be. No one should be. Never have I seen this kind of approach not re-traumatize or escalate the person in crisis; and I can’t help but have empathy for the police officers and the stress they must experience after a call like that as well. As I have watched this scene play out multiple times, I have asked myself, where is the evidence that we are really helping, and not causing more harm.
I have joined clients during housing intakes – the assessment/evaluation meeting a person referred for housing services will have to attend. The purpose of this meeting is to offer information about the program and assess the individual for eligibility, need, and housing goals. A person is asked about their mental health diagnoses, medical conditions, and substance abuse history, but rarely if ever is a person assessed for trauma, or the role past trauma currently has in her life. If accepted into the program, she is admitted in to a community residence with approximately 12 other individuals (usually co-ed), or a supportive apartment program, never having met the housemates or roommates. The majority of these programs are staffed with individuals who have big and wise hearts, but little to no training on working with trauma survivors, despite the majority of the population they are working with having moderate to severe trauma histories. How are residential direct-care staff, the ones who spend more time with clients than any other provider, able to empower individuals to cultivate change if they are not oriented to the psychological and biological ripple effects of trauma experienced by those they serve?
Navigating homelessness and obtaining social service benefits can be traumatizing in and of itself, because of the attached shame and stigma our society has assigned to a person asking for help. I have been the advocate sitting with a woman at the department of social services who was finally able to leave an abusive home, asking for help to get food and a temporary roof over her head, only to be placed at a shady motel not on a bus line with no resources or support around her. And our culture calls this “helping.”
I have felt helpless so many times throughout the past two decades, as I have attempted to help others be seen and heard; as I have longed to be seen and heard. It wasn’t until my parenting survivor advocacy efforts seeped into my professional life that I started to uncover a new language. After publishing Parenting with PTSD: the impact of childhood abuse on parenting with my dear friend and soul-sister Joyelle Brandt, I stumbled upon Nadine Burke-Harris’ TED talk How Childhood Trauma Affects Health Across a Lifetime. I remember pulling over on the side of a busy highway because what she was explaining were things I had never heard before and I just needed to be still and listen. I was equally in awe and pissed off. Never in my own treatment or in my life helping to treat others had I been educated on the role trauma has on the mind and body. Never was I guided nor given the opportunity to guide others in understanding that the ability to heal takes more than time, positive thinking, and will power, instead actual physical and psychological repair.
That’s when my professional life got personal.
I dove into learning everything I could about the Adverse Childhood Experiences (ACE) Study, the mind/body connection, and information on trauma-informed care (TIC).
Seeing that term ‘trauma-informed care’ for the first time, I didn’t understand what it meant, but I could feel that it was important. I knew in my gut that I was on a path to discovering a language for the absence in care I have felt since early in my career.
A trauma-informed approach is defined by The Substance Abuse and Mental Health Administration (SAMHSA) as:
“…a program, organization, or system that realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.”
As I gained more knowledge, the cracks in the systems I’d been jumping over to help myself and others morphed into gapping, glowing canyons. The issue is not only the vulnerable falling through the cracks. The absence of trauma-informed organizations is pushing the workforce, a population of vulnerable individuals as well, to the point of breaking.
Care managers need the training and tools to identify and help people utilize trauma-informed health, community, and family support services. Housing providers need the knowledge necessary to ensure physical and emotional safety of their residents and staff. Medical communities need support to engage patients in a way that will address more than the physical manifestations of their emotional pain. Insurance companies and governments that fuel payments to human service organizations need to start seeing the value in trauma-informed recovery services by ensuring payment for those that provide them.
Boots-on-the-ground human services providers are absolutely capable of helping people move forward in their trauma recoveries, and break generational cycles of abuse and dysfunction, but only if given the training, tools, and support they need to do so. I intend to keep turning the volume up, creating, and collaborating until that happens.
The workforce will continue to burn out until those at the top are willing to prioritize the mental health of those on the ground. Individuals receiving the service will continue to suffer the hopelessness and helplessness that comes from spinning through revolving doors. Nothing changes until our systems begin to prioritize trauma awareness and repair.
When I was young and someone would ask me what I wanted to be when I grew up, I always said I wanted to help people. I didn’t know what that meant then, but I do now. I’ve spent the last four years as the program director for a mental health and substance abuse recovery community residence. It’s been an honor to be in a position to create programming that gives both the staff and the individuals we are serving the information and tools they need to thrive.
This movement to acknowledge the whole person remains slow moving, but it’s happening. The volume is getting turned up. Survivors with boots on the ground in the human services fields won’t stop until the blaring gaps in our systems begin to be acknowledged, honored, and repaired. We know better now. It’s time to do better.