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Trauma-informed vs. Trauma-driven?

Are we getting carried away?

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In my work as a consultant on issues related to trauma-informed practice, supervision, and ethics, I get the opportunity to travel around the State of Oregon and to see what a lot of agencies are doing. This is an exciting era! So many organizations are learning, embracing this framework, re-looking at their business-as-usual baseline, and driving deep, innovative change in their practices, policies, structures. They are becoming more responsive to clients who struggle with histories of trauma and adversity.

But there have been multiple moments in the last year–during question and answer periods or smaller meetings–that have given me pause, when I wondered if we were taking this approach past the limit of its effectiveness.

Before I share my reflections, I think it would be helpful to remember the goal of becoming a trauma-informed organization. Here’s the SAMHSA definition:

Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.  

It’s pretty broad, right? I interpret this passage to mean that organizations using this framework are re-looking at ways routine service delivery–“business as usual”–may be a barrier to accessing help, especially when it comes to that initial engagement in services. Thus, because of the ubiquity of early adverse experiences and their interpersonal fallout, we adopt an approach of universal precaution that minimizes triggers, to the greatest extent possible, strives for greater sensitivity, and regards the continuum of post-traumatic conditions as invisible disabilities that require accommodation.

So what’s the problem?

Of course reasonable people can disagree, but I want to share some observations based on some recent conversations. TRIGGER WARNING: These might be controversial.

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Over-reliance on the word “trauma.” One of the hazards of the trauma-informed era is an over-reliance on the word trauma itself. We have started to use it imprecisely. The original Adverse Childhood Experiences Study (ACES) did not document the ubiquity of post-traumatic stress disorder, per se. It underscores the prevalence of adverse experiences (not necessarily trauma) that interfere with brain development and attachment and that lead to health-interfering behaviors and poor health outcomes. Trauma refers to horrific, out-of-the-ordinary event(s) in which we fear for our lives or the lives of loved ones.

In my workshops, whether I’m addressing clients or employees, instead of using the word trauma, which applies to a narrower subgroup, I’m talking more and more about toxic stress: stress levels that are so high they can make us physically sick. (I don’t usually say “vicarious trauma” anymore either.) Many people who experienced adverse experiences as children are not necessarily traumatized because they had enough protective factors, individually and environmentally. They may even consider themselves more resilient as a result of their challenges.

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Trauma effects as static vs. dynamic. Trauma survivors struggle with trauma effects, symptoms that play out powerfully in relationships, including those with professionals. Sometimes when I hear agency staff talk about trauma survivors, whether they’re referring to clients or themselves, there is an assumption that PTSD is a static condition, unmovable, that survivors are defined categorically by past events, and that helping professionals need to accommodate this unchanging condition.

While PTSD symptoms are often persistent, no one wants to be defined by them. Most trauma survivors want to heal, to change. To what extent do we create workplace conditions that may, in fact, maintain trauma symptoms–e.g. emotional dysregulation (emotional reactivity, defensiveness), fight or flight behaviors–because we’re walking on eggshells and not gently challenging both clients and employees to a higher standard of self-awareness, self-regulation, and behavior?

In innovating programs, we want to take into account that trauma effects diminish when we are in healthy, healing relationships. We need employees who are committed to their own self-awareness and mental health, who are responsive to clients without being enabling of more dysfunctional, self-protective behaviors. We need organizational environments that place a premium on safety. This is the delicate balancing act of trauma-informed practice.

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The illusion of the trigger-free zone. One of the inaccuracies I hear frequently is this idea that if agency staff are trauma-informed enough, they will never trigger anyone, whether they are employees or clients. This is impossible.

Triggers–those sensory details that activate our limbic system, causing distress, pain, reactivity, and other post-traumatic effects, the residue of past traumatic experiences–fall on a continuum. On one end there are triggers that can be generalized to a large, historically targeted group of people that has a history of oppression (e.g. catcalling women). It’s always wrong. No one should ever do it. On the other end of the continuum, there are triggers that are more specific to an individual’s experience. For example, once I  showed a movie clip that included a mother and daughter having a volatile argument. Someone complained to me that they were triggered because of growing up with an abusive parent. But we can’t protect against all the individual experiences of past trauma. In these instances, managing and neutralizing triggers is the responsibility of the survivor.

Fear of conflict is increasing. Conflict with another person can be stressful: emotions may reach a pitch; voices may raise; people may persist in disagreeing. It’s unpleasant, maybe even triggering for people. But honest face-to-face conversation to address differences should not be avoided. The ability to tolerate healthy conflict–to manage the emotions it brings up in us–is an essential skill for navigating any relationship, whether personal or professional. One aspect of the illusory, trigger-free environment, if we’re taking trauma-informed practice to an unhelpful extreme, is that we should be protected from face-to-face conflict. We should not. It’s an important part of being human and connected. It’s hard but it’s important.

The key message I want to drive home is that creating environments responsive to individuals (employees or clients) who suffered adverse childhood experiences, who may even have PTSD as a result, is a delicate balancing act. We want helping environments that are intentional and trauma-informed, not reactive and trauma-driven.We want to engage vulnerable people and eliminate unnecessary barriers to getting help, while also recognizing that in order for people to heal, we need to anticipate and support healthy behaviors as well.