Unmasking trauma-informed care


The state psychiatric hospital where I work has implemented mandatory training of all staff in trauma-informed care and nonviolent communication. A recent email from the staff development department containing the link to this first of several mandatory training sessions said that “culture change was not easy.”

Without going into what exactly has been the culture of our institution, why it needed to be changed, or who was responsible for this decision, this communication simply announced that trauma-informed care principles were now going to form the basis for the operation of our facility. A subsequent email announced the unveiling of the “Empathy Room,” where staff members, many of whom have worked in mental health for decades, could take their “first step toward greater empathy for others” (italics mine) and also “experience symptoms of mental illness all around you.”

Courtesy Boris Vatel, M.D.

Dr. Boris Vatel

The need for “culture change” in institutions such as ours becomes plain to anyone who attends trauma-informed care training. It turns out that all these years, we have wrongly used the medical model as a prism through which to view our patients. Apparently, the medical model focuses on what’s wrong with the patient instead of asking what happened to him. Whereas the medical model looks for symptoms and deficits, the “recovery model” emphasizes strengths. Indeed, so trauma-informed theory teaches us, we ought to recognize symptoms as means of adaptation to stress and to reframe disease in terms of past trauma exposure. And it is trauma, first and foremost, in all of its possible manifestations, that should form the paradigm through which to see our patients, or, as the training refers to them, “clients and consumers.” Trauma is pervasive, trauma is anything that is experienced by the individual as physical or emotionally harmful, and it might even be “historical,” with effects on several generations. Trauma is so universal that we, all of us, must become co-sufferers, presumably taking turns soothing and “validating” one another.

Traditionally, medical care has been informed, if one wanted to use this term, by the need to relieve the suffering of the patient through the use of medical knowledge and expertise acquired during specialized training. It is the sort of care that the Hippocratic Oath speaks of. Physicians, as practitioners of medicine, therefore operate on the principles of medicine-informed care, or on what is known as the medical model. A culture based on the medical model assumes that there is such a thing as illness in distinction to health, that there is a body of knowledge about the causes and treatments of various illnesses, and that there are people who are specifically trained in diagnosis and treatment of illness. Implicit in the medical model is the idea that there are those in need of medical help (i.e., patients) and those with the expertise to offer it (i.e., physicians).

Trauma-informed care makes rather different assumptions. Apparently, terms such as disease, pathology, doctor, and patient are divisive, hierarchical, and focused on someone’s incapacity. Rather, we have to adopt a new paradigm emphasizing strengths and survival. Even the term “sympathy” is considered an insufficient way of expressing positive regard for the patient. Rather, we should empathize with our patients which, according to the common dictionary definition, means that we ought to identify with them and vicariously experience their feelings. Since empathizing with medical disabilities we might not possess is difficult, it becomes necessary to find a nonclinical cause for empathy that could be shared by as many people as possible. The new, trauma-informed method of health care delivery focuses on the assumption that in one way or another, we all suffer trauma and can therefore empathize with one another’s trauma experience.

Marxist agitators sought to awaken in the proletariat the sense of being oppressed by the bourgeoisie. Trauma-informed care theory apparently seeks to awaken in everyone the sense of having been traumatized. Both ideologies aim at “culture change,” the former by eliminating the privilege of privileged classes, the latter by deconstructing the notions of health, illness, and medical expertise implicit in the medical model. Trauma-informed care is essentially a strategy for changing a treatment philosophy rooted in the medical model to a political philosophy in which patients are seen an oppressed class – victims of but potential victors over trauma. Somehow one senses in trauma-informed care a kind of conspicuous compassion campaign, orchestrated by the few who have been traumatized to convince the many who have not that the problem belongs to all.

Medically speaking, trauma has usually been defined as physical or psychological injury resulting from an outside event or force. An automobile accident may or may not cause trauma to the body, but the collision is not trauma, per se. However, trauma-informed care training teaches that traumatic stress already constitutes an injury, and since the definition of traumatic stress is whatever one may find stressful, we are all potential trauma victims. Because trauma-informed care has no language for dividing pathology from normality and because everyone’s experience and pain are seen as equally “valid,” trauma-informed care actually trivializes severe trauma by placing it on par with experiences that objectively would be classified as merely unpleasant. Considering the statistics typically cited in trauma-informed care training on how widespread and disabling trauma experiences are, it is a wonder that anyone in our traumatic history has ever survived childhood with an intact capacity to function in the world.

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