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Spring 2009 | Vol 12 No 3

Focus

Beyond survival

Facing the past, claiming the present

By Tim Wall

A sexual abuse survivor is involuntarily hospitalized in a psychiatric ward for suicidal behaviour. She writes in her journal: “I feel like I am being raped over and over again. I feel like I have to tell things to people I don’t know who scare me with their presence, people who play tricks on me, who use their power to control me. These people ask question after question with no emotion, with no care for me. I am merely an object for analysis. Look at the poor freak.”

It is estimated that one in four people have been affected by trauma and that one in 10 Canadians suffers from post-traumatic stress, according to the Canadian Mental Health Association. Trauma generally refers to experiences or events that are over-whelming and devastating to the victim, resulting in profound feelings of terror, shame, helplessness and powerlessness. For many, like the woman in the above fictional scenario, trauma is not simply an event or series of events – it is a life-defining experience that can shatter a person’s sense of self and their view of the world. From the time that a trauma occurs, people with post-traumatic stress feel the effects in all aspects of their lives.

In social service and health care settings, people with trauma are at risk of being retraumatized because their behaviour may be misinterpreted and misunderstood. What is a normal response to an abnormal event is pathologized. This risk is largely due to our lack of knowledge and sensitivity to the needs and experiences of people with trauma. These experiences are so prevalent that service providers should assume that a significant number of people they serve have experienced some type of trauma. Yet we do not. This misunderstanding can create fear, retraumatize people and create ghettos of care within the health care system. Many service providers consider trauma a Pandora’s box – something to be feared and avoided. Yet this avoidance only increases clients’ sense of alienation, hinders their recovery and increases their risk of being retraumatized.

Given the high rates of trauma experienced by clients and the risk of retraumatization through insensitive practices, we as care providers must find ways to weave recognition of trauma into how we approach our work. This trauma-informed care needs to be integrated into the entire system of care – at the clinical, organizational and systemic levels. It does not mean that we must all do trauma therapy; it means that we must be sensitive to how trauma affects clients and how the care we provide, and the system itself, can retraumatize clients.

Every health care provider and social service worker can play a role in supporting people in their healing process, without doing actual trauma therapy. And not everyone who has experienced trauma requires trauma therapy. Practicing trauma-informed care does not apply only to our work with people who have experienced trauma – it is a philosophy of care that treats all clients with sensitivity and respect and acknowledges that the system itself can be traumatizing or retraumatizing.

Klinic Community Health Centre in Winnipeg, Manitoba, practices trauma-informed care, which grew out of the trauma recovery work we have been doing for more than 30 years. Much of our work has focused on developmental trauma, family violence, sexual assault and suicide bereavement. Our move towards trauma-informed care was motivated for many reasons, including our own self-preservation. As the number of referrals to our post-trauma program grew and far exceeded our capacity, it became apparent that the larger system of care needed to change. We identified various systemic issues:

• While some people required more specialized trauma recovery services, many did not and would benefit from a service provider who was trauma informed but was not necessarily a trauma specialist.
• People already being seen by therapists were often referred to specialized services once they were identified as trauma affected, fragmenting their care and potentially sending a powerful, negative message.
• Trauma seemed to heighten service providers’ anxiety, which clients undoubtedly sensed and reinforced their belief that something was very wrong with them. This discomfort reflected the general level of fear and ignorance that permeated the system around trauma issues.
• For people in need of longer-term counselling, limited resources were available and waiting lists were growing. Many clinicians were reluctant to take trauma clients because they believed this would require a long-term commitment. The health care and social services systems appeared reluctant to expand their involvement, focusing instead on short-term and crisis services. It was becoming increasing difficult for people seeking trauma recovery services to find and access them.
• There was growing frustration with policies and practices within various institutions that seemed to re-traumatize clients rather than provide a safe, healthy environment for recovery.
• There was great concern about the lack of resources and information for people affected by trauma in remote and rural areas.

In an effort to begin addressing these problems, Klinic, along with several partners, and with support from the provincial government and the Public Health Agency of Canada (PHAC), organized a provincial trauma forum to explore how to increase the capacity of organizations and systems to better meet the needs of people affected by trauma and to promote trauma-informed care. The forum produced various recommendations that were compiled into a report, available on Klinic’s web site at www.klinic.mb.ca. A provincial trauma leadership committee was established to explore strategies for implementing the recommendations.

With funding from PHAC, a trauma-informed toolkit for organizations and service providers was developed and is available at www.trauma-informed.ca. I hope over the next year to develop a multi-disciplinary trauma recovery consultation team to provide support to clinicians and that specific training about trauma-informed care and trauma recovery will be developed.

Much work lies ahead, but there is a climate of change and openness to working together to address this major public health and social issue. This change does not require large investments in new infrastructures; it depends on sharing knowledge and promoting awareness and understanding. Compassion, interest, curiosity and understanding cost little; ignorance, prejudice, apathy and misinformation cost everything.

Tim Wall is director of Counselling Services at Klinic Community Health Centre in Winnipeg, Manitoba.