Widening their aperture: Why organisations need to be sensitive to trauma right now
It doesn’t take much to scratch the surface of almost any mental health organisation to see that they depend on a resilience approach in their practice and policy, but without being trauma-informed. Trauma-informed here means using interventions, treatments, etc., sensitive to the needs of trauma survivors (Jennings, 2004). The positive psychology movement, which began in the U.S. and has grown over half a century, aims to study “the conditions and processes that contribute to the flourishing or optimal functioning of people, groups, and institutions” (Gable & Haidt, 2005, p.103). This movement is the chief promoter of the notion of resilience as an end in itself for recovery from trauma which can be problematic (e.g., Misrachi, 2018). Some even make reference to “potential trauma” with “resilience being the modal response to adversity” (Galatzer-Levya, et. al., 2018, p.41), a position which ignores whether or not trauma is truly present.
Adopting a “potential trauma” stance can be considered harmful. First, it goes against trauma research which stresses the critical importance of establishing trust in a person’s often fragmented narrative for the purpose of their trauma recovery (e.g., Herman, 1992; Kezelman & Stavropoulos, 2019a; 2019b). Second, credibility of the trauma-survivor’s narrative is under assault, undermined by doubt sowed by authority figures adopting a biomedical model. This contrasts with Engel’s (1980) seminal bio-psycho-social model where understanding a person’s subjective experience, among other things, is to this day understood as essential if one is to make an accurate diagnosis (e.g., Maier, et. al., 2018). Being genuinely trauma-informed drives a more accurate diagnosis.
Essentially, if we care about making people resilient, we’ve first got to understand the circumstances under which they are living and lived as children or adolescents. This needs to include any history of interpersonal trauma (which may not always be obvious), irrespective of how well they’re faring today as adults (Misrachi, 2012). After all, bodily responses caused by interpersonal traumatic experiences, such as chronic diseases pertaining to liver, lungs and heart, cancer, stroke, diabetes, skeletal fractures (Felitti, et al., 1998), are seldom tracked to their antecedents (Herman, 1992). Kauffman and colleagues’ (1979) coined the term “superkids” to depict resilient children suffering from interpersonal trauma. Irrespective of how “super” someone is, abuse, neglect or interpersonal trauma during childhood, leads to trauma responses across their lifespan (e.g., van der Kolk, 2015). This precise phenomena has been reported since at least the 1920s (e.g.,Canavan & Clark, 1923). But are today’s organisations widening their aperture?
It seems when people present to an organisation for help they are often met with this kind of approach: We the organisation will help you by locating your own existing resources and make them a foundation for resilience. Then send you back into the maelstrom. Resilience is within you and it’s our job to shine a bright light on it and bring it to the fore.
Trauma is a normal response to an abnormal event or series of events (Herman, 1992; Lanius, Vermetten, & Pain, 2010; van der Kolk, 2015). Some researchers do try to understand resilience in the context of high stress. For instance, Haglund and colleagues (2007) attempted to look at the psycho-biological mechanisms of resilience and its relevance to prevention and treatment of stress-related psychopathology. But trauma (e.g., (Kezelman & Stavropoulos, 2019a; 2019b) as is the case with grief (e.g., Misrachi, 2015; Hall, 2011) is not about ‘pathology’. Although trauma can potentially lead to poor health outcomes (Felitti, et al., 1998), trauma itself is definitely not a disease and ought never be pathologised.
Mental health organisations need to become more sophisticated. Before being quick to have their clinical staff prescribe ‘resilience pills’, they first need to encourage the examination of what sits beneath apparent resilience in order to treat the traumatised individual as a whole person. Professionals and mental health organisations that hew to the concept of resilience without being trauma-informed may be remiss in their critical thinking. Any institutional passion for resilience, without heeding context, is hazardous to our collective health (e.g., Miles, 2004). All staff within any medical organisation must also look under and behind presentations of resilience.
There are consequences if organisations push a resilience approach without context involving trauma knowledge. For instance, without being trauma-informed, mental health organisations promoting resilience as if it is a ‘cure all’ rather than what it actually is — an unnatural construct (Luthar, 2015) — do little to contribute to clients’ psycho-emotional safety and may (unknowingly) be doing harm (e.g., Miles, 2004). Could it be that such organisations’ obsession with efficiency and scale that, for them, resilience building becomes an easy out? If so, then this type of assembly-line mentality may facilitate and perpetuate iatrogenic damage (Caplan & Caplan, 2001). For instance, mental health organisations walking away from seemingly ‘resilience-achieved’ individuals without looking at their contextual histories risk abandoning them to further states of abjection thus fuelling a diabolical dilemma. On the one hand, such people were pushed into becoming resilient in the first place to simply survive their early traumas. On the other, they are resilient therefore, let’s all go home now. Why give further attention? Here’s the short answer: psychological trauma essentially begins and ends where it is held — in the physical body — and if context of any early trauma is not acknowledged and dealt with it’s likely to play catch-up in physical diseases, mental illness, addictions or early death. This is because, according to Felitti and colleagues’ (1998) seminal research, there is a relationship between childhood abuse and household dysfunction in many of the leading causes of diseases and early death in adults, e.g., people with “high levels of trauma are at triple the risk for heart disease and lung cancer” (Burke Harris, 2014). The late Royal Australian College of General Practitioners (RACGP) president, Dr Harry Nespolon, reporting on Australian’s health, stated “the more significant your mental health problem is the more likely you are to have some significant physical problems as well” (Chalmers, 2018). Here, we should also include doctors’ suicide risk (Galbraith, Boyda, McFeeters & Hassan, 2020; Ventriglio, Watson, Bhugra, 2020).
Increasing an organisation’s staff sensitivity to trauma makes them better equipped in preventing problems. Mental health organisations rushing in to adopt the positive psychology movement’s embrace of resilience without investigating any presence of trauma are, in essence, proactively avoiding a trauma-informed approach. By contrast, an organisation’s culture that embeds a trauma-informed approach takes into account models for developing trauma-informed behavioural health systems and trauma-specific services. In other words, they see the need to be sensitive to trauma and they take into account the shape and situational context involving trauma’s various complexities in their clients’ trauma histories, and they know that not doing so spells trouble (Jennings, 2004).
Beware of resilience being marketed as the easy, quick answer to complex narratives for under-resourced community organisations (e.g., Pressley & Smith, 2017). For example, mental health organisations blindly adhering to the current vogue of adopting a resilience framework without a firm grip on trauma-informed interventions and services are not saving anybody money (e.g., Kezelman, et. al., 2015) and may inculcate a “just get over it mate” attitude. Such an attitude could deepen an already self-destructive social norm as those unable to meet expectations of resilience could be viewed as ‘problematic’. That is, the operational manifestation of such a social norm might be isolation, loss of trust, loss of a sense of belonging, threat of estrangement from the familiar, and perhaps in more extreme cases, suicide (Falcone &Timmons-Mitchell, 2018). In fact, worldwide, approximately “one person every 40 seconds” suicides annually (WHO 2014).
Ignoring trauma helps nobody (see Teach Trauma website). Tracking any type of trauma is highly relevant as Devine (2017) aptly reminds us: “It’s OK That You’re Not OK”. Yet according to John Mendoza at the Brain and Mind centre University of Sydney, in 2017 more than 3,000 Australians died by suicide (Van Extel, 2018). What we also know is that “childhood abuse, neglect and trauma is the strongest predictor of later development of mental health problems and suicidal behaviour in adolescents and adulthood” (Mendoza, 2014). Yet sadly, for most organisations two co-existing realities sit side by side: an over-focus on resilience with a gross under-focus on interpersonal trauma. It’s worth asking if these two contrasting co-existing realities contribute to traumatised individuals attempting to end their life? For instance, Prytherch’s (2018) research reveals how using a trauma-informed approach, i.e., “reframing suicidal feelings as a reasonable response to events in people’s lives” (abstract), was helpful to participants as it provided safety, freedom and thus control. Such a trauma-informed approach within organisations will more likely promote resilience without a need for any officially imposed resilience framework.
Perhaps we need to ask the right questions. Scientists at the National Scientific Council on the Developing Child at Harvard University (2014) reported being challenged by how someone could appear “just fine” (p.18) despite significant earlier traumas. It’s tempting to focus on why such individuals may display resilience rather than the what and how. Given that trauma is a hidden epidemic (Lanius, Vermetten & Pain, 2010) taking decades for its impact to surface (e.g., Felitti, et al., 1998), we should be more sceptical of the notion that resilience alone will fend off these impacts into the future. In their (2017) book chapter called “The Challenge of Context”, under sub-heading “How Do We Prevent Harm to Patients?” (1.8.1), Godbole and colleagues note it is the adverse events (not resilience) that first needs to be reported and analysed:
“We prevent harm to patients [this naturally includes doctors who are also patients] by understanding which adverse events are causing or posing a risk to patient safety and putting in place measures to prevent them from occurring or by mitigating the effect of those adverse events. The key to this is reporting and analysing adverse events”. (p.8)
Better questions were asked over ten years ago: What are the predisposing, precipitating, perpetuating and protective factors at play in a person stepping into a mental health organisation asking for help? (Havighurst & Downey, 2009). These are classical clinical questions understood as the “4 P’s” (Broder & Hood, 1983). But missing is a fifth “P”: what are the preventative factors? That is, what can staff and the external parties they liaise with do to prevent the perpetuating or precipitating factors in the affected person from continuing? After all, your formulation guides your assessment, which in turn leads (or misleads) your treatment (or non-treatment). Therefore, your reasoning in the context of mental health should be based on solid trauma-informed knowledge.
We cannot afford to be dazzled by resilience. Ironically, resilience alone acting as camouflage for trauma survivors is precisely what can stop or delay their much needed trauma-informed interventions.
Ethically, all mental health organisations need to be sensitive to trauma. They need to recognise the limits of any resilience-alone approach. Nadine Burke Harris, a paediatrician, puts it in plain language in her 2014 Ted Talk: “childhood trauma isn’t something you just get over as you grow up”. Even an impressive level of resilience can act as dangerous camouflage if a person’s concealed trauma remains buried by the very mental health organisations whose aim it is to prevent, not hasten, illness and death.
The shock of the Covid-19 crisis ushers in new challenges, new worries, and new traumas, e.g., concerns about social connected-ness and unavoidable financial distress (Henriques-Gomes, 2020). Researchers at The University of Sydney are also worried about an increase in suicide (Reiner, 2020). If we add consequences of Australia’s bushfires and the health emergencies under climate change (Yu, Xu, Abramson, Li & Guo, 2020), there is an even greater urgency for organisations to be well equipped with protective and protected trauma informed policies and practice. Only with a trauma friendly approach can we see whether resilience might kick in, as determined by the sufferer him- or herself, not by any externally imposed expectation or hope. We may be better off exploring what a person needs in terms of internal and external resources, skills, connections (e.g., Reeve & Lee, 2019) rather than anticipating expectations of “resilience” which could become an added burden due to its narrow focus (Brown & Dixon, 2020). Resilience needs to be a natural outcome for the traumatised rather than an artificially imposed framework. Assuming good organisational intentions is simply not good enough. Something needs to change. Here are three quick take-home messages:
- Never overlook or underestimate context, as otherwise ‘resilience’ offers little help to traumatised ‘superkids’ or anybody else.
- Resilience on it’s own doesn’t mean terribly much because nobody is made of rubber and anyway, rubber melts under high temperatures.
- Herein lies a clear-cut message to all mental health organisations employing doctors and mental health practitioners: Be brave. Go beyond outward appearances of resilience. Go read “10 Questions Some Doctors Are Afraid To Ask” (Starechesk, 2015).
Suzette Misrachi, Master of AdvSW (Research). Consultant and professional supervisor specialising in trauma and grief, international presenter. For info relating to Suzette’s research on Competent and Non-disordered Children Of Parents with a Severe Mental Illness (CaN-ACOPSMI) email: suzette.misrachi@gmail.com Therapy or supervision via Skype is now available under special circumstances (with G.P. referral) for those in regional Victoria, interstate or overseas. Website here.
This article was originally published in Mind Cafe, February, 2021, Issue 67.
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