Trauma-Informed Approaches: The Good and the Bad
Going beyond screen-identify-treat strategies is often reaching too far.
Posted Sep 17, 2017
I recently had an interesting discussion with a scholar who is conducting her dissertation research on how trauma-informed approaches in social services are shifting urban policies. She contacted me to ask if she could interview me for her research. She had read the skepticism in my last blog, Have You Lost Your Mind?, about the toxic stress theory of trauma and she thought I might have an instructive viewpoint.
I can be a bit cantankerous when it comes to giving interviews, but I realized that this was a topic that I had been wondering about myself. As trauma-informed approaches are popping up everywhere, with captivating catchphrases like trauma lens and trauma toolkits, my concern is whether consumers are truly benefiting from these approaches or are they being bamboozled by a vogue of gobbledygook? Maybe this grad student could help me as I helped her.
Some of the issues, I knew, are straightforward. A trauma lens is not a physical lens. It’s a metaphor for an altered way of thinking for those who were not thinking of trauma before. Personally, I have not needed to alter my thinking to be aware of trauma. Having a Thomas Hobbes-like view that life can be inherently nasty, brutish, and short, I am unsurprised that traumas occur. It was probably wise that I self-selected myself to work in this field. But for others, who seem constantly surprised that traumas occur, I can see the value of a corrective lens.
A trauma toolkit refers to informational handouts, self-care tips, questionnaires that screen for exposure to trauma and for PTSD symptoms, and exercises to help folks cope with the effects of trauma. Toolkits have sprouted everywhere. There are trauma toolkits for child welfare, pediatric medical trauma, teachers, schools, yoga, vicarious trauma, and more. Someone needs to invent the toolbox to carry all the toolkits.
Some other issues however are not so straigtforward. A trauma-informed approach is a catch-all phrase that encompasses all of the above and anything else that seems related. It is this one that is more nebulous, and the one that I hoped might become clearer when I talked with this eager young mind of the graduate student.
We talked on the phone for about 45 minutes. We discussed things like, what does trauma-informed mean for judges who are passing out sentences? For schools that deal with disruptive children? For child welfare? For mayors who administer violent cities? Baltimore and Philadelphia decided recently to become trauma-informed cities. What exactly does that mean?
I came away with two conclusions. My first conclusion is a favorable one. At the nuts-and-bolts level of trauma-informed approaches, there are strategies for a simple level of screening that makes sense. Screen to identify those persons who have been exposed to life-threatening trauma and impacted by symptoms of PTSD, and then get them to appropriate treatment. The screen-identify-treat strategy is what you would do for any medical or public health issue that is vastly under-recognized. That’s exactly what we are doing in my Louisiana Child Welfare Trauma Project funded by the Children's Bureau.
My second conclusion is a fairly negative one. There seems to be a more extreme agenda within the trauma-informed approach. When folks start moving beyond concrete screen-identify-treat strategies, the aims seem to get misty. The more nebulous “trauma-informed approach” catchphrase encompasses all things beyond individual screening and seems to tackle the question, "How can we reshape society?" Guidance of legislation and public policy seems to be the ultimate, grandiose goal. For example, in the more extreme agenda of trauma-informed approaches, proponents claim that toxic stress damages the brain, something the evidence clearly does not support yet.
In these extreme versions of trauma-informed approaches, proponents also frequently evoke the famous Adverse Childhood Experiences Study (ACES). In the ACES, researchers asked over 17,000 adults about the number of adverse events in their childhoods. These events included life-threatening events such as sexual abuse, physical abuse, and witnessing domestic violence, but also about non-life-threatening events such as emotional neglect, parental substance abuse, parental separation or divorce, and incarcerated household members. Researchers found that persons who had more ACES events in childhood also had more health problems as adults. They interpreted this association as a dose-response relationship by asserting that these childhood ACES events caused the adult health problems.
How does one infuse a trauma-informed approach through a whole society by guiding legislation and public policy and reshaping cities? The Wisconsin state legislature has made the most far-reaching stab so far. In 2013 they passed a resolution that formally declared that toxic stress, such as ACES events, permanently damage the brains of children, and that all of their future legislation should take this into account.
What’s the harm in that, right? The harm could be that these extraordinary claims of toxic stress and ACES effects are wrong, and as comedian Stephen Colbert has re-framed the illusion-of-truth effect, they only have truthiness.The harm could be that the Wisconsin resolution is an overreach of the facts. There are other explanations for why ACES events cluster together and why persons with high ACES scores have more health problems as adults, and ACES events can’t be blamed for all,or any, of those problems. The harm that could result might be that the Wisconsin state legislature allocates funds for some misguided projects to prevent ACES when scarce funds could be spent on something more useful. It becomes an issue of spending taxpayer money. This overreach also is troubling on the grounds of being consumer misinformation. Consumers don’t want to be bamboozled and lied to. It’s not a fact that stress damages the brain and experts ought to respect the limits of their knowledge.
Trauma-informed proponents who have political motivations and want to reshape society and guide legislation keep repeating that stress damages the brain and ACES events cause you to die early despite the shaky science behind the theory. The political motivations may include the desire to get funding for their causes (see my Stress Is Not Trauma blog), or the phenomenon that humans need someone or something to blame when things go wrong, or the attraction to a theory that claims you can literally shape children’s brains. The prospect of being able to shape a person’s brain does not come along every day.
This type of overreach has now crept into the city-wide level. After crises, it is becoming a go-to move to pivot towards a trauma-informed approach (e.g., Baltimore following the 2015 riots). The graduate student asked me about New Orleans because that is where I live. She asked me, “How did Hurricane Katrina affect New Orleans in terms of trauma?” On the one hand, there are very specific effects of Katrina. Folks still have untreated PTSD. About 100,000 people have never returned. Some neighborhoods still have large empty spots. Structural damages are still being repaired. On the other hand, it’s hard to put your finger on a zeitgeist effect on the daily culture. Many other things have happened, many other things will happen, and life has to go on. New Orleanians are hardly defined by Katrina.
Trauma-informed proponents will keep pushing the extreme agenda forward. They will keep repeating the ACES mythology. They will craft more resolutions and stimulate more trauma-informed cities. To create more believers in the more extreme agenda, it seems like the strategy of proof by repeated assertion. It’s an essential technique of propaganda that if you repeat something enough times, it’s real, right?
During the interview with the graduate student, she did not disclose her personal opinion of the trauma-informed agenda, and I was relieved by her impartiality. At the end of the interview, the graduate student asked me if I had any questions for her. I asked her if she had figured out if or how trauma-informed approaches reshape urban societies after all of her interviews and research on this topic. She said not yet, but she was going to keep working on it.