How (Not) to Re-traumatize Our Clients

We invest energy in becoming skilled in delivering effective treatments to address trauma, which is great. Yet the venues where many of us offer services are re-traumatizing, causing clients exactly the sorts of harm we seek to minimize and counter. They are not trauma-informed in their policies, practices, and physical premises. If you already are persuaded and aware of this read no further. Otherwise, join me while I become activated, even agitated, about it.

I recently spoke with a friend who began our phone call by saying he was “fine” then mentioning that he had learned, by email, from his primary care physician that, in effect, she had been fired. He went on to make up a story (because that’s what we do when the world around us gets crazy) to help explain why someone he considered so capable, considerate, kind, and generous with her time – “the best doctor I’ve had” – might have been the victim of agency expansion and her part-time commuter status. As he began (arguably catastropic, black-or-white) thinking about whether to switch to a local group practice for medical care because patients spoke well of it, confusion emeged. Maybe it would be difficult to coordinate ancillary health services such as pharmacy, laboratory, and psychosocial services; now, all he need do is walk across the street.

“My head is spinning. I don’t know what to do. At the same time I feel immobilized and stuck,” he said. I heard the panic and the shutdown. I thought “Fear … freeze. Go ventral.” So I said “You’re very well connected at that organization,and you do a lot for them as a volunteer. You know a lot of people and a lot about what’s going on. I’m wondering if there’s someone you could talk with, who could help you figure out what to do, who you trust and feel would be fairly unbiased?” He immediately remembered that he has good rapport with and respect for the agency’s patient advocate. As soon as he thought about getting in touch – “I’ll call and make an appointment as soon as we get off the phone” – he said he felt calmer. Whereupon, I stepped up to my soapbox and engaged in a brief but pungent rant about how agencies re-traumatize the very clients they intend to serve.

The specific organization in this case is the principal provider of services to gay men with AIDS and HIV infection in a relatively rural location with a proportionately very large gay population. In addition to medical and mental health care, this agency provides a plentiful array of recreational and personal development programs. It provides affordable housing for hundreds of clients and housing assistance for still others. It administers financial services including food and transportation vouchers, prescription assistance, and counseling/advocacy regarding health insurance and disability coverage. Symbolically (transferentially, for those inclined to think that way), it is a substitute family insofar as it provides for so many practical, survival needs including, in my friend’s case, shelter. Because clients are predominantly gay men, for many clients it is, potentially, a corrective family: it serves a population that has experienced the various sorts of trauma inherent in a non-normative sexual or gender identity and intends to be gay-friendly. In my friend’s case, the subtle and pervasive shame of growing up gay in a heteronormative world was compounded by an alcoholic mother and a father who raged, neither of whom knew what to do with a “sensitive” son. It included being the victim of a violent hate crime, not to mention lifelong exposure to hundreds of thousands of microaggressions and the unrelenting public drumbeat of homophobia and transphobia that continues despite legal progress. It includes being diagnosed and living with a life threatening, chronic medical condition which, in his case, means a disability that precludes employment.

Over several years, my friend has observed and experienced arbitrary and sudden staff changes, outright hostility directed at agency clients and volunteers, erratic behavior and moodiness among some staff, lack of communication, lack of physical security at his housing complex, abrupt changes in administrative requirements for continued eligibility for services, and a continued and pervasive sense of things being in flux. It’s as if an organization were trying to reproduce the conditions of a dysfunctional family: inconsistency, lack of transparency, emotional lability, arbitrary and inconsistent rules, outright threats to survival, the sudden disappearance of people who can be trusted without closure or explanation. This is a laundry list of what not to do to serve people with a history of trauma:

  • Inconsistency in personnel, procedures, programs, rules.
  • Arbitrary decisions without consultation or explanation.
  • Rumors and back-channel gossip.
  • Lack of choice.
  • Uncertainty that basic survival needs will be met.
  • Recurrent or intermittent threats to clients’ sense of physical safety.
  • Emotionally abusive behavior without corrective repair.

Just two days before this phone call, I was at a book signing party. A friend had recently published a book about why and how all human service agencies need to and can become trauma-informed: Through a Trauma Lens: Transforming Health and Behavioral Health Systems by Vivian Brown. Aware that trauma is pervasive and that organizations, often inadvertently, operate in ways that re-traumatize clients, Vivian wanted to study “positive deviants,” those leaders who had made a difference, to identify how, why and what they did to re-invent their organizations from a trauma-sensitive perspective. Her book shows that becoming trauma-informed and making suitable adaptations can be done and everyone benefits. Alongside a comprehensive account of the problem and enumeration of best practices, her book is packed with moving testimonials from those leaders who have re-shaped their agencies. A favorite tool she helped design is the agency walk-through, in which staff and clients step through the process and the experience of clients who are new to an organization and take a client’s-eye view of what it looks and feels like. It’s always an eye-opener.

In the secure, caring, intimate bubble we seek to create in our offices, it’s easy to forget the bigger picture of what it takes for clients to get there. Many of us work in agencies: community mental health, substance abuse treatment, hospitals. Few of us can, individually, exert control over institutional behavior and decisions. We can remind ourselves to take a client’s-eye view . We can be advocates. And we can educate and, thereby, try to help immunize our clients against some of the most serious assaults to their safety, security, and welfare that are inflicted by the very organizations tasked with improving their well-being and quality of life. If nothing else, we can normalize responses to agency-perpetrated re-traumatization and encourage self-compassion: just getting to and through the office door can sometimes feel like a day’s work.