Trauma Informed Care & people of colour

“If you are silent about your pain, they’ll kill you and say you enjoyed it”                

                                         Zora Neale Hurston

There are different kinds of wounds. Not all pain is deemed legitimate. Oppression causes trauma. Amidst the (fairly) obvious, debates around what really constitutes trauma as laid out in criterion A of the Diagnostic Statistical Manual (DSM)’s diagnosis for Post Traumatic Stress Disorder (PTSD); are alive and well. Criterion A now requires that an individual has been ‘confronted with: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence’ in order to qualify as having experienced trauma. In contrast with the DSM-IV and previous versions, the DSM-V notably includes sexual violence but not racial violence…troublingly evoking the fight for racial justice.

Looking back in history, (white) women’s rights have always taken precedence over the rights of people of colour. For example, in the US white women were afforded the right to vote in both state and federal elections in 1920 but, it was only in 1954 that people of Asian heritage could vote and; well into the 60s that measures specifically designed to bar African Americans from voting (e.g. voting taxes, literacy tests or intimidation) were rendered unlawful. The recognition of racial violence and injustice historically takes much longer than the recognition of sexual violence. It is important to bear that in mind. With some luck, we may get some intersectional thinking within mainstream mental health systems within 50 years.

Still…many of us continue to exist under the weight of racial (and intersectional) violence and more critically; continue to be affected by smaller, less extreme but repeated traumatic experiences. They rarely involve threat to life or to the integrity of our body but, they nonetheless create threat to livelihood, affect life course and limit life chances. They may not cause us to be confronted with overt violence, all the same, they create unsafeness and insecurity, pain and, a sense of futility and resignation or helplessness. Often too, they lead to internalised silencing or self-censorship due to repeated experiences of denial, invalidation or minimisation.

I am amongst those who believe in speaking of our pain.  As marginalised people when we are silent when violence is done to us, we offer a hiding place to perpetrators and to oppressive systems. Oppression and abuse often create a felt sense of shame. And, shame thrives in silence. This is also how oppressive systems reproduce themselves, they locate the pathology, dysfunction or anomaly within those they harm. We do the master’s work when we internalise these (projective) beliefs. Moreover, when one cannot speak of the violence they experience or have experienced, they are done violence all over again. Silence is violence. Often.

Insidious trauma

There is nothing new in considering oppression as a traumatic agent, nothing new at all. Feminist scholars have long critiqued DSM conceptualisations of trauma. Many have advocated for a theoritical expansion so as to locate the experience of trauma within socio-political contexts. The concept of insiduous trauma is born out of this scholarship. Insidious traumatisation (Root, 1992) is centred on the daily ‘subthreshold’ traumatic stressors marginalised people experience which, when taken cumulatively, amounts to trauma because they are constant reminders of one’s precariousness and unsafeness in the world. Some feminists have sought to include insidious trauma within PTSD criteria or put forward conceptualisations of oppression-related psychiatric disorders.

Understanding insidious traumatisation is vital. Nevertheless, I am not sure that some sort of pathologisation parity is required or would be helpful. Nor that pathologising responses to trauma more generally is desirable. This is not because I uphold a hierarchy of suffering or injustice or, because I think, insidious trauma necessarily produces dissimilar physical or psychological reactions to more ‘classic’ traumatic events or experiences. I am simply not convinced that the legitimisation of the psychological harm of racial violence should be via an extension of the DSM/psychiatric classification systems; systems that are based on alleged ‘deviation’ from unpacked and unproblematised norms (and let’s be real which themselves have a long history of doing violence to marginalised groups and indeed may easily be charged with actively living up to that legacy) when being deemed ‘abnormal’ and treated as such in the world is, by definition, the root cause of insidious trauma.

Trauma Informed Care?

When a traumatic event is extreme or when we are able to identify a specific event, it is easier to see and recognise the need for support and care. When the damage is done covertly or more subtly over months, years or decades or; when it is part of the fabric of society culturally or ideologically, it can be much more difficult to attend to our suffering or to legitimise the need for support; even to ourselves. Such violence becomes the norm and our responses the pathology, our inability to cope. Smaller but repeated acts of denigration, of discrimination, of othering; constant reminders of structural inequalities and injustices do culminate into significant psychological distress. The evidence is there. There is nothing abnormal or deviant in survivors. The deviance lays in the violence.

There has been a global push towards what is often referred to as Trauma Informed Care (TIC). Various definitions of Trauma Informed Approaches (TIA) exist; all have at their core, a will to configure services and/or care around the developmental impact of trauma on all level of human functioning including on the psychological, neurological and on social development. TIA, further; seeks to ensure all social systems understand the impact of trauma on families, groups, communities and other social systems. TIC may be less stigmatising and, there are many benefits to understanding how trauma can affect attachment, worldviews and more generally people’s experience of the world and thus how structures can retraumatise.

I remain cautious though, when it comes to uncritically embracing the approach. I am not sure there is a huge conceptual difference between envisaging people as traumatised rather than as ‘mentally ill’.  For starters, most proponents of the medical model would probably argue that both propositions are not mutually exclusive. Indeed, it is precisely what has been proposed of late ‘there is something wrong with you… (in your brain, your emotional responses, your personality, your perceptions, your cognitive or relational processes etc…) because of what you have been through’. Thus, saying or implying, you are damaged because of trauma is no more humanising as a narrative, to me, than saying or implying you are damaged because of faulty brain structures.

Both explanatory models locate the disturbance or pathology within the individual.  In other words, you are still saying to me that there is something wrong with me as opposed to, there is something wrong with the way that I have been treated and everything ‘right’ in the way I have responded to try to survive. Further, and more importantly, the main focus remains on ‘treatment’ rather than on prevention, at least not on holding structures of power to account.  I have seen very little of this within TIA. ‘What has happened to you’ is infinitely more compassionate than ‘what is wrong with you’ no doubt, better still is asking ‘what has happened to you’ then, turning to oppressive systems and those with more social power; to ask ‘what are you doing to stop harming people’ or ‘how are you abusing your power’. Much more difficult questions of course but, necessary ones to balance the focus here and not lay our gaze exclusively or even primarily, onto individuals who survived violence or try to survive the harm done onto them but onto those who abuse their power, individuals and systems.

Trauma Informed Care and oppression

Psychiatry and mental health systems do not own distress or trauma. Or how it is defined. Or how it is or should be experienced. Trauma is not patented by the American Psychiatric Association (APA). Our experience of the world does not cease to exist simply because a group of white American men at the APA, or dominant systems more generally have decided, the daily violence we suffer is not that traumatic or worthy of a name or of a mention in their (conceptually and empirically flawed) book. Or because mental health systems, by and large, continue to struggle to make themselves relevant to so many of us.

I note that despite the recognition that racism constitutes trauma within most TIA I have come across and, the expressed link between trauma and historical and cultural contexts as one the principles of TIC,  I am still to see a single intervention within the framework specifically addressing the damage of whiteness within any mainstream mental health system in the UK. This, I find quite ironic. Racism reproduced at cultural-symbolic level is a source of trauma too. This invisibilisation or disinterest is consequently quite rich.  There is thus no evidence that TIC would be more relevant and/or more centred on people of colour’s needs or experience. Although the potential that it could is certainly there.

Although I am still ambivalent but open about TIC in relation to people of colour and their experience of oppression particularly, I do believe that we could benefit from using insidious trauma to make sense of our lived experience and to render visible and legitimate, the psychological effects of racial oppression. Although here too, the danger of individualising social trauma by narrowing analytical lenses looms very near indeed, constant efforts are required to avoid this process. Sill, by claiming the term, irrespective of dominant groups or systems’ approval, we are choosing self-definition. We are too, asserting our right and power to define reality. We are choosing to centre our experience of the world and hopefully to orientate ourselves towards self-care. And, to be clear, self-care in my book absolutely entails organising and resisting. History, teaches us that it makes little sense, to seek social approval for our struggles before taking action. Eventually, we tend to be proved right.  TIC and particularly, oppression-focused TIA may well prevent more debilitating manifestations of oppression-related or insidious trauma in people of colour, but the evidence base is simply not there and, I cannot say I have seen a rush for it.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Root M. P. (1992). Reconstructing the impact of trauma on personality. In Brown L. S., Ballou M. (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 229-265). New York: Guilford.

Thank you for reading.

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4 comments

  1. This is brilliant. I’m a trauma informed care advocate and clinical therapist in America and have been researching TIC and resilience theory for 15 years. In the past 5 years I’ve been implementing practices with my team and conducting trainings for other public servants and healthcare professionals. It’s a slow boat to awakening. Having grown up and through complex trauma, poverty and homelessness I consider myself a rare breed within my profession and continue to hope to do justice in using this platform to speak for the many still unheard voices; many of whom exist within my family of origin. The DSM is an incomplete tool with multiple ties to pharmaceutical and insurance companies. A billing code fails to provide the complete spectrum of human experience and behavior. And finally, while not qualified through an evidenced based measure, those of us with the highest rates of resilience are those of us who have walked through hell and continue to preserve. So forward we go. I applaud your efforts.

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