By Raymond Dougherty
While I was familiar with trauma-informed care in the past, I found it became much more important to my practice after the 2017 firestorms in Sonoma County.
Hundreds of our healthcare providers and patients lost everything that year. Our hospital was evacuated in the dark of the night and remained closed for 17 days as the fires raged on. In the end, 5,643 structures, half of which were homes in Santa Rosa, were destroyed, and 22 people died. The whole community endured persistent toxic smoke, rolling power outages, evacuations, and the daily fears of the raging firestorm.
“Tell me more” is a common spiritual care phrase. For those experiencing trauma, however, this process of sharing their story could lead to re-traumatization. I witnessed tense body language, panicked speech, heightened vigilance, and rapid breathing of those who began recalling their harrowing escape from their burning homes. I realized then that I needed to be more aware of how my well-intentioned interventions impacted those in trauma.
I began learning new techniques to calm the nervous system and begin the healing process — for myself and those I served. It has been a journey into a vast, burgeoning field of care that helped me recognize and respond to trauma in an informed way.
A trauma-informed approach is guided by four assumptions, known as the “Four R’s”:
- Realization about trauma and how it can affect people and groups,
- Recognizing the signs of trauma,
- Responding by integrating knowledge about trauma into our practice, and
- Resisting re-traumatization.
I am not an expert on trauma-informed care, but just keeping these “Four R’s” in the forefront can help all of us be more aware of trauma in ourselves and others and take some steps to address it.
One model that has helped me, developed by Dan Siegel, MD, is the “window of tolerance.” This has been especially helpful for the medical staff who are dealing with trauma on a regular basis and/or experiencing secondary or vicarious trauma.
When we are handling the inevitable ups and downs of life, we are within our window of tolerance. However, if we move outside of our window, we can become either hyper-aroused or hypo-aroused. When my nervous system is hyper-aroused, I might notice that I’m more defensive – or blaming and judging others (or myself) more harshly. Maybe my mind is racing, or I can’t sleep. I might be more, angry, anxious, or panicky. Or in hypo-arousal, I might be more apathetic, checked-out, disconnected or dissociating, sluggish, burned out, and have weaker boundaries.
Does any of this ring a bell? These common responses to leaving our “window of tolerance” help us deal with unwelcome sensations, but often create problems if left unattended. This is where we as chaplains come in. We can develop and promote healthy, nurturing strategies to help restore the body to a more regulated place.
In a trauma-informed practice, this process is called resourcing. Resourcing works to help calm the nervous system and restore a sense of calm, peace and safety in the body, bringing our nervous systems down from a state of hyper-arousal or lifting the fog of hypo-arousal. Many examples are familiar to chaplains, such as prayer and meditation, breathing practices, pet therapy, shaking or dancing, taking a mindful walk, exercise and engaging the senses through music, aroma therapy, or focusing on something beautiful, etc.
So, to go back to the “tell me more” scenario: Rather than repeating the traumatic story, a trauma-informed response might be to “pendulate” between the story and the safety of the present moment in the body. Because trauma is stored in the body, trauma-informed interventions frequently incorporate somatic expressions and interventions.
So, in good old CPE fashion, try it out for yourself:
- Imagine something that distresses you (nothing too intense for this exercise – maybe a 4 or 5 on a scale of 10, slightly outside of your “window of tolerance”). Rather than focusing on the story of the distress, start by noticing the “felt sense” of your distress – in your body. Where do you feel the distress? What does it feel like? Take a moment and experience the sensations. If you become overwhelmed by focusing on the distress directly, bring your attention out to just the edges of it.
- Now scan your body for a place that feels calm. Maybe in your hands or feet, maybe just your pinky toe – some place in the body that is free from the distress. Or try bringing to mind a pleasant memory and notice how your body feels as you recall that memory. What does that feel like? Rest in that calm for a moment, really giving yourself time to experience it, to savor it.
- Pendulation is the act of shifting your attention between these two experiences in your body. From distress to safety or calm, slowly touching in on the distress but in a way that is safe and healing. Be present for the feelings of distress for just as long as is tolerable, and then shift your attention back to the part of your body where you found peace or calm. Slowly shift back and forth and notice how the distress changes or perhaps becomes more tolerable.
Another good resourcing technique we introduced to the staff is the Self-Compassion Break, developed by Kristen Neff. It, too, starts with locating the stress or emotional discomfort in the body. The next step is to mindfully acknowledge that this is a moment of suffering. You might say to yourself “this hurts” or “this is what stress feels like.” Next, say to yourself something like, “this suffering is part of being human” or “other people feel this way too.” This moves us from a sense of isolation to acknowledging our common humanity. And finally, put your hands on your heart (or belly or wherever you are feeling your distress) and extend kindness and compassion to yourself as you would a good friend in the same distress. Using this myself, and introducing it to stressed-out staff, has been a great way to introduce a form of resourcing that is easily incorporated into our day-to-day work flow.
Most of our patients are experiencing some form of trauma and distress, and many of us carry some measure of trauma or vicarious trauma in our bodies. The spiritual care interventions we provide every day can be even more profoundly healing when we provide them in a more trauma-informed manner. Trauma-informed care is a vast and fascinating field that I hope you will consider learning more about and adding to your “chaplain tool box.”
Raymond Dougherty is director of spiritual care services at Kaiser Permanente Marin/Sonoma in California.
Trauma-Informed Care Resources
Waking the Tiger: Healing Trauma by Peter A. Levine
by Resmaa Menakem
Self-Compassion: The Proven Power of Being Kind to Yourself by Dr. Kristin Neff
Sounds True: Tami Simon with guest Arielle Schwartz, “Trauma Recovery and Post-Traumatic Growth”
On Being: Krista Tippett with guest Resmaa Menakem ‘Notice the Rage; Notice the Silence’
Traumahealing.org (includes list of Somatic Experiencing Practitioners)