If You're Not Contextualizing Behavior, You're Not "Trauma-Informed"
A Trauma Psychologist on the Hollowing Out of This Therapy Buzzword
Readers of this substack might know me as a trans person who loves music and loves our community, or perhaps as a psychologist who knows a lot about trans mental health. What y’all may not know about me is that a lot of my work focuses on traumatic stress, and psychotherapy for recovering from trauma is some of my favorite work.
And I’ve been highly trained in this realm. My first ever work as a student therapist was in a program for active duty military personnel dealing with trauma-related mental health issues. I then trained in trauma-focused CBT and working with traumatized youth and families. Later, I worked in the trauma clinic of a southern, semi-rural VA, and I learned how to administer prolonged exposure - an incredibly effective and difficult form of exposure therapy for trauma survivors. My internship training was at Cambridge Health Alliance (technically through its affiliation with Harvard Medical School) and a significant part of my time there was spent in the sadly now-disbanded Victims of Violence (VoV) trauma clinic established by Mary Harvey and Judith Herman (author of seminal trauma text Trauma and Recovery and her recent expansion Truth and Repair).
I was drawn to VoV because of its firm rooting in psychodynamic theory and feminist trauma work. Feminist models of trauma move away from pure pathology/disease models, and instead understand traumatic stress as a set of internal and interpersonal behaviors that develop as safety mechanisms in traumatic contexts but are often maladaptive outside of those traumas. My dissertation applied feminist models of trauma and related models of racial trauma to argue that trans people are at risk of traumatization from the chronic physical and emotional violence we face. And I argued that trans people’s increased rates of psychological distress and psychiatric diagnoses were manifestations of complex traumatic stress. (As an aside, this research was published in the journal Psychology of Sexual Orientation and Gender Diversity and documented that non-affirmation and bias experiences predicted PTSD symptom severity even after controlling for exposure to events traditionally thought of as trauma.)
Anyway, a large part of my work has been advocating for therapists generally to become more knowledgeable about trauma, traumatic stress, and what that requires in psychotherapy / of psychotherapists — and especially I have wanted this for therapists who work with trans folks. (My research and others’ have found that upwards of 40% of the trans community met provisional criteria for a PTSD diagnosis — and that was before the rise in anti-trans legislation and intensifying of anti-trans societal discourse and climate.)
So I am pro being trauma-informed, y’all. In fact, one of my favorite pieces of my professional writing is the chapter I led on trauma-informed mental healthcare with trans and nonbinary clients.
You can imagine that seeing so many people in the mental health field start to describe themselves as “trauma-informed” was initially relieving to me. Oh good, I thought. People are realizing that we need to understand traumatic stress in order to be effective and safe therapists. Ah, my naivety.
This week in a facebook group for therapists, a member posted to inquire about the appropriateness of their behavior in and after a recent session. (I will use they/them pronouns to further anonymize this person.) They described a clinical encounter in which they were a few minutes late for session and their client was activated by this and expressed anger with the therapist. The therapist (who seemed from their post to feel justified in being late because their previous session had just ended) reportedly apologized and said they could still have the full amount of time; they would just end later than usual, seemingly acting as though it wasn’t a big deal. The client was upset and this did not assuage their feelings - they said they didn’t work to work with this therapist anymore and the therapist reportedly said okay and offered to give them referral options. The client then left the virtual session. The therapist charged them for the session as a late cancellation without discussing it with them. To this therapist’s partial credit, they sought consultation (albeit through an unvetted facebook group…) about whether the charge was “okay,” but they didn’t seem to be wondering about whether their response in session was clinically and/or ethically sound.
I’m taking the time to detail all that because I went to this therapist’s bio and found that they describe themself as “trauma-informed.” Readers, I was livid. Aghast. Disturbed. They described complex PTSD as a specialty - also transgender people, among many other areas. They listed EMDR and other trauma-focused modalities among their trainings. I will one day write about why I don’t use or refer folks to EMDR, but that’s not the point here. The point is that this therapist is marketing themself as equipped to work with traumatized people.
Clients who have experienced trauma, particularly complex/relational trauma, often are seeking therapy because their traumatic stress is getting in the way of their relationships with themselves and with others. The relational dimensions of their traumatic stress will emerge in the therapy. Their trauma will affect how they feel about their therapist and certain of the therapist’s behaviors, and how they feel about how they feel about their therapist. It will affect how open or guarded they are. How much they believe they can change. How much they believe the therapist can care about them and what they need to witness/experience in order to internalize that care as genuine.
Trauma-informed therapists should be observing client behavior — including or maybe especially interpersonal behavior directed at us — with curiosity about the internal and external contexts that behavior exists within. By internal and external contexts I mean what the client is feeling, what they understand they are responding to, what has happened to them in the past, what reminders of the trauma or of traumatic systems are present, what they are wishing for as the outcome of the behavior, etc.
I hate that people seem to think they can take a (what I assume must be mediocre, sorry) training on a trauma modality and call themselves trauma-informed. The word is so overused and misused as marketing term, it’s become useless and hollowed out. Declaring oneself “trauma-informed” should not be an empty statement. It’s been defined and heavily written about. In our chapter, we used the CDC’s six guiding principles of trauma-informed care and SAMHSA’s “Four R’s” of implementing trauma informed care.
SAMHSA’s Four R’s of Trauma-Informed Care:
Realization of the possibility of trauma
Recognition of the signs and symptoms of trauma
Responding to signs and symptoms of trauma
Resisting Retraumatization
CDC’s Six Principles of Trauma-Informed Care:
Safety
Trustworthiness and transparency
Peer support
Collaboration and mutuality
Empowerment, voice, and choice
Attending to cultural, historical and gender issues
It is not trauma-informed to argue with a client about whether they should be angry about you being late to session. The limited description I read about that clinical encounter seemed to miss any recognition that this response could be tied to the client’s legitimate internal experiences and/or history that the therapist may or may not be aware of. It violated frankly all four R’s, particularly because the therapist’s inability to receive the client’s anger and preserve the relationship would almost certainly be retraumatizing. And the six principles are really nowhere to be found. Here’s how a therapist could respond in a truly trauma-informed way (there are lots of options and the best ones will depend on that particular client and on the particular client-therapist dynamic and history):
“Tell me more about how my being late upset you — you don’t have to justify your anger to me; I just want to understand your experience better.”
“I totally get how my being late feels disrespectful of your time and our commitment to each other. It seems like it would be helpful for you to have a chance to just be angry about that - let it out, I can handle it and it makes sense.”
“I think your frustration is justified, but I’m worried that you’re using it to push me away. Can you tell me what you’re hoping I’m feeling right now? What you’re hoping I’ll do?”
“I’ve been late a few times now and I think your anger makes sense in this context. It’s not just about today is it? What am I communicating to you by this pattern of lateness?”
“I am sorry I’m late and cut into our scheduled time together. We have a couple options that I can see for how to proceed: 1) we could talk about what’s upsetting you about this; or 2) we can jump into whatever you were hoping to talk about today. There may be other options I’m not thinking of. What do you want to do?”
“I am realizing how important it is to you to start on time and ensure we can end on time while having the full session. I’m sorry I didn’t honor this before. I will take some time after our session to figure out what I need to do to reduce the chance of being late again. If it looks like it’s going to be an unavoidable part of our work or my scheduling, we should talk about what that means for you.”
“I know lateness is often interpreted as inconsiderate of someone’s time. You’ve had so many people be inconsiderate of your feelings and needs, I know you don’t need another person in your life, let alone your therapist, repeating that.”
Hopefully you can see in these fundamentally that they come from the therapist contextualizing (at least internally/privately) the behavior and responding from that understanding. Most also center client empowerment and collaboration, involve transparency into the therapist’s response, and/or display clear commitment to preserving the relationship and continuing to care for the client in the face of their anger.
The latter is also informed by psychoanalytic theory. D. W. Winnicott described that one of the critical tasks of an analyst is to survive the client’s projected rage without retaliating, withdrawing, or collapsing. One of my former mentors adapted this advice and told me we have to tolerate being the “bad object” sometimes. Clients need to be able to work through their anger with others, themselves, and the world in our therapies — and that often unconsciously means working through it by making us the object of that anger, feeling as though we’ve wronged them. (We have to be careful to not use this to let us off the hook when we have failed or wronged clients; it’s not all projection.)
I should add that I don’t mean to pick on this particular therapist and I don’t want to over-emphasize this particular incident. I don’t even really know what happened in that session or what preceded it in the course of therapy. I used this example because it is illustrative of a trend I have seen in the way therapists often discuss their blatantly non-trauma-informed work during an era where naming trauma as a specialty and getting trained in pseudoscientific trauma-focused interventions (e.g., brainspotting) is seen as an opportunity to attract clients and generate income.
I also want to add that all therapists make mistakes. Having spaces and trusted, skilled people to consult is really important to continuing to provide effective therapy. A therapist getting defensive or shutting down in the face of a client’s anger doesn’t necessarily make them a bad therapist or mean they don’t generally operate from a trauma-informed lens. It does mean that they should prioritize returning with clients to clinical interactions involving anger once everyone is re-regulated, and working outside of sessions to resolve these responses to anger that interrupt effective and compassionate work. Part of what was so disturbing about the therapist post that triggered my substack today is that there seemed to be no humility or awareness that their response to the client’s anger missed an important clinical opportunity and likely did harm. I wouldn’t entrust therapists who behave like this with the care of someone with traumatic stress and yet such therapists are actively recruiting traumatized clients and touting the line of being “trauma-informed.”