Trauma-Informed Care in Crisis Work

Many years ago, when I was working on an in-patient psychiatric unit, one of our patients was a woman in her 30s who cut herself frequently.

At the time, “Marjorie” carried the pejorative label “Borderline Personality Disorder.”

These days she would be given the diagnosis of a person afflicted with Complex PTSD.

Back then, we hadn’t figured out that many of our BPD patients had been sexually abused as children, their symptoms reflecting the horrors of their traumas.

On many occasions, Marjorie’s behavior escalated into yelling and threatening to hurt herself. At times, she banged her head or cut herself superficially. When she refused to go voluntarily to the “quiet room,” the male mental health staff would do a “take down,” carry her into the quiet room, and put her into leather restraints.

I shudder thinking about this practice, given what we know now about the high incidence of childhood sexual abuse. Although we didn’t have the term for it back then, we finally figured out that Marjorie was “re-enacting” something from her past.

Defining Complex PTSD

In Understanding Complex Trauma, Complex Reactions, and Treatment Approaches, Dr. Christine Courtois summarizes complex traumatic events and experiences as stressors that are:

1. repetitive, prolonged, or cumulative
2. most often interpersonal, involving direct harm, exploitation, and maltreatment including neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults, and
3. often occur at developmentally vulnerable times in the victim's life, especially in early childhood or adolescence, but can also occur later in life and in conditions of vulnerability associated with disability/disempowerment/dependency/age/infirmity, and so on.

Incorporating a trauma-informed care approach

Eventually, someone on the treatment team came up with an idea:

We should change the way we respond to Marjorie’s behavior. Instead of using male staff to restrain Marjorie, we decided to use female staff.

The plan worked. It took one episode with female staff carrying out the restraint for Marjorie to curtail her behavior.

It is important for healthcare and crisis workers to be aware that the body remembers somatic and other sensory experiences of trauma.

When a previously traumatized person is in a situation that evokes the past, somatosensory memories can roar back, hijacking a person’s ability to be present, to think clearly, to listen, and to calm down.

This is why crisis workers should take whatever measures they can to de-escalate the situation, create a calm environment, assure the person of his/her safety, and orient the person to the present reality versus the past while being respectful and sensitive—especially when the person is touched. 

About the author

Author of The Comfort Garden: Tales from the Trauma Unit, Laurie Barkin worked in psychiatry for 22 years as a staff nurse, head nurse, educator, and psych liaison nurse. For the last 17 years, she has been a UCSF consultant, providing emotional and psychological support for psychiatric staff. Laurie is a member of the Bay Area Red Cross Disaster Mental Health group and volunteers at a nursing home giving end-of-life care.