Trauma Stewardship Read online

  Rooting our concept of trauma stewardship in a larger framework of systematic oppression and liberation theory is extremely important. Oppression plays a leading role in creating and maintaining systems that perpetuate suffering and trauma for all sentient beings, as well as the planet we share. The more we can understand this relationship, the better our insights into the ways that trauma affects us individually and collectively around the globe.

  Oppression can be defined as the negative outcome experienced by people who are targeted by the cruel exercise of power; the term is generally used to describe how a certain group is being kept down by unjust use of authority, force, or societal norms. When a society institutionalizes oppression formally or informally, the result is called systematic oppression. Around the globe, liberation movements promote the undoing of negative outcomes and the elimination of the causes of individual and systematic oppression.

  In recent decades, many liberationist thinkers have made their voices heard in indigenous and diaspora freedom movements, as well as in environmental justice movements worldwide. Examples include Father Gustavo Gutiérrez, a Peruvian Catholic priest and liberation theologist; the late Paulo Freire, a Brazilian educator; Rigoberta Menchú Tum, a Guatemalan advocate of indigenous land rights and winner of the Nobel Peace Prize; Reverend Allan Aubrey Boesak, a South African anti-apartheid activist and theologian; and Vandana Shiva, an Indian biophysicist and environmental ethicist. There are many others.

  One example of systematic oppression is structural violence. This concept was introduced in the 1970s by Johan Galtung, a pioneering Norwegian researcher in peace and conflict, and founder of the International Peace Research Institute. He describes structural violence as “a form of violence which corresponds with the systematic ways in which a given social structure or social institution kills people slowly by preventing them from meeting their basic needs. Institutionalized elitism, ethnocentricism, classism, racism, sexism, adultism, nationalism, heterosexism and ageism are just some examples of structural violence. Life spans are reduced when people are socially dominated, politically oppressed, or economically exploited. Structural violence and direct violence are highly interdependent. Structural violence inevitably produces conflict and often direct violence including family violence, racial violence, hate crimes, terrorism, genocide, and war.” Paul Farmer, an American medical anthropologist and founder of the international health and social justice organization Partners In Health, elaborates: “Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress.”

  “Speaking personally, I haven’t had my day, and I’ve never met any dog who has.”

  If we lived in a society where equity, respect, access, and justice were realized, and unearned privilege and inequality and oppression were transformed, the impact of trauma exposure in our lives would look dramatically different. Suffering would still occur. People would sustain injuries and contract illnesses and even hurt each other. The difference is that we would only have to confront that suffering at face value: an injury, an illness, a hurtful act. We would not have to wonder if disparities between rich and poor, white people and people of color, heterosexual people and gay/lesbian/bi/transgendered people, and so on contributed to the suffering. We would not have to wonder if we personally benefit from the disparity that underlies the suffering. We would not have to wonder if we are vulnerable to the same disparity. We would not have to decide whether we should act to change the disparity, or if we should blame the person suffering for the disparity, or if we should ignore the disparity altogether.

  In this ideal society, people would respond to our work differently as well. If, when you told others what you did, they stopped, looked you in the eye, thanked you, and offered to make a donation, the impact of your work would look very different than it does now. If we feel that it’s consistently a conversation stopper, or if we believe we have to lie about what we do because so many people don’t understand it, or if we perceive that others constantly judge us when they express disgust about our work or make objectifying comments like, “You’re such an a-n-g-e-l! I could never do that job!” the toll of our work is that much higher.

  We can see an example of that toll when we look at those who attend to our elders. “Caregiver stress is directly related to the way our society views the elderly and the people who care for them,” elder-care expert Vitaliano says in the LeRoy article on CNN.com cited in the introduction. The text continues: “Today, caregiving is viewed largely as a burden in this country. If it were viewed as more of a societal expectation and people were willing to offer more support, fewer caregivers would suffer in isolation, [Vitaliano] says. In turn, fewer elder and disabled people would experience abuse or neglect at the hands of caregiving individuals or institutions.”

  The researchers and trauma experts Bessel A. van der Kolk and Alexander C. McFarlane write, “Reason and objectivity are not the primary determinants of society’s reactions to traumatized people. Rather . . . society’s reactions seem to be primarily conservative impulses in the service of maintaining the beliefs that the world is fundamentally just, that people can be in charge of their lives, and that bad things only happen to people who deserve them.”

  I have frequently seen such irrational and defensive “conservative impulses” applied to organizational systems over the years, but perhaps never more than when I have collaborated with child protective services (CPS) workers and firefighters. Both groups have grueling, scary, demanding jobs, and yet the way people react to them is strikingly different. CPS workers carry a heavy burden of feeling that they are hated—by everyone. Firefighters, on the other hand, tend to have the benefit of an age-old image of them as saviors and heroes. This contrast speaks to every level we’ve touched on: the personal, the organizational, and the societal.

  There are several underpinnings to this discussion of systematic oppression. Oppression thrives on misunderstanding, alienation, and us/them binaries. Many people have judgments about those who are hurt, raped, sick, addicted, and so on, and as a result, people are often uncomfortable when we tell them what we do. The way people act toward us in response to our work makes the impact of trauma exposure more profound because it increases our sense of isolation, and isolation is one of the staples that keeps systematic oppression firmly in place. Of course, we participate in sustaining this dynamic of isolation ourselves—for example, when we avoid speaking about our work because we fear it will initiate a debate we don’t have the energy to engage in, when we lie about what we do because we believe that others will not understand, when we react defensively because we expect other people’s comments to be judgmental or dismissive, or even when we, in a particular field, keep to ourselves because we anticipate that our work—with families in the suburbs, with abandoned animals, or with endangered ecosystems—will be derided as diverting resources from more urgent human service needs.

  We are hardly alone in avoiding potentially troubling interactions. In the book Traumatic Stress, van der Kolk and McFarlane write that “individuals, and even entire cultures, build up elaborate defenses in order to keep these stark realities out of conscious awareness.” In writing these chapters, I have tried to begin a weakening of these defenses. This overview aims to alert you to the far-reaching consequences of trauma exposure response and to its effects on trauma stewardship. I am drawing the atlas for a terrain that you already inhabit, although you may not know exactly where. In a sense, I have sketched out the borders of a large country—and in part 2, I will provide you with the information you may need to determine exactly what state you are in.

  PROFILE CINDY PARRY

  THE OZARKS, RURAL MISSOURI

  CURRENTLY: Clinical resource manager for Air Evac Lifeteam, an emergency helicopter service for rural America, with 68 bases.

  FORMERLY: Paramedic, nurse (emergency room, post-anesthesia care, and flight), childbirth educator, community activist.

  I was
fine. I mean, I was tired of taking care of sick people. It was always best for me when they were intubated and paralyzed and couldn’t talk at all... so ... well, so I guess it was time for me to get out.

  Here’s the deal. When I first got into the paramedic field, I was one of a very few women in the profession, and I think that made a difference in the attitude that was out there. The attitude was, if you can’t take the heat, get out of the kitchen. The critical incident stress debriefing, or recognizing a normal response to an abnormal event, was just starting to come around; there was not much consciousness about a trauma exposure response. You just toughed it out, and if you weren’t able to deal with it, then you needed to get another job. You just quit.

  I can clearly remember the day and the specific call when I had had enough. I was like,“That’s enough, I’m done.” I realized then how it had impacted me. You see so much, and there are certain things that get revisited that still come up, certain situations and calls, and I remember this one so clearly. We’d gone to a motorcycle accident, and as you approached the scene, it was clear he was dead and he was in several pieces, his body. I had this long-standing irritation with my paramedic partner about his leaving his belongings all over the place when we worked. I was always having to clean up after him. So at this accident, for some reason I thought it’d be funny to take his camera from the ambulance and take photos of this motorcycle accident so that when he developed his film, he’d come across these photos. I was clicking these pictures, and I thought it was a great joke. And a couple of days later I thought,“You know what, maybe I need to do something else.”

  It wasn’t that I could not do my job, because I did it extremely well, partly because I could get totally disconnected from what I had to do. And I saw those people who’d been doing it a while, and I thought, “I don’t want to be like those people; those people are assholes.” This motorcycle accident was the turning point for me. It wasn’t necessarily the bloodiest or the worst accident I’d worked on, but the fact that I could start taking pictures with my partner’s camera and the fact that that would be a big joke to me—it was like, how the hell could you do that? I mean, that is just sick.

  After quitting being a paramedic, I moved to southern Missouri, which is a place where it’s really hard to make a living unless you have a portable skill. I intended to train as a midwife, but instead I got back into this emergency medicine thing. That is what I knew how to do, so I finished up my bachelor’s degree and took care of my dying mom while going through nursing school. I thought I’d do anything but the ER, but then there’s something about the ER that I just love. There’s something very compelling about it. I like the variety of what you see. It’s real. It’s amazing to save a life. I mean, my God, it’s just totally amazing. When you feel like you’ve had an impact in a big way, that a person wouldn’t be alive, and not only just alive but recovered, and you’ve had a big part in that, that’s pretty compelling.

  One of the ways I’ve been impacted by my work is I just view everything as a head injury waiting to happen. I’m a lot less callous about things. I’m much more aware of how fragile everything is. [At Air Evac Lifeteam, where she works now] part of what I do is read through flight records, and with some of the more dramatic calls I think,“This is the day the person’s life changed forever, this family’s life changed forever.” I am much more aware of the impact that has on people. It’s so easy to slip back into the “You’re just dealing with the broken arm,” the compartmentalizing. It’s a struggle to keep a consciousness that you’re dealing with human beings and not just dealing with body parts, and it’s a struggle to be present on all the levels you need to be for people and their families.... Ohhh, I hate the families. It’s so easy to check out and just fix the thing that’s broken. I’m aware that I need to have my whole self present, but it’s so hard to do.

  Most of the people who survive and go on and who are people I want to be like are people who keep their whole selves there while doing this work. I guess that’s about compassion in some way.

  What’s hard about the families is that feeling of “Don’t bother me anymore” that I have. In the ER and the ICU and the critical care and I’m sure any nursing thing, there are constant demands on you. You’ve got to do your job, which more and more is paperwork and reports. So with the families, they’re just a pain in the ass. . . they keep you from getting these things done. We used to joke to remind ourselves that the patient’s the point and not the problem. We’d joke that it’d be a really great job if it wasn’t for all these pesky patients. The other thing is control, control, control. I want control and the patients want control and the families want information and want to be in control, too. There’s been this whole evolution of nursing being more overloaded and things being crappier. I think part is the overload from administrators, part is from the health care system, part is from the direct patient care.

  It sounds trite, but I’m more appreciative of things now than I ever was before. It’s always amazing to me what the human body can sustain. Like, I love skin. Skin is an amazing thing. How can you be so broken and you don’t even have a cut on you? It’s always just so puzzling, and there’s the great mystery: What the hell will kill you is the little thing, and what won’t kill you is the hugest thing. Someone is walking, trips, and they’re dead. Then a car goes off a cliff and that person survives. The randomness of life is mysterious, and as much control as you want to have over things, you just don’t have any control over shit, and in a way that’s not frightening. I used to think that was scary, but in a way it’s not. You can be as careful as you can be and then a bale of hay can fall on you and kill you. And so you realize you don’t have any control. You really don’t. You can lose it in a flash. I have such impatience with whining. With friends and with myself. I think, for God’s sake, you don’t even know how lucky you are.

  What helps me keep on keeping on is that I don’t do direct patient care anymore. Also therapy, man. I don’t think I’m particularly sane. I don’t think I’ve always been able to be so balanced. I put my hands in dirt. And I have the most amazing drive into work. Forty-five minutes of some of the most spectacular and beautiful scenery. When you see the mist come up from the river and you see the sun come up and you think, “Holy crap, look where I am,” and if that’s the way you’re starting out your day as you go into work, it puts things in perspective. Being able to be outside and connected with things that are so much bigger than I am. I have a great community and a connection with the outdoors. I’ve got to be out there. Even in my home there’s a very thin wall between me and the outside, literally.

  I decided to change jobs five months ago [when she left her direct patient care work and took an administrative job with Air Evac]. I was just tired. I thought I’d miss it. I loved the people I worked with in the post-anesthesia care. They say that’s where critical care nurses go to die. I loved the women that I worked with. They were so smart and funny and so good at what they did, and I learned so much from them. It was like hanging out with your friends all day. But I just got tired of taking care of people. And I was physically tired. Sometimes I feel drawn to be a flight nurse again on the helicopter, but then it’s raining out or really cold, and I get some horrible call. Because we’re in such a rural area and because of some crazy thing that happened, those people are out there with their asses literally hanging out of the helicopter and they’re having to make these life-and-death decisions. I’m thinking,“Thank God it’s not me.”What I miss is not patient care. I miss the camaraderie of being with my friends. Sometimes I miss that adrenaline-junkie state of “Damn, didn’t we do a good job?”The kick is that you take chaos and you make order out of it, and I miss that. But I don’t miss taking care of sick people.

  I remember when I first thought about getting into emergency medicine. I was in Colorado at a Girl Scout retreat, and we were in the mountains and there was a lightning strike and the airlift came in to get someone, and I thought,“Cool, I co
uld do that. That could be fun.” And so I did. It’s been a blast. In looking back about why I got into it, it makes sense. I like to have control, and I like to fix things. And for not a very good or healthy reason I was really able to compartmentalize, to separate. I would say that my ability to dissociate got stronger. Sometimes that breaks down, though, that ruptures.

  I don’t know what triggered it, but when I took on this new job at Air Evac Life, things came back to me. I thought,“Wow, look at this again.” I remember being at the site of a car accident, and there was a young boy who was maybe 16, and this kid has stuck with me forever. It was some stupid thing, the accident, I don’t remember what had happened, but he was dead when we got there. We worked on him anyway, but he was dead. The mother showed up on the scene, and as we were zipping him into a body bag I remember her screams—just that grief, you know that grief—and I looked up to the sky and it was an absolutely gorgeous night. It was a dark, clear sky with beautiful stars, and I remember thinking,“How can these things exist at the same time?”

  That was 15 years ago, and I have carried that guy around with me. I knew I did, but to have it come back again was a shock. And I have carried his mother around with me, too. She turned up at the ER later with a picture of her son to show us. I remember thinking, “Man, I do not want to be here right now. I do not want to deal with you.” And then years later she comes back to me and becomes fresh again. We were just looking at a slide show of different accidents, and they came back. I remember this 18-month-old and I still see him in his little train pajamas, and his mom was eight months pregnant. I remember her arriving at the hospital, I was feeling so absolutely helpless, and what do you say to them? I couldn’t do it. I could not save your child. Sorry.