Hektoen International

A Journal of Medical Humanities

Trauma stewardship

Laura Lipsky
Connie Burk
Seattle, Washington, United States


trauma stewardshipThis article was excerpted and adapted from Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others © 2009 Laura van Dernoot Lipsky. For more information about the book and this work, please visit the Trauma Stewardship website.

“Are you sure all this trauma work hasn’t gotten to you?” he asked.We were visiting our relatives in the Caribbean. We had hiked to the top of some cliffs on a small island, and for a moment the entire family stood quietly together, marveling, looking out at the sea. It was an exquisite sight. There was turquoise water as far as you could see, a vast, cloudless sky, and air that felt incredible to breathe. As we reached the edge of the cliffs, my first thought was, “This is unbelievably beautiful.” My second thought was, “I wonder how many people have killed themselves by jumping off these cliffs.”

Assuming that everyone around me would be having exactly the same thought, I posed my question out loud. My stepfather-in-law turned to me slowly and asked his question with such sincerity that I finally understood: My work had gotten to me. I didn’t even tell him the rest of what I was thinking: “Where will the helicopter land? Where is the closest Level 1 trauma center? Can they transport from this island to a hospital? How long will that take? Does all of the Caribbean share a trauma center?” It was quite a list. I had always considered myself a self-aware person, but this was the first time I truly comprehended the degree to which my work had transformed the way that I engaged with the world.

That was in 1997. I had already spent more than a decade working jobs that had brought me into intimate contact with people who were living close to or actually experiencing different types of acute trauma: homelessness, child abuse, domestic violence, substance abuse, community tragedies, natural disasters. As I continued on this path, my roles had grown and shifted. I had been an emergency room social worker, a community organizer, an immigrant and refugee advocate, an educator. Over time, there had been a number of people—friends, family, even clients—urging me to “take some time off,” “think about some other work,” or “stop taking it all so seriously.” But I could not hear them. I was certain that this work was my calling, my life’s mission. I was convinced that I was just fine.

And so in that moment, on those cliffs, my sudden clarity about the work’s toll on my life had a profound impact. Over the next days and weeks, I slowly began to make the connections. Not everyone stands on top of cliffs wondering how many people have jumped. Not everyone feels like crying when they see a room full of people with plastic lids on their to-go coffee containers. Not everyone is doing background checks on people they date, and pity is not everyone’s first response when they receive a wedding invitation.

After so many years of hearing stories of abuse, death, tragic accidents, and unhappiness; of seeing photos of crime scenes, missing children, and deported loved ones; and of visiting the homes of those I was trying to help—in other words, of bearing witness to others’ suffering—I finally came to understand that my exposure to other people’s trauma had changed me on a fundamental level. There had been an osmosis: I had absorbed and accumulated trauma to the point that my view of the world had changed. I realized eventually that I had come into my work armed with a burning passion and a tremendous commitment, but few other internal resources. As you know, there is a time for fire, but what sustains the heat is the coals. And coals I had none of. I did the work for a long time with very little ability to integrate my experiences emotionally, cognitively, spiritually, or physically.

Rather than staying in touch with the heart that was breaking, again and again, I had started building up walls. In my case, this meant becoming increasingly cocky. I had no access to the humility that we all need if we are to honestly engage our own internal process. Rather than acknowledge my own pain and helplessness in the face of things I could not control, I sharpened my critique of systems and society. I became more dogmatic, opinionated, and intolerant of others’ views than ever before. It never occurred to me that my anger might in part be functioning as a shield against what I was experiencing.

I could have ignored the realization that began on those cliffs. In the fields where I work, there is historically a widely held belief that if you’re tough enough, you’ll suck it up: Self-care is for the weaker set. I had internalized this belief to a large degree, but once I realized that this way of dealing with trauma exposure was creating deep inroads in my life, I began the long haul of making change. I needed a new framework of meaning—the concept that I would eventually come to call trauma stewardship.

Trauma exposure response is only slowly coming to the fore as a larger social concern. It was first recognized a decade ago in family members of Holocaust survivors and spouses of war veterans, but it has only recently attracted wide attention from researchers, who are working to assess its broader societal implications. To cite one example: According to a March 2007 Newsweek article, a US Army internal advisory report on health care for troops in Iraq in 2006 indicated that 33 percent of behavioral-health personnel, 45 percent of primary-care specialists, and 27 percent of chaplains described feeling high or very high levels of “provider fatigue.” The article concluded with this blunt appraisal: “Now homecoming vets have to deal with one more kind of collateral damage: traumatized caregivers.”

In 2007, CNN.com published an article by Andree LeRoy, MD, titled “Exhaustion, anger of caregiving get a name.” It begins, “Do you take care of someone in your family with a chronic medical illness or dementia? Have you felt depression, anger, or guilt? Has your health deteriorated since taking on the responsibility of caregiving? If your answer is yes to any one of these, you may be suffering from caregiver stress.” The article reports a finding by the American Academy of Geriatric Psychiatrists that one out of every four families in the United States is caring for someone over the age of 50, with projections that this number will increase dramatically as the population in America ages. Another source for the article is Peter Vitaliano, a professor of geriatric psychiatry at the University of Washington and an expert on caregiving. He reports that many caregivers suffer from high blood pressure, diabetes, a compromised immune system, and other symptoms that can be linked to prolonged exposure of elevated stress hormone levels. Unfortunately, many “don’t seek help because they don’t realize that they have a recognizable condition,” the article says.

Trauma Exposure Response
A trauma exposure response may be defined as the transformation that takes place within us as a result of exposure to the suffering of other living beings or the planet.

© Copyright 2010 Larua van Dernoot Lipsky

Pioneering researchers have given our experience of being affected by others’ pain a number of names, which I refer to as “trauma exposure response.” Charles Figley uses the terms “compassion fatigue” and “secondary traumatic stress disorder.” Laurie Anne Pearlman, Karen W. Saakvitne, and I. L. McCann refer to the process as “vicarious traumatization.” Jon Conte uses the words “empathic strain.” Still others call it “secondary trauma.”

Here, we include trauma exposure response under a larger rubric: trauma stewardship. As I see it, trauma stewardship refers to the entire conversation about how we come to do this work, how we are affected by it, and how we make sense of and learn from our experiences. When we talk about trauma in terms of stewardship, we remember that we are being entrusted with people’s stories and their very lives. We know that as stewards, we create a space for and honor others’ hardship and suffering, and yet we do not assume their pain as our own. To participate in trauma stewardship is to always remember the privilege and sacredness of being called to help. It means maintaining our highest ethics, integrity, and responsibility every step of the way.

The essayist E. B. White once wrote that the early American author, naturalist, and philosopher Henry Thoreau appeared to have been “torn by two powerful and opposing drives—the desire to enjoy the world, and the urge to set the world straight.” If even a few individuals can enhance their capacity for trauma stewardship, we can expect to see consequences, large and small, that will extend beyond us as individuals to affect our organizations, our movements, our communities, and ultimately society as a whole.

As I turned toward trauma stewardship, I sought input and direction from every wise person and every loving tradition I could find. Whether in a dharma talk, pipe circle, temazcal, or midrash, or in the teachings and biographies of Nelson Mandela, Pema Chödrön, Desmond Tutu, Wangari Maathai, Thich Nhat Hanh, Viktor Frankl, and others, I looked for the specific ways that people maintained clarity and wisdom in the face of suffering. The ancient traditions and the contemporary teachers I studied consistently valued one thing in particular: being awake, present, and aware in this moment. While it is an understatement to say that the cultural, spiritual, and religious traditions I explored have many differences, the core of their collective wisdom is an invitation to live your life from the here and now, not in an anticipated future or a ruminated past.

There are a number of reasons why being in the present moment is helpful in trauma stewardship. One is that until we slow down enough to honestly feel how we are doing, we can’t assess our current state and what we need. As the American actress, playwright, and screenwriter Mae West said, “When in doubt, take a bath.” When we keep ourselves numbed out on adrenaline or overworking or cynicism, we don’t have an accurate internal gauge of ourselves and our needs.

According to Peter Levine, what we need to do is to attune to our “felt sense.” The felt sense is what tells you where you are and how you feel, moment by moment. While it is subtle and we often take it for granted, it is an extremely powerful first step to “trust your gut.” Levine states, “Nature has not forgotten us, we have forgotten it. A traumatized person’s nervous system is not damaged; it is frozen in a kind of suspended animation. Rediscovering the felt sense will bring warmth and vitality to our experiences. . . . We have built-in mechanisms for responding to and moving towards natural resolution of trauma.”

Hyperintellectualism occurs when we seek to abandon the felt sense altogether. We may attempt to move out of our bodies, hearts, and spirits to live only in our heads. In humans, part of the left cortex in our brains is programmed to try to make meaning of our experiences. Thus, when humans become profoundly overwhelmed or confused, the left brain works double-time to arrange our experiences into some sort of rational, manageable order—even if this order is disconnected from our right hemisphere’s experience of the felt sense. One thing we want to explore, however, is how we can bring our felt sense and our sense of meaning together—in other words, how we can reconcile the two distinct impressions to create an “integrated state,” as Daniel Siegel refers to it in his work on the neurobiology of mindfulness.

As we deepen our ability to make contact with our inner selves, we slowly build our capacity for self-diagnosis and self-healing. Dr. Liu Dong is a master of qigong, an ancient Chinese healing art based on Taoist principles. His tradition teaches that the more we know what is going on externally in the world, the less we know what is going on internally in ourselves. Like other Taoists, Dr. Liu believes that we all hold a piece of the universal spirit. As we live our lives and become attached to the outside world, this light within—which some traditions call the divine, some call yuan shen, some call self-awareness—becomes clouded over. By coming into the present moment and bringing our awareness within us, we can self-purify and self-transform.

These Chinese teachings state that self-healing and early diagnosis of personal ailments comes out of quieting our external attachments and channeling all our energy into one intention—an act of focus that leads us to the qigong state, which we hope eventually to experience in every moment. The qigong state can happen only in the now. While Chinese medicine acknowledges it is human nature to be externally focused, Dr. Liu grew up being told, “Study, but not too much. Think, but not too much.”

These beliefs are reflected in other traditions around the world. Science is beginning to reflect what sages, shamans, and healers have known for centuries. Brain wave testing shows that many healers—from Native American medicine men and women performing rituals to meditating Buddhist monks and nuns—reach a state in which their brains are producing delta waves, the same type of brain waves that newborns produce day-to-day. This may, in part, be why parents of newborns often don’t lay their infants down in a bed once they are asleep, even though they themselves are extremely sleep deprived. Holding a sleeping baby, they may feel an essential life energy that, for many of us, can be experienced only at the hands of healers.

When we are able to make ourselves as still within as an untouched mountain lake, we have an exquisite reflection of all that is in and around us. When ripples do arise, we can recognize their source, whether it is the rain or the wind or the fish jumping. Without the stillness, all we know is that the waters are tumultuous, and we may want to do anything possible to escape the feeling of unease.

There are innumerable ways to return to stillness, including such centering acts as breathing, meditation, mindful movement, and prayer. Any of these can be a saving grace, and they are all free and portable. It is worth noting, however, that being present is real work. Meditation and yoga are referred to as practices for a reason—they require repetition and commitment to a process.

Still, while this practice is not for the faint of heart, it should not be seen as inaccessible. You are fully capable of becoming present, but you must be willing to introduce some new habits as a counterpoint to your old familiar ways. For example, during a recent vacation with my family, I was struck by how entrenched my patterns of thinking were. I was thousands of miles away from the 11 children who attend school at my home each day and all my other at-home responsibilities, but it took nothing for me to transfer my sense of worry and alertness to conditions on the beach. Was it low tide or high tide? Would those clouds eventually produce rain? How were the surfing conditions?

It was absurd, as none of these things really mattered at all. But I was amused by how diligently my mind was working, and in its habitual way—the surroundings had changed dramatically, but my thoughts maintained the vigilant status quo. Once I came into the present moment enough to notice my thoughts, I was able to stop the pattern. I returned my awareness to my family and the sensations of air and sand.

Many of us who work in helping professions are used to operating at a sprint, so coming into the present moment may feel like a powerful contradiction. Nevertheless, it is difficult to appreciate our lives when we are not paying attention to them in a conscious way. I don’t believe that I am imparting new information. Rather, the concept of trauma stewardship draws from lore that people from different walks of life, cultural traditions, and spiritual practices have known for millennia. There is a Native American teaching that babies come into the world knowing all they will need for their entire lifetimes—but the challenges of living in our strained, confusing world make them forget their innate wisdom. They spend their lives trying to remember what they once knew. (Some say this is the reason why the elderly and very young children so often have a magical connection: One is on the cusp of going where the other just came from.) All of the wisdom described here and elsewhere is known to you already. The text is simply a way to help you remember.



LAURA VAN DERNOOT LIPSKY, MSW is the founder and director of The Trauma Stewardship Institute and author of Trauma Stewardship: An Everyday Guide to Caring for Self while Caring for Others. Having worked directly with trauma survivors for 25 years, Laura consults with organizations and institutions on trauma stewardship while also maintaining a counseling practice. She has trained a wide variety of people, including zookeepers and reconstruction workers in post-Hurricane Katrina New Orleans, community organizers and health care providers in Japan, US Air Force pilots, Canadian firefighters, public school teachers, and private-practice doctors. She has worked locally, nationally, and internationally. Laura is known as a pioneer in the field of trauma exposure.

CONNIE BURK has directed The Northwest Network of Bisexual, Trans, Lesbian and Gay Survivors of Abuse since 1997 and trains internationally on responding to secondary trauma in organizations, transforming abuse in LGBT communities, integrating community engagement throughout programs, sustaining a practice of ethical advocacy, and taking the crisis out of crisis-response organizations. She is a consultant for the Center on Trauma, Domestic Violence & Mental Health, the National Domestic Violence Hotline, the National Council of Juvenile and Family Court Judges, the Asian Pacific Islander Domestic Violence Institute, and many other national and regional organizations.


Highlighted in Frontispiece Spring 2012 – Volume 4, Issue 2
Spring 2012  |  Sections  |  Psychiatry & Psychology

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