Anatomy of a Safety Incident #5, Part 1

Content warning: PTSD, generational trauma, suicide, self-harm

Unpacking this particular safety incident here on the blog will probably seem like an unusual choice to some readers, but I hope by the end it makes sense.

From March 9th through March 12th (last weekend), POCA Tech had its reaccreditation site visit with ACAHM. I was (am?) the point person for events like this, but I missed approximately 1/3 of it because in the middle of the site visit, I had a full blown PTSD meltdown, the like of which I haven’t experienced in years, the kind I’ve been hoping I’d never have again. I had to leave and my two co-Directors, Sonya and Jersey, had to take over. If something this disruptive happened with a patient in the POCA Tech student clinic, I would absolutely be unpacking it here.

This particular incident is also pretty irresistible as a teachable moment. Once my brain was working again (which took about four days) I realized that nowhere in our materials on trauma informed care do we really dig into how bureaucracy can function as a trauma trigger, especially for low income people, and I bet there are a lot of people who don’t really understand how that works. Also, while unpacking safety incidents for reflection purposes is valuable no matter who does it, it’s rare for the person who got triggered, the person at the center of the disruption, to be in a position to write about it. So I’d like to take full advantage of this as a learning opportunity.

Before I get into unpacking bureaucracy as a trauma trigger, though, I want to describe what being triggered is like for me. Everybody’s experience of trauma is intensely individual so I’m not claiming to speak for anybody else. (TIME Magazine actually has a pretty good description of trauma and triggers in an article about psychology terms.) There are some common themes, though, and recognizing those common themes has been very useful to me as a practitioner, especially in a high volume setting. So when I say “you” in the following paragraphs, what I mean is “me”.

PTSD is terrifying not just because it’s technically an anxiety disorder (so basically it’s all about fear anyway) but because it involves not being able to control yourself in public. Once you’re triggered, you can’t predict or trust your own reactions or your own grasp of reality. It can feel like your selfhood is literally dissolving. I have lots of metaphors for being triggered because metaphors help me get a workable distance from my experiences. Being triggered feels like a chemical spill in my brain. Being triggered feels like an avalanche: it can start with the displacement of a tiny pebble, something somebody else might not even see if they were looking right at it, but in no time at all it becomes a thundering, crushing wave that you can’t get out from under. PTSD feels like driving on black ice: by the time you recognize that something’s wrong, you’ve already spun out. I know some people think of “trauma informed” as a meaningless buzzword phrase, so please believe me, PTSD means something in every area of your life. It doesn’t mean anything good.

Learning about the neurobiology of trauma and trauma informed care was transformative for my ability to function in the world. Before I understood that the fear conditioning circuits in my brain were responsible for the incidents where I lost control of myself, my reactions, and my perceptions, I thought that these incidents were proof that I was a bad person. Or a non-person. One way to manage trauma is through dissociation, but a result of dissociation is that you don’t feel real to yourself.

So, yeah, it’s awful.

A hallmark of PTSD is avoidance. Once you have a clue about what triggers you, you start to try to avoid those things -- because why wouldn’t you? See above: it’s awful. But like all anxiety disorders, the more you try to avoid what causes your anxiety, the more space your anxiety takes up and the smaller the rest of your life becomes. The smaller your life becomes, the fewer resources you have to manage your anxiety. If an aspect of your PTSD is suicidal ideation, as mine is, those thoughts become more compelling, more insistent, and also harder to argue with when you have fewer good things to balance them against. So it’s not just that you have a hair trigger, outsized response to certain stimuli, it’s that you can become trapped in vicious cycles with dangerous outcomes. It takes a lot of energy and planning to stay out of those vicious cycles, and unsurprisingly, many people don’t succeed. See also: the opioid epidemic.

Someone is no doubt thinking, okay Lisa, we’re sorry for your trauma but what could this possibly have to do with bureaucracy?

I got my basic education in trauma informed care from the caseworkers of Care Oregon’s hotspotting program for high utilizers of the healthcare system, to whom I am forever grateful. If you want to get an idea of their perspective please read this article. Before I met them, though, I remember an interaction I had with a new patient at WCA as she was filling out forms in the lobby. She said to me, “I’m having trouble with this” and I said, “I’m sorry about that, how can I help you?” and she said, “You can’t, really” -- and then she launched into a story. There was a period of time where she didn’t have housing, and when she tried to apply for housing by filling out applications with well-meaning social service agencies, the result was that more and more authorities got involved until she almost lost custody of her daughter. In the end things worked out; she got an apartment and her daughter was attending a local four year college, living in a dorm, and their family remained intact. She came to WCA in hopes of addressing the long term consequences of traumatic stress resulting not just from poverty but from being terrorized by the bureaucracies that were supposed to help her. “Paperwork is just really stressful for me,” she said.

This morning I read a good article titled “Ordeals and the Empathy Gap” by Sam Freedman. The context is British politics but it’s spot on for understanding bureaucracy as a trauma trigger:

“Political scientists... have developed a language for talking about what is often a hidden world of policy decisions. In this literature, deliberate attempts to create barriers to accessing services are known as “ordeals”... The welfare system is full of ordeals, whether in the form of complex assessments needed to access services, or the threat of sanctions, for those receiving benefits, if various conditions aren’t met...

In a recent report – based on deep personal experience of helping people through the benefits system – Kayley Hignell, the Director of Policy at Citizens Advice, makes a critical point. It is one that is not complicated and yet is widely ignored in policy-making:

“If you want people to focus on improving their income from work, it’s arguably more helpful to take actions that reduce the demands on their cognitive bandwidth, and free up more space in their minds to think about other things….Some things that use up a person’s cognitive bandwidth are actually caused by other parts of the benefit journey. For example, the challenges of figuring out levels of childcare support and payment cycles that are out of sync with wages and bills. Things like this cause repeated budgeting nightmares for people. There are hundreds of policy trade-offs like this, hidden in the detailed design and processes of claiming and maintaining benefits. Currently, we don’t factor in the downside of overloading people's cognitive bandwidth against trying to make a system easy to deliver.”

There are mountains of research about the costs of this type of cognitive overload, much of it was collected a decade ago by Sendhil Mullainathan and Eldar Shafir in their book “Scarcity”. Not having enough money by itself reduces bandwidth because you’re thinking about that absence a lot which reduces time for good decision making. As they put it “time for reflection is a luxury good”... In the US the Biden Administration has acted in accordance with the research by asking federal agencies to reduce burdens, following another book “Sludge” written by Cass Sunstein, an adviser to Obama and now Biden. This explicitly requests that agencies:

“Describe and discuss sources of psychological costs that certain information collections impose on individuals, such as the cognitive load, discomfort, stress, or anxiety a respondent may experience as a result of attempting to comply with a specific aspect of an information collection.”

... (To sum up), trying to create incentives through ordeals, whether via admin burdens or threat of sanction, makes it harder for many to engage. The fear that you might lose your benefits because, for instance, you’re late to an appointment due to traffic, is debilitating. The inability to understand this is an empathy gap. It’s not about sympathy – it’s entirely possible to sympathise with the plight of someone in need of welfare but also think the right approach for their own benefit and the taxpayer is a tough sanctions-based regime. But empathy requires actually understanding what life is like for someone in that position.”

If you’ve never been on the wrong side of bureaucracy, particularly bureaucracy that has the goal of improving you to meet its own standards while your goal and your full time job is survival, it’s difficult to grasp why filling out forms or answering a barrage of questions from someone wearing a badge can trigger literal terror. So on some level I’m asking you to take my word for it (or I guess you could take the long way round and dig into the research cited above).

Many acupuncturists suffer from an empathy gap in relationship to their patients. Most acupuncturists don’t recognize when they’re creating ordeals for people trying to access their services -- and that particularly applies to low income people, but by no means is limited to them. Long intakes with invasive questions represent an ordeal. Income verification to qualify for a sliding scale is an ordeal. And an accreditation site visit for a school whose goal is to train acupuncturists to serve marginalized people -- yeah. It was an ordeal.