The Ethics of Not Treating Trauma

We are entering a new era of trauma awareness.  We are just starting to be able to make visible the central role that trauma plays in human development, physical health, and in relationships of all types.  We are recognizing that trauma is about us too (#MeToo).  Once we find firm footing in this new paradigm, we will look back with a different lens than we looked forward.  We will not look favorably on the systems that promoted invisibility.  Once you come to see trauma, it’s difficult not to see it.  We will judge harshly the systems who were responsible for treating or mitigating it, yet purposefully looked the other way.  We are just now beginning to see trauma for what it is–the longest, most expensive, and most devastating public health crisis in the history of the Western world.  Once clients understand trauma and can see clearly the bodily burden they now have from carrying untreated trauma, they are likely to ask a very sensible and poignant question.  They are going to ask it first to you.  Then they will ask a lawyer: “I have been a client at this mental health agency for many years… why has no one treated my trauma?”

I only saw Betty once.  She came to my agency because the new prescriber at her agency refused to continue the astronomically high doses of Valium that she had been taking for decades.  She was hoping our doctor would.  Her trauma history was staggering and she clearly met criteria for PTSD.  She was hypervigilant and scanned the room throughout the assessment.  She slept only a few hours a night since middle childhood and reported severe and persistent trauma-related dreams.  She was having flashbacks during our assessment.  She did not want to see me for counseling because she had been seeing the same therapist for her “anxiety” for over 30 years.  She and her therapist were “best friends… we have gone through everything together and I will never leave her.”  She was certain that her therapist had never diagnosed her with PTSD.  Her therapist never attempted to help her develop coping skills to better manage the fires that consumed nearly every waking and sleeping moment.  One of the things she and her therapist went through “together” were all the client’s trauma-related autoimmune disease diagnoses that might have been prevented entirely had the client’s trauma been made visible and treated decades ago.

Trauma is ubiquitous in mental health clinics.  Therapists are already trauma therapists in the same way that ER physicians are by default doctors of accidents and infections.  Trauma work is essential to the work that we do as professionals and it’s is no one else’s job to see it, normalize it, and effectively treat it.  Betty’s therapist didn’t treat her trauma because she probably doesn’t know how.  Based on what Betty told me, her therapist probably had her own personal trauma-related reasons for not being able to visualize and treat Betty’s trauma effectively.  Betty did not have a therapist.  She had a friend and a warm witness to her ever-growing suffering.  There is a difference.

After broader culture becomes more trauma aware, Betty’s therapist may be at serious risk for malpractice for not attempting to treat a clearly identifiable and debilitating disorder (if she wasn’t already at risk for keeping a severely unwell and unimproving client on her caseload since the 1980s).  The fact that you don’t see trauma isn’t a defense.  In fact, failing to treat something that is right in front of you is one of the surest cases of malpractice.  Lawyers will use your own intake assessment against you.  The fact that you didn’t know how to treat one of the most common and debilitating mental health conditions isn’t an effective defense against arguments of incompetence.

Cultures are talented at vanishing trauma.  The mental health profession has been more than a little dissociative in its relationship with trauma.  When broader culture becomes more fully trauma informed, broader culture will demand that heads roll.  They will want to know who knew—or should have known—and did nothing.  From one therapist to another: please learn to see and treat trauma.  Trauma is treatable.  Even severe trauma is treatable.  You can help people rescue the self from the past.  You can help people avoid the irreversible pain of stress-related autoimmune disorders.  You can do your job.  No other profession is responsible for this.  There is no medication for this.  This is what we do.  I will do my part to help you.