Do No Harm: Considerations and Trauma-Sensitivity

When working with traumatized groups it is important to begin with time for individuals to become familiar with their setting. For example, sessions can start with time to ensure participants feel comfortable with their surroundings, give them time to notice the room and identify the exits, and then notice other participants gradually. Grounding exercises can be supportive in feeling safe, such as noticing and feeling where they are touching the ground (sitting bones or feet). Given trauma often results in dissociation from the body, grounding helps to keep people connected to their physical selves and the present moment and begin to find comfort in their new surroundings. Click here for a sample of wellbeing and resilience practices, including Grounding practices

Use language and approaches that offer a form of choice or sense of individual control. Always offer an alternative and let people know they can choose whatever makes them comfortable to minimize anxiety and reinforce safety. Using prompts that offer choice is also supportive, such as inviting (not instructing) attendees to move when they are ready, or to close their eyes, if it feels comfortable to do so, or to give them an alternative: keep their eyes open yet gazing softly at the floor in front of them.

It is always helpful for an individual who is traumatized to have a roadmap of what you will be offering to help mitigate uncertainty. Ensuring participants know the agenda, what to expect, and have ways to ask for any accommodations (e.g., a quiet space to move to when needed, or a seat away from other people) can also ensure they will not be surprised and have the supports they need to participate. It is also useful to let them know that they may experience a release of emotion, during which stress, sadness or painful memories may arise. This is part of the healing process, but if they do experience prolonged, upsetting emotions or flashbacks, they should work with a skilled therapist to help them in processing their memories.

Always validate feelings experienced. Crying may not be a sign of a traumatic memory, but may just be a release of emotion. Be aware of your own impulses to “fix” or respond, and then inquire if they need anything. Sometimes people simply need the space and privacy to experience their emotion. A facilitator’s capacity to respond with wisdom depends on their ability to be completely present.

It is important when working with traumatized populations that you do not offer meditation for long periods of time with only silence. Start with less than five minutes, and speak periodically (e.g., "breathing in, breathing out"). Meditations are more effective if done as guided meditations – inviting (not instructing) participants to pay attention to their breath, thoughts, feelings, sensations, etc. Too much time in silence can trigger a traumatic memory or flashback.

It may be useful to discuss in simple terms what happens in the body during a traumatic experience – that they were able to survive because they have a stress response system that gave them the strength to run or protect themselves. It is important to note that this is a biological function that we have no control over and that it is a good thing - that it worked, because they survived. But sometimes this system gets stuck on, resulting in the feelings they are describing. And with certain mind-body practices, their body may be able to move back into self-regulation over time.

Honoring a participant’s consent and protecting privacy is essential. It is important to ask the participants themselves, not just the leadership of an organization or location, what is necessary for them to feel comfortable to participate. This may require a private location, smaller group sizes, and the most advantageous timing. Consent is always necessary before any engagement with an individual participant – such as before using touch, sharing personal stories, or suggesting an intervention. It may take time to build trust between facilitators and participants, as well as among participants. In some cases, cultural stigma around mental health and the fear of gossip have meant working in groups too quickly before trust is established has created more harm than good.

Local empowerment, capacity-building, and participatory engagement help restore dignity and agency after traumatic experiences and help offset the dependency often felt with outside aid. Partnering with local organizations and local professionals allows for a responsible evaluation of the effectiveness and relevance of any unfamiliar practice as well as any necessary adaptations. Working with communities and groups in trauma healing efforts can capitalize on community engagement as well as the multiplier effect. Social networks can leverage resources, disseminate information, and share skills, so long as there is trust, confidentiality, and consent.

It is often helpful to focus the initial explanation of particular trauma-healing methodologies, especially mind-body modalities, on the physiological benefits rather than any underlying spiritual or religious philosophy. Limiting explanations to the biological experience of trauma and the physiological treatments for trauma also helps avoid mental health stigma or religious concerns. Training local facilitators helps mitigate cultural differences, allows for adaptations, and facilitates explanation of the rationale behind unfamiliar practices.

If facilitators are not local, care must be taken for language differences. Seek feedback regularly, track non-verbal cues, and take pauses to gauge understanding. Watch for when participants are not connecting with the material (but may be continuing out of respect for “expert” providers). When some words do not directly translate, it may be necessary to work locally to create new terms that signify a similar meaning in the local context.

Stigma against mental health may limit participation, including simply convening people to offer psychological support. Integrating trauma-healing programs into other social support services through a local partner organization may be important to avoid stigma for exclusive mental health programming.

Prioritize access for the most vulnerable, especially where travel is expensive or impossible due to mass disaster, where those who are most marginalized may have few resources for participation, and where disabilities and injuries need to be accommodated. Consider the need for child care. Also consider the timing of programs to ensure they do not interfere with accessing food, water, medical care or other aid services; regular household needs; work; school times if in session; and the need to travel in daylight for safety. Ensure programs are co-designed locally to incorporate needs and draw ideas from lived experience. As much as possible, bringing programming to participants where they live will reduce obstacles to access and ensure the broadest impact.

After disaster, mental health infrastructure is often lacking - there may be few mental health workers present or such personnel are also traumatized. Methods that do not require a skilled, one-on-one therapeutic relationship over time, may be more immediately supportive. Using low-tech but effective techniques that can easily be taught and shared allows for spread in under-resourced areas. Program providers must be prepared to work in locations without power or sanitation facilities, or in otherwise suboptimal conditions. Mind-body practices that require few props, technology, electricity or other material support are distinctly advantageous.

Using modalities where people can physiologically feel the impact from a practice in a single session, helps acceptance. It makes it more likely that participants will want to learn more, practice on their own, and share with others.

In the aftermath of trauma, there must be a sustained commitment to ongoing care for individuals and community, which can take years, if meaningful healing is to take place. There should be enough time for participants to learn a method and experience the benefits from practicing it over-time. “Participation itself is psychologically beneficial” in its tendency to “restore people’s dignity and sense of control” following traumatic experiences. Helping participants to maintain the practice on their own, conducting regular gatherings to offer ongoing facilitation and support, and building local capacity for continued services is important. Outside interventions are most beneficial when they “work in a manner that increases the capacity of local people to meet their own needs on a sustained basis”.

Measuring impact may require customized methods depending upon the context. Working in a foreign language requires translation into the foreign language and then back translating by another party to ensure accuracy. Understanding the limits of language or the capacities of participants is important in accurately assessing impact. For example, converting a 5-part Likert scale to a visual analog scale can allow people to choose the severity of their symptoms between two extremes when language might not adequately capture the spectrum of possibilities (quantitative measures can come from measuring the distance of the tic-mark along a line.)

Increasing awareness of the common coping mechanisms for trauma exposure will ensure facilitators too have greater capacity for investing in self-care when it is needed. This includes not only personal transformation and self-awareness work, but it understanding one’s own needs and limitations, and taking time to restore one’s self to protect from burnout.