Why We Need Trauma-Responsive Care in Chaplaincy
Thanks to Bessel van der Kolk (or a clever marketing team), most of us are now familiar with the idea in trauma theory that “the body keeps the score” (see his book The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma [Penguin Books, 2015]). Van der Kolk uses this catchy phrase to explain how trauma stored in the body can manifest in our lives, whether through illness or disease, relational patterns, beliefs and values, or day-to-day reactions and habits.
As a chaplain, I have witnessed the various ways the body keeps the score in the lives of patients, their families, and healthcare staff, and I have learned the importance of trauma-responsive chaplaincy. One patient, whom I will refer to as Madeline, made this especially apparent.
I met Madeline, a patient in her mid-eighties who lived in a skilled nursing facility, while working as a hospice chaplain. Madeline was managing advanced stages of Alzheimer’s and dementia, rendering her unable to communicate verbally. Our visits usually consisted of listening to music, looking at family pictures, praying, and just being together. I found Madeline to be gentle and content. Madeline’s hospice nurse reported similar findings in our weekly meetings.
But then, suddenly, everything changed. The nurse reported that Madeline had begun refusing bathing and personal care services. Madeline, though unable to speak, would cry out and scream when the nursing assistants attempted to offer her care. The team theorized that her physical pain was no longer well-managed, causing discomfort during personal care. In turn, the physician tinkered with her medication in hopes of solving this new issue.
A few weeks passed, and at our team meeting, Madeline’s nurse reported that Madeline continued to scream when it was time for personal care. Her nurse reviewed the case with us, hoping to find a solution to Madeline’s situation. During the review, the nurse casually mentioned that Madeline’s nursing facility had hired a new group of nursing assistants a few months ago, including one male attendant.
I visited Madeline later in the week and found her, as usual, showing no signs of distress or pain. She seemed comfortable looking out the window at the sun and the birds. After my visit, I called Madeline’s daughter, Andrea, to offer support.
Andrea expressed concern about her mother and noticed that her mother's hygiene and comfort were declining due to the refusal of personal care. This conversation eventually led us to talk about Madeline’s life prior to the facility. Andrea revealed that when Madeline was a child, she experienced sexual violence at the hands of multiple male family members. I gently inquired if Andrea thought that maybe Madeline was suddenly upset when receiving personal care from the new male nursing assistant due to her trauma history. Andrea gasped and agreed that we should advocate for Madeline to receive personal care only from female staff to see if anything changed.
I informed Madeline’s nurse of her trauma history. Together, we collaborated with the facility where Madeline lived to ensure she received personal care exclusively from female nursing assistants. We suspected Madeline might feel terror when receiving such vulnerable care from a male due to what happened to her in childhood.
About a week later, at our team meeting, the hospice nurse proudly announced that Madeline had stopped crying out and was now accepting personal care after being attended to by all-female nursing assistants.
Madeline remembered very little at the end of her life, but her body kept the score. Even though she could no longer verbalize why male attendants, no matter how kind and competent, caused her to fear for her safety, she still responded as if she were back in the moments when her male family members abused her.
It is very hard for children and youth to flee homes and families that are abusive and traumatic because they do not typically have the financial and social capital to do so. Instead, many choose to either defend themselves as best they can or comply with the abuser to survive while using disassociation as a coping strategy. I do not know how Madeline survived the abuse she endured as a young person. Nonetheless, it is clear she courageously spoke about the abuse to at least her daughter. And in a way she told her healthcare team, through non-verbal communication, what she needed to be safe and content in her final days.
As chaplains, we cannot be merely informed about trauma; we must be trauma-responsive. This means listening to the stories that care recipients share to enable the entire healthcare team to provide contextualized, appropriate care for each person based on their needs.
