Why Clinicians Need to Address Institutional Trauma:

According our country’s cultural delusions, social institutions take care of people and deliver social justice based on a persons’ merits. Institutions for education, law, health, religion, athletic achievement, arts, recreation, work, transportation, housing, and social entitlements are often thought to be entities that people can trust to learn from and get the support they need to thrive in society.

Yet, there violence in the streets. Many come out of jail worse than they were when they went in. Help proffered in our involuntary psychiatric units leads to a revolving door and distain for therapy.  Board and care homes and halfway houses may subject individuals to a sense of poverty. Many of our institutions become the source of pain and trauma. Some institutions work for some people. Some people get targeted, punished and hurt and become marginalized.

Intersecting generalizations about race, socioeconomic status, gender, sexual orientation, gender identity, citizenship, mental and physical health interfere with a person’s capability to self- actualize. Some people are raised to fight and fend for themselves by any means necessary and there are institutions built for them; while others are insulated from these challenges and have wealth and sometimes luxuries to lean on; and there are institutions built for them.

Cliques and societies are formed in every institution that push out people who don’t belong. Some peoples’ skills are celebrated while others are ignored and undermined. Sometimes based on a stigma, a slander or a gossip, skills or abilities get lost.

While often abuse is thought to start in the family system, much of our lives are spent outside the family in institutions that are supposed to guide us in the right direction. How, then, can some of us become mired in mental anguish? Institutional abuse is important to consider when people are suffering.

The Importance of Doing an Institutional Analysis: 

Assessing a persons’ attitude towards the institution is important towards knowing if that institution has functioned to abuse the person. Institutions can do harm in many different kinds of ways. It doesn’t only depend on what the institution is meant to do.

Consider people who thrive in an institution. If they have dealt with an institution that is positive about them like earning a spot on a travel sports team, has it led to better performance and has the selection turned out to be a good outlet for their skills and esteem?

There is a lot that can go wrong on a sports team. When a person doesn’t thrive and optimize their skill it is important to know what happened. Perhaps they went elsewhere and found another outlet or discipline to perform. This happens when we assess people’s passions and interests.

Many clinicians tend to do an institutional analysis in this manner without thinking about it. When dealing with institutional trauma, it becomes important to help a person utilize contexts and times they have thrived in institutions in order to look at the times when they haven’t.

When there is a positive experience, it is important to extract resources from those institutions. If they have a negative outlook on an institution, it is important to learn about the institutions that they did feel good about. If they did have some good experiences in which they thrived, it is important to understand what went wrong.

Often, one doesn’t get this kind of information on the first psychosocial experience. A clinician needs to remember institutional issues and return to them and excavate them later in session.

It is also important to consider resources that often aren’t addressed. Have they had success with a peer group? Have they any attachment to counterculture? In some contexts, it is important to consider institutions that are not given legitimacy like jobs working for black market industries. It is important not to judge the institution, but rather to explore it for resources.

Mental Health Institutions:

Not always do institutions with negative stigmas do people a disservice. Even when the purpose of the institution appears to be to ruin the person’s life, there are often opportunities for good learning experiences that help a person avoid complete defeat.

Thus, if they have come to contact with an institution that is thought to be negative such as a county jail or a county mental health facility, the question becomes what have they learned about themselves from the experience? In the case of mental health institutions labeling a person with a diagnosis with a poor prognosis: do they agree with the negative prediction? What happens to their social performance when they leave?

In my experience with public mental health institutions, compliance may result in a worse outcome. In twenty-five years of working in them, I have tended to see that many programs are built for social control and to maximize financial gains.

Often the way things are set up is so top down that the individual’s needs get lost in the process. Cookie cutter concepts of evidence-based practice often fail to promoting health and healing and personal growth. Some people just get worse and worse over time so that labels like schizophrenia get to be thought of as illnesses of progressive decline.

It is clearly arguable that understanding any person involves understanding how they fit in to the institutions in which they associate. It is not enough to simply learn about the list of institutions that have impacted them. It is important to learn about how they dealt with socialization in the facility in order to learn what they learned from their experience.

Thus, a clinician needs to be patient and not make too many generalizations. After all the secret stories and heaps of bullshit that might need to be excavated. A great question to ask is about people who worked in those contexts that didn’t fit the mold. Part of my reason for writing this is to encourage more people to work in these contexts who learn to counter the negative missions of many institutions.

Assessing the Impact of Abuse Within the Institution:

Often, institutional abuse is covered up and needs to be drawn out to even get seen. The victim may not even have the power to have anyone believe a word they say and that is frustrating!

To help a person heal from institutional trauma, a clinician must learn to see the person they support in a different manner than the institution that damages them sees them. That means acknowledging than an injustice is happening becomes a first step. Too many clinicians working in an institution aren’t inclined to do that. Many workers accept the status quo and impose increased trauma on an individual especially when the person is negative about the institution as they are going through it.

Acknowledging the harm is the first step. Often this is simply a listening skill that needs to develop and a sense of justice is necessary. Sometimes a clinician can suspect this is going on and ask questions that can draw out stories and abuse.

Then, a clinician can develop an alternative narrative for how things might be if the institution was being fair to them. It’s true a clinician can’t change the institution, but they can articulate and advocate for what is needed for a particular client without being able to deliver it. This is essential to building an alliance and mitigating the damage being done. It is a direct route to healing.

It becomes essential to look at what is happening through the client’s eyes.

Understanding Your Institution’s True Mission:

Each institution has a mission and people it is trying to serve. For example, if the county mental hospital is there to prevent homeless people from committing suicide it can be important to acknowledge that that is what the institution is trying to do. This might help the person who has been damaged by the institution realize why they did not fit in and get the help that they needed.

Puzzling through a county’s mentality in treating people also involves considering the bottom line which is the way the institution makes money and survives. This involves understanding the counties finances and the need of the contracting agencies to make money.

In a federal prob the county where I work has been deemed to be criminal in its services. A lot of money goes to emergency hospitalization services and not a lot is set up for treatment outside the hospital.

Abuse might involve more than just suspension of a persons’ bill of rights. It might be an institution is built to control violence and impose involuntary medication and this might have nothing to do with a person’s needs.

It might involve exposure to substandard facility hygiene and this might or might not be what the person is used to. Some might see an unhygienic unit as an insult while others may recognize it as like many other unkept situations they are exposed to.

A therapist is keen to understand the mission of their institution. Believe me it is not in the institutions mission statement! It is more likely to be seen in the metamessages that the institution puts out. It requires real-life interpretation and perhaps some Marxist financial analysis.

What was wounding about the true mission of the institution when it didn’t suit the person you are seeing in the therapy room?

Examples of Differing Institutional Missions:

In my life I have had a lot of conflict with the missions of the institutions that most powerfully affected me. I share them now to demonstrate the kind of race and class bias inherent in institutions. Indeed, if I were your patient, understanding how the mission of three of the institutions I have been subjected to is important to understanding my trauma.

When I was admitted to a state hospital during a break, it seemed like the institution was there to prepare me for living in permanent poverty. The presumption was that I would not be able to work and that I would therefore have to adjust to board and care poverty. It was built into the institution as a mechanism to fill the local businesses, according to my observation.

Enduring that mission, being treated like a piece of cattle in the field, was very hurtful to me when I transitioned back into professional work. It is important to understand the impact that being treated in such a manner has on a person.

In contrast when I attended a private prep school, ten years prior, I was taught that my classmates and I could be anything we wanted to be if we just did what they said and got transferred to an elite university. What mattered was the prestige of the university.

When I decided that I didn’t trust that institution and figured that prestige was some bullshit, four years later I graduated from a local commuter campus in the inner city. The message I got as a freshman, that most people I went to school with weren’t going to graduate, demonstrates that the mission of that particular institution was very different than the mission than my private prep school.

The help I got from the career center suggested I should be a cop. I don’t think many of my prep school graduates became cops. Believe me, it’s not the only time I was invited to join a gang that may exacerbate social violence. I received several offer in the state mental hospital.

In my case, I could see the contrast in the different institutional missions and I always knew that I didn’t fit the mold. I didn’t trust the mission of the prestige prep college. That is something you would definitely want to explore.

Luckily when I was discharged to the streets from the State hospital, I had three thousand dollars to start my life over and prove that I could work in spite of my “break.” There is a lot to explore and many stories to be told. I am in favor of letting the stories be told while assessing the re-traumatization factor. Too many clinicians are afraid to know or counter the mission of their appointed institution. We need more therapists who stand against the mold in the institutions. They do matter and can help.

The Importance of Having Faith and Extracting Resources:

It is true work on institutional trauma takes time and is best done when the clinician has a strong sense of the persons resources. There are times when the person needs to rant and rail against the way they are or have been treated. A clinician who does not believe the resources that might exist or who starts to extoll the virtues of the institution really can set the person into a traumatic response.

Thus, I think clinicians need to have faith in a person’s inner resources. I can be hard to teach this especially when the clinician is not native to the persons culture or contexts. It takes a long time to learn these multicultural skills. Setting up systems in which students and young workers are responsible for knowing things they just don’t get is not a good way to train or heal institutional trauma.

Keeping pay at entry-level salaries, hiring people who don’t have a background outside a degree, and having young managers who are eager to advance and lack cultural understanding is not a good way for organizations to address institutional trauma.

I believe clinicians who have humanistic views of various kinds of people who don’t judge people about external behaviors have a better chance of extracting a person’s resources and helping them love themselves again. Conversely being fearful and condemning of a person who has behaved in problematic manners is a good way to have the person clam up about their resources. When a clinician maintains that kind of stance, it can become a self-fulfilling prophesy that exacerbates institutional trauma