THE CENTRALITY OF CARE

The first time I met someone with Dissociative Identity Disorder (DID), I was five years old. I recall sitting in a chair in the waiting room of my parents’ psychotherapy office and wondering “why is a child’s voice coming out of this adult’s body?” I was immediately curious, and refused to accept the all-too-common response at that age, “We’ll explain when you’re older.” As I learned basic elements of what causes harm, what leads to dissociation, and what encourages healing, they made sense to me intuitively – just like I needed to pet the cat softly and be careful not to cause it discomfort, humans needed to be treated with gentleness and care, or they, like my cat, might need to hide before feeling safe to carefully reemerge. If people were harmed in an ongoing way and not treated with care growing up, they still needed to get the care they needed once they were adults. While my young mind was initially confused, the information quickly lined up with my observations and experience of the world.

Cultivating the opposite of trauma

As I grew older and forged my professional path, I noticed that too few people had this basic context of threat, harm, and appropriate response; it was more common to label a problem and pathologize it than to understand its context and causes. Through this lens I cultivated early in life, I considered the role of trauma and dissociation in psychological theories, interventions, and in general problems I observed in the world. In my early twenties I studied to become a yoga teacher and learned the term pratipaksha bhavana – a yogic principle that describes exploring the opposite. This initiated a journey of reflection – What, might we say, is the opposite of trauma? Of dissociation?

One thing that is clear is that harm and violence are key causes of trauma and dissociation. We know that neglect, interpersonal harm, and betrayal trauma can play an important role in symptoms related to posttraumatic stress disorder (PTSD), complex trauma, and dissociation. What, then, is the opposite of neglect, harm, or betrayal? I’ve come to see care as that converse force.

Over the past two decades the term trauma-informed care has grown in popularity. While the construct and practices of trauma-informed care have yet to permeate healthcare professions, there has been significant growth in interest in trauma-informed modalities in recent years, particularly among psychotherapists. When we talk about practices being trauma-informed, sometimes we drop that last word – care, or interchange it, as I have above with “practice” “policy” or “modalities.” Though these practices and modalities are easier to research, I encourage us to keep our attention on what appears to be a significant antidote to the impact of trauma. That is, the caring presence of another human being.

The presence of care

What is care, and how do we define it? I suspect many of us would say “I know it when I see (or feel) it.” We certainly know what happens when people, pets, or even plants, do not receive care. It only takes one week of vacation and in the absence of my usual care, my office plants seriously struggle to survive on their own. Care can make the difference between life and death, between struggle and survival. While plants’ needs are quite basic – water combined with a good balance of sun and shade satisfies most – humans have more subtle ways of describing their experience of care. My clients and students have described feeling cared for in a variety of ways, ranging from sensing another person’s genuine interest in their well-being, to feeling that another person invests their time and attention in them, to witnessing someone’s willingness to pursue solutions with them when challenges arise. Some say that the simple quality of the presence of another person can indicate whether they feel cared for, or dismissed.

The Oxford English Dictionary defines care in four ways (Simpson, Ja & Weiner, 1989). It describes the care itself, the word in its noun form, as, “the provision of what is necessary for the health, welfare, maintenance, and protection of someone or something,” and “serious attention or consideration applied to doing something correctly or to avoid damage or risk.” As a verb, the act of caring can mean to “feel concern or interest; attach importance to something,” or to “look after and provide for the needs of.” Each of these captures something familiar about clinical work in trauma recovery. We pay attention, look out for, promote health, show interest, search for needs, and help identify ways those needs might be met.

These are qualities each of us bring to our work with complex trauma and dissociation in our own way. Often we do so without much thought or formal skill development; and yet our ability as providers to offer appropriate care is foundational to everything we do. Our theoretical inclinations, chosen interventions and specific techniques layer atop our capacity to practice presence, and communicate care in the way a client or patient can receive. Presence, like care, can be challenging to define, but we feel when someone is “with us” and, conversely, when their mind wanders. As clinicians, we notice (hopefully!) when it becomes difficult to stay present with a client, and we explore that challenge. Our efforts to practice presence, to connect, and to explore the meaning of what is happening when presence wavers, can also communicate care.

Clinician self-care

Care then, appears to combine aspects of presence and goodwill, and applies to both clinician and client. In order to “provide” the service, clinicians need to be practicing self-awareness, tracking their own present-moment mental, emotional, and somatic shifts. As Lynette Danylchuk pointed out in her 2015 Presidential editorial in this journal, “By necessity, the training begins to include self-knowledge, thoughts, and sensory awareness. Over time, the therapist in training becomes better able to witness his or her own process, noticing how interactions with the client impact body, mind, and emotions. That expanded awareness helps attune the therapist’s responses to the client.” (Danylchuk, 2015). Rather than waiting for burnout and vicarious trauma to initiate self-care, we can continuously attend to and care for ourselves to create a foundation for the caring work we do with others. In this way, we model care, and bring our personal practice of care into our sessions.

Mindfulness + Responsiveness = Securefulness

Often when I teach about care I use an acronym to spell out its component parts: Compassion, Acceptance, Responsiveness, and Expression. These four components do not provide an exhaustive description of care, but they capture some of the core aspects of the act of caring. The first two words, compassion and acceptance, are similar to mindfulness practices, which encourage “awareness of present-moment experience with a compassionate, non-judgmental stance” (Kabat-Zinn, 1990). The second two, responsiveness and expression, lend themselves to the secure relationships described in various models of attachment with an emphasis on being seen, heard, and responded to in a safe way. By offering this safer space, we provide our clients an opportunity to learn and internalize the dynamics of secure attachment. These four words I use to make up the CARE acronym boil down to two central components of care: Mindful presence, and secure attachment.

As Christine Forner noted in her Presidential Editorial in this journal, (Forner, 2018) the areas of the brain associated with mindfulness are responsible for nine basic functions, including body regulation, attuned communication, emotional balancing, response flexibility, empathy, insight, conditioned fear modulation, intuition, and morality (Siegel, 2007). For me, this list immediately calls to mind a parent holding an infant, gazing into its face, swaying side to side, attempting to soothe any discomfort the infant experiences, and supporting the tiny human in adjusting to whatever might be challenging in the present moment. Each of these qualities describes a good caregiver. As Forner’s article continues, “The mindful brain seems to be more about connection and dissociation seems to be more about how to survive disconnection.” When we meet a need with presence and care, things tend to move forward in a positive manner.

What happens when we meet a dissociative experience with presence? While presence may seem like the antidote to dissociation, this hasty approach can lead to a client feeling flooded by previously disowned affect and knowledge, which in turn presents the therapeutic duo with a wide variety of challenges. When we add artful attunement to our presence, we can adapt our delivery of care to the needs of the person before us in any given moment. I have come to use the term “Securefulness” to describe this overlapping mixture of mindfulness and relational care. By training ourselves in present moment awareness, and keeping the sometimes numerous and competing needs of those we serve in the front of our minds, we develop a care-giving brain that is flexible and receptive. Since mindfulness and dissociation represent quite the opposite function, we as clinicians can assist people living in a primarily dissociative state to bridge that gap with our mindful, responsive presence. We bridge the gap with care.

This “Securefulness” describes the times I’ve felt cared for – by myself and by others – and it also speaks to what I’ve provided for others, as I am mindful of their experiences and seek to create a safe space for them to explore themselves. Since we have science to study both mindfulness and attachment, perhaps these lines of inquiry can inform our understanding, and study, of care.

Care-ful power dynamics

It’s important to include a discussion of power dynamics in any relationship, and a caring relationship is no different. Thus, it makes a difference if we offer treatment, which lends more power to the clinician, or if we offer care, which feels more inclusive of both parties. The notion of egalitarian relationships and analysis of power imbalances in psychotherapy have been studied for decades by practitioners in the field of trauma and dissociation, many of whom helped to establish the field of study of childhood trauma and interpersonal betrayal that is foundational to our work today (Courtois, 1988; Herman et al., 1987). We can have care that exhibits “rational authority,” in which the party with more power seeks to serve the party with less (Fromm, 1976), or we can have care that seeks to exploit. Many of our cultures are built on power dynamics that exploit entire groups based on race, class, age, gender, sexuality, and more. Perhaps we have devalued care in the largely patriarchal world, because care has long been delegated to mothers, and women have historically been assigned less power than their male counterparts (Brown, 2018). To this day, we have a hard time assigning monetary value to care, particularly of the psychological nature. Many new (and seasoned) clinicians grapple with assigning monetary value to their work, and too many accept wages that are far inferior to those charged by professionals who provide physical care. Given how central care is to life, I hope that we can recognize the immeasurable value of this quality and act. Care is priceless.

Care-centered models

This discussion lends itself to an exploration of our identity as mental health professionals. Who are we and what precisely do we offer? Are we offering treatment or care, and what might be the difference between the two? The way we conceptualize, communicate, and study our work has an impact on our own lives, and on those of our clients and patients.

Care-centric models align with many recent developments in trauma-informed care. Stephen Porges’s emphasis on the healing capacity of ventral vagal states (Porges, 2017) supports the notion that simply being in quiet, still space with another being – without fear – can help us connect with biologically regenerative states. Donna Hicks’s description of dignity (Hicks, 2011) allows us to more deeply understand the needs we often reduce to “respect.” Her ten elements of dignity – which include acceptance of identity, recognition, acknowledgment, inclusion, safety, fairness, independence, understanding, benefit of the doubt, and accountability – form a baseline that recognizes the humanity of each participant in a conflict. These are the grounds upon which care is born.

From the groundwork of practicing dignity for ourselves and others, we can extend care to larger systems and seek to perpetuate it at the organizational level by practicing Institutional Courage (J. J. Freyd, 2014). The Center for Institutional Courage (2021) describes this as, “ … an institution’s commitment to seek the truth and engage in moral action, despite unpleasantness, risk, and short-term cost. [Institutional Courage] is a pledge to protect and care for those who depend on the institution. It is a compass oriented to the common good of individuals, institutions, and the world. It is a force that transforms institutions into more accountable, equitable, effective places for everyone.” Rather than neglecting, abandoning, or betraying those who have been harmed by the institution, the institution can communicate care by recognizing the harm with non-judgmental (and perhaps, non-reactive) present moment attention, and can seek to respond to the harm with adequate repair. Institutional Securefulness, anyone?

Re-centralizing care

Care has become a word we tack onto the end of a phrase, without much thought or attention to what it really is, who can offer it, what compromises it, and how we can provide it. Perhaps we have stripped the study, teaching, and modeling of care from our profession because we take it for granted – of course we care for our clients and patients. Or perhaps it’s simply easier to value what we can deduce, study, and measure easily. Despite the popular focus on manualized interventions, powerful research can and does show that what happens in therapy is about the relationship between the people in the room (Norcross, 2011; Matrin et al., 2000). Ignoring the essential elements of care puts us into a place where we lack clarity and consciousness around what we are offering, so let’s bring care back to the center of the stage, and include it in our course of study. Let’s research care, think about how it works, and ask those we serve about what it means to them. My hope is that by re-centering our attention on trauma-informed care, we can create cultures where harm is reduced, needs are responded to, and people feel cared for by the people and systems that surround them.

Reflection questions

1. What makes you feel cared for?

2. How do your clients best receive care from you? Note both similarities and differences between clients.

3. How might the research community investigate care? Consider the avenues of mindfulness and attachment, as well as the potential contributions of both quantitative and qualitative research.

4. How might a business communicate care for its members while holding to the boundaries it needs to thrive?

Additional information

Notes on contributors

Lisa Danylchuk,

Lisa Danylchuk, LMFT, E-RYT, is a licensed psychotherapist and founder of The Center for Yoga and Trauma Recovery. A graduate of UCLA and Harvard University, her work has pioneered the field of trauma-informed yoga and transformed our understanding of embodiment practices in therapeutic work. More than 400 providers from 28 countries have completed Lisa’s Yoga for Trauma (Y4T) Online Training Program, the first virtual program to train providers offering trauma-informed yoga.

Lisa currently serves as President for the International Society for the Study of Trauma and Dissociation, and has served in leadership roles for the organization for the past 5 years. Her research has been published by the American Counseling Association and she has contributed to many peer-reviewed articles in the fields of trauma, resilience, and human development. She’s written for the American Psychological Association, and Good Therapy. Lisa’s books include Embodied Healing: Using Yoga to Recover from Trauma and Extreme Stress (2015), How You Can Heal: A Strength Based Guide to Trauma Recovery (2017), and most recentlyYoga for Trauma Recovery: Theory, Philosophy, and Practice (2019). She is also contributing editor for the Best Practices for Yoga for Veterans, published by the Yoga Service Council.