(This article appeared in the Summer 2016 issue of SSA Magazine.)
Girls who grow up experiencing trauma often become women experiencing trauma. In order to help these women and girls, researchers and social workers need to learn more about the sources of their trauma, develop programs that help them better cope with their trauma, and advocate for them.
In this issue’s conversation, Gina Fedock, Assistant Professor at SSA, and Candice Norcott, the Director of Behavioral Science at the Cook County-Loyola Family Medicine Residency Program, discuss their work with women and girls who experience trauma.
Fedock’s work spans the boundaries of public health, criminology, and social work, centering on the complexity of factors that impact the physical and mental health of women. Her research focuses on women’s interactions with formal systems and evaluating interventions that are designed to improve the quality of women’s lives in the community and in correctional settings such as prison.
Fedock was a practicing clinical social worker prior to her doctoral work. Her clinical work encompasses trauma-informed practices, violence prevention, and treatment.
Candice Norcott is a licensed clinical psychologist. Before her current appointment, she spent about three years developing and implementing girls’ services at the Cook County Juvenile Detention Center.
Ms. Norcott, who received her PhD in clinical psychology at the University of Connecticut, did her pre- and postdoctoral training in Yale University’s Department of Psychiatry. During her time at Yale, she worked with adults diagnosed with serious mental illness.
Ms. Norcott is also a certified training associate for “Voices: A Program of Self-Discovery and Empowerment for Girls.” The curriculum was developed by Stephanie Covington, PhD, who created an innovative, gender-responsive, and trauma-informed approach to the treatment needs of women and girls.
Norcott: Yes, that was interesting how we talked about that life course; that we should be able to identify these girls in juvenile detention, determine that they need help, and keep them from getting into the adult system. In fact, we see that is not what is happening at all. The very same girls that are in juvenile detention find their way or are even directed towards the adult systems, which is really unfortunate. When we met I was working at a juvenile detention center, and now I’m working in behavioral health, where I am actually placed in a family medicine health clinic and many of my clients are adult women. And so what I’m seeing are the girls who didn’t get the services they needed are all now adults with chronic health conditions.
Fedock: One of the things about women with life sentences is that a lot of them are serving their first prison sentence, which speaks to me about the need for prevention-focused services before they end up in prison, even starting in the teen years. Based on interviews with this population of women, I see that in their pre-prison lives, a majority of women are not getting connected to needed services, especially for trauma, substance use, and mental health. Relying on prisons for interventions does not seem like a sound or ethical solution. And I think it’s the same for physical health care.
Norcott: To speak to your earlier point, I’m seeing the results of the interpersonal and systemic trauma that they’ve experienced as girls. So I’m working with women very similar to those you worked with years ago. They might not be serving these life sentences in prison, but they’re serving life sentences of health conditions that are the result of the trauma. And yes, as we continue to work on keeping the Voices curriculum up-to-date and relevant, that’s going to be something that we rely more and more heavily on. I believe our kids are receiving the message that undervalues emotional education, as there’s no real wellness curriculum for them. For a variety of reasons, kids aren’t learning interpersonal skills, how to tune into their emotions, how to contain extreme emotions until it is safe and useful for them, and how the risk for them extends to their physical health.
Fedock: We aren’t incorporating emotional skills within educational settings. When I think about these women’s experiences before prison, I see it as more of this cumulative neglect on a community level, that they’ve been ignored or marginalized. I’m not capturing micro aggressions that they’ve experienced [in my research], but definitely I see a sort of system level neglect of not intervening and not feeling a sense of engagement or worth or care for the lives of marginalized girls and women. There needs to be a larger intervention here. We keep hearing these stories nationally about women experiencing abuse by police officers once they return to their communities, or even prior to prison, as well as by correctional officers in prison. To think about that combination of abuse by powerful figures is really distressing. And while I think intervention development work is very important for women and girls involved in the criminal justice system, there is no curriculum that addresses how to deal with trauma from correctional professionals. We see policies like the [federal] Prison Rape Elimination Act [of 2003] that seek to end these forms of violence, but there isn’t corresponding work to change organizational culture. Are we asking why are our systems continue to traumatize women and girls? We often hear this term of trauma-informed care—what do you think that would look like on a community level or on a systems level?
Norcott: We have to be careful that we aren’t creating curricula for women saying “this is how you deal with the trauma we’re going to continue to impose on you.” We also have to advocate for women. When we pull back and think structurally, so much of trauma and violence is about that power and control. We have a corrections system that is based on power. And one of the principles of being trauma-informed is getting service providers to talk and communicate with one another. At the Cook County Juvenile Detention Center the number of girls has dropped dramatically in the past five years. That’s a bonus, and that has to do with diversion. The Department of Children and Family Services has played a role in terms of changes they have made as well as the powers that be who are saying there are too many kids here that don’t need to be here. I was working with this girl there and you would have thought she had an Axis 1 diagnosis [having acute symptoms that need treatment], just beyond help, and she just screamed all the time, all night, and kept everybody awake. You would hear people say, “That girl is crazy.” And then I saw her walking down the street a couple years later, and she looked amazing. She stopped me and we talked for a little bit. I had to ask her, “What changed, what was different?” And she said “I got into a good group home.” Her environment changed such that she could flourish. And I believe that’s being trauma-informed, to create an environment for girls to grow, recover, and heal. And I don’t know that we really are doing that in a lot of our services, because it’s hard.
The following web-only content is the continuation of professor Fedock and Ms. Norcott's conversation.
Fedock: Yes, yes. As you mentioned this, we have seen some organization-level focus in our policy recommendations which are attempts to streamline practices into everyday practices. For example, there are US Task Force on Prevention requirements that primary care settings should be screening for intimate partner violence and following up with some type of intervention. But we see across studies, that a majority of health care providers don’t screen and have a wide range of how they respond, if at all, to patient disclosures about intimate partner violence.
Norcott: There are several factors at work here. One piece is that providers are not told what to do next. Or perhaps a community agency that used to take referrals has now shut down due to lack of funding. There are plenty of examples of that in this state (Illinois). Providers may not ask because there is nothing they feel they can do with a positive screen. Another piece may be that a provider may have had similar experiences and have not yet addressed their own personal challenges. And yet another compounding factor is that they may be working in a system that is not very trauma-informed, and then you’re asking them to do interventions and screens with no support. It’s no wonder why they’re not happening, when those are all contributing factors.
Oftentimes when I’ve done trauma trainings both for physicians and corrections officers, or counselors that worked in various juvenile detention centers in Illinois they’ll say “what about our trauma?” In order to make room for empathy, you have to address the person’s trauma as well, right? Is there room, because of their wounds, for them to help heal another [person]—and that’s very real. We can act as if we’re professionals and that trauma shouldn’t happen to us, but it’s still happening and people are still walking around, exhausted, fatigued, and traumatized.
Fedock : Yes, and providers seem to have a variety of different responses. There’s some research that has found that there are providers who say “I don’t have time,” but there are providers who find ways to embed it into what they’re already doing. Medical assistants who as they are taking a woman’s blood pressure will ask, “How are things going at home? They’ve come up with their own questions to ask. Some providers say that just by starting a conversation with “Tell me how things are going for you, what’s been stressing you out,’ using these more neutral terms opens a patient up. And a lot of providers share that they take the time because they have personally experienced depression, trauma, excessive stress, etc. But sometimes that opens the patient up so much that there are many needs the provider can’t address. Then that starts to backfire because now they know 12 different things that a woman needs and they don’t really have those resources to supply them. Also, it’s about 12 different things that are beyond just the clinic and health care.
[This] is part of trauma-informed thinking and how we understand the various ways that violence occurs. It’s not just sort of what hits the news. Trauma is happening in our homes, it’s happening in our schools, it’s happening in our faith-based organizations, and our places of worship or religious and spiritual engagement. It’s happening across settings in subtle ways and then also in very dramatic ways. So I think partly expanding that knowledge, and expanding the thinking about prevention includes considering the wide continuum of ways which trauma happens.
Norcott: What would it be like if we could have a regular gathering of neighborhood police officers, the neighborhood school, the neighborhood primary care health center, and just say what does our community need this year, what does our community need in the next six months? What’s been going on and what can we do that is coordinated to address these events or challenges given our different specialties? Why does that have to sound like such a wild dream?
Fedock: Yes, and there are communities engaging in such partnerships and it would be great to think about supporting such efforts nationally. I think about schools expelling young girls for acting out, and we’re seeing that trauma-informed high schools help lower those rates of expulsion. When you think about the sexual abuse to prison pipeline, especially for black girls, if we stop punishing, if we stop throwing people out of treatment whenever they relapse, if we let people know that you’re not going to get arrested for calling the police if they are getting beat up, what would it look like to move beyond a punishment-focused response system?
Norcott: I wonder what our services or what our budget crisis would be if we didn’t have prison to catch everybody. If prison wasn’t an option, I think we’d work a lot harder to find solutions for our schools, housing and placement, and child abuse. I think we would work a lot harder at that. We really need to pay attention to this trauma-informed school idea. Traumatized kids are getting triggered in schools. This is a problem because when girls stop going to school, that’s when the risks magnify. When they start disengaging from school, that’s a problem.
Fedock: With trauma-informed high schools, a key aspect seems to be a network of care. It’s about connecting the school with physical healthcare and with mental health care and really thinking about a whole network of care with different organizations. So thinking about creating systems of care seems to be essential.
Norcott: I believe that some of the best systems I’ve worked in we met with medical doctors, psychiatrists, and the mental health providers weekly or biweekly to talk about cases and to talk about the mental health aspect of cases. Part of the Affordable Care Act and the Patient Centered Medical Home model used in primary care is that before each day all the practitioners that are on a team will huddle—who’s coming in today, what do we need done, how is the flow going to go. And so it’s this idea that we all need to come together on a regular basis.
Fedock: That makes me think of two things. I like the idea of if you have a patient who keeps meeting with their medical doctor about their mental health. If you think about having these personalized relationships where, if you have these huddles and the doctor can say, well, I have the psychologist here who I would like to bring in and to talk with us. As you said, the patient already has trust with their medical provider, so how can you build on that trust, to use it as a bridge. And that would support the medical doctor as well as to help the patient and the mental health professional start the engagement process.
The systems level factor of every time we add something trauma-informed, how do you not make it add on? So if engaging mental, behavioral health within medical care settings, or if it’s thinking about trauma-informed practices, how does that become a true integration? How do you think about cultural change with the dominant organization, too, where it’s not just add and mix? Or it’s just something we do at the beginning of our process, but it becomes really a cultural shift, which seems to be reoccurring theme.
Norcott: Yeah, and the change happens when you convince people that it will make their lives easier, really. If doing it in a way that will actually help your delivery of services, you’ll feel better about what you’re doing, and you’ll just be delivering the best care and it’ll feel like that. And we’re reactionary. I’m a planner. I guess that’s just a personal skill. And so much of service delivery is, oh, we’ve been told we need to do this in the next 30 days, so we need to do this.
Norcott: So you aren’t getting buy-in. You’re actually getting a lot of resistance because you can’t have a thought out plan in that time. But I do believe that the key has to be that it can’t be framed as ‘this is something else you have to do.’ We’re talking about primary care, we’re talking about mental health care, thinking about juvenile facilities, about prisons, and even talking about the role of the community and schools. We are talking about all these different institutions, and thinking about changing the culture and practices, beyond thinking about change, trauma-informed practices, and prevention as just the checklist, as you said. Thinking about what does it mean to really seek to address these different needs, and to think about the role of trauma, and the role of prevention and intervention within these different institutions, or within these different settings, and thinking more about cultural shifts, about the way we view providers, and the way we view the people that are engaging with them.