As If: The Case for Trauma as Universal Precaution

When I was in college, I worked at a runaway shelter for teens, where we were constantly cleaning up cuts and scrapes from the latest brawl or dealing with a teen who came in drunk and throwing up-lots of blood, sweat, and worse. This was in the early nineties, in the days of the full-blown AIDS crisis, and it was drummed into all our heads that bodily fluids were to be handled cautiously. We were all trained in universal precautions.

They’re ubiquitous now, so it’s easy to forget how powerful and nearly fool-proof universal precautions really are. The rationale is elegant: you can’t tell if someone is sick by just looking at them. The cleanest cost/benefit solution was to treat each teen as if he or she could pass on some dangerous virus. Waiting to get a teenager tested for HIV, Hep C or whatever would take weeks, and obviously they needed care and cleaning-up now. But the reasoning went on, you couldn’t go overboard either. I wasn’t going to say, “Here kid, take this six-week course of antibiotics before I put a band-aid on your cut, just in case you have something I can catch”. Simply protecting ourselves was quicker, and it was harmless. It was also cheap. A few cents’ worth of latex gloves and some bleach water was all we needed. Compared to the catastrophic costs of getting devastatingly (or even fatally) sick, the time and expense of treating everyone as if nears zero. It’s brilliant, and it works.

In the world of I/DD, we should treat trauma as simply and effectively as we manage the risk of getting hepatitis. Trauma should be a universal precaution: treat everyone as if he or she has some traumatic stress, some scary or dehumanizing experiences with other people, some deeply-wired procedural codes to keep safe by flailing out, or by staying frozen. Treat them this way first, before we ask anything else of them, or of ourselves, for that matter. Every single person.

Every new study about trauma and DD announces more dismal estimates of traumatic experiences, from bullying to rape. “Big T” trauma- the kind of event you only need to experience once to have problems, is higher in our individuals than the general population. We can screen for some of these events, and as an industry we are doing better (not perfectly) at that. The problem is two-fold: many Big T traumas are not ever reported: the individual was too young when it happened, they have a hard time communicating, they’ve been fooled and frightened into keeping quiet.

The next problem, the sneaky and tenacious problem, is “little t”. I’ve seen a variety of screening tools for Big T traumas, but I’ve never yet seen anything that can calculate how many times someone felt unheard, unseen, dehumanized or belittled, stressed, overwhelmed and confused. For some of the people we serve, this is their everyday lives. We know that these small stressors are death by a thousand cuts; it’s not the depth, it’s the number.

When you put them together, estimates of trauma for our population top 90%*; for my money, that’s basically every individual we see. Take these two things together: we can’t see all traumas, and the number is nearly everyone.

We have to weave a tighter net or we will miss some of what we’re trying to catch. Universal precautions in I/DD should be that we treat everyone as if he or she has experienced trauma. We may be aware of what that trauma was, or we may never know. With universal precautions, we’ll do the right things anyway.