Today we continue our conversation with CareNet’s Laneita Williamson to dig deeper into the effect of trauma on well-being and the impact of adverse childhood experiences on a patient's health. Laneita Williamson welcome back to the move to value podcast

Thank you so much I'm glad to be here

Last time we talked quite a bit about trauma and trauma informed car. Can you share how health care providers can help patients address their trauma?

Yes, so healthcare providers can learn about trauma-informed care and they can use that at the individual level, the organizational level and even advocate at the system level through legislation. But at the individual level once you learn about trauma-informed care, there are four Rs that we kind of want everybody to be utilizing with every person they come into contact with. Those four Rs are realizes, recognizes, responds, and resist.

So realizes means that we realize the widespread impact of trauma on patients. That there are adverse childhood experiences that changes the architecture of the brain when it's pervasive and toxic and then those changes create a latency period to adulthood. And then there's around 40 plus diagnosis that have a correlation to those childhood adversities and just knowing how many people, nationally and globally, have childhood adversities is the first step. We want to realize that the people we are treating today we are seeing the symptoms of what occurred decades ago in their childhood.

So when we realize that, our next step is going to be to recognize what those signs and symptoms are. How they show up in a clinic setting. Is it showing up through their social status? Is it showing up through their behaviors? Is it showing up through their inability to be part of the treatment plan, leaving against medical advice? Is it showing up with diagnosis that we know are correlated to that adversity or that trauma in childhood?

And then once we recognize those signs and symptoms, the our logical next step is, well how do we respond? You know, what do we do? Well we respond by fully integrating our knowledge about trauma with that individual you know asking them you know how are things in your life impacting you? What in your life has impacted you that may be working against you with your health right now? That can open up a discussion with the patient. Another way that they can, physicians or providers, can respond is to look at the hospital policies, procedures, and practices. What are we doing that may be hurting our patients instead of actually helping them?

Which that leads us into our last and final R which is resist. We want to seek to actively resist retraumatization and that may look different from one patient to the next. But once we become trauma informed, we learn very quickly to ask what makes you feel safe. We want to make sure that we're helping you in the space that you're in, and we do things from a lens of curiosity. Is what I'm about to do possibly a trigger for a person? And if it is, how can I work with this patient to help them know what may be part of their treatment plan and how we can navigate through it so that they are not traumatized.

So although there are four R's that will know of in trauma informed care, there are two more Rs that have been used in a recent book that I'm familiar with, and the first is repair and the second is resilience. Repair means it's important for us to acknowledge the ways in which our systems and our communities have been harmed through judgment, rejection of abuse, and how we have impacted those trauma survivors. And then resilience it's important that we recognize individuals may not have resilience. Resilience comes from having tools provided to an individual family or community that allows them to build resilience. So as we're working with our patients, what can we offer them to help any repair that may need to happen and to build their resilience to help take care of their health?

Our next Move to Value Summit is about community health workers and community resources and we talked a little bit about this leading up to our Nursing event that we held in December of 2022. I'm curious as to what community resources might be available to support trauma outside of the practice that a provider might be able to say “hey between our visits here somewhere you can go and talk to someone” - or if that resource isn't there, do you see a need for one?

So community resources is a challenge and the reason it a challenge is that nationally and globally we have not recognized the impact of trauma until we’re already behind the curve. So we don’t have enough centers or organizations to handle the influx of the trauma outcomes that we are seeing but what I want to, you know, encourage, is that communities can help heal from within. So part of trauma-informed care and being a provider is giving education. Just like we give education to new parents about covering up their outlets or using a car seat, you know, how to feed their babies sitting up and in ways to sleep, or if you're an adult your risk factors for smoking and what that does to you. As clinicians, we provide ongoing education every single day. So one of the things that's so good about trauma informed care is that we can provide education to our patients to take back into their communities and communities can utilize this information to heal in the way that they need to heal because every community has different historical trauma. different adversities. They know what they need. They also have the wisdom to heal from the inside out once they get the knowledge. Once they understand how they've been impacted and have been validated. Now that's not to say we don't need to continue to advocate for our nation to help our healthcare systems have more resources in the community, such as CareNet or Parenting Path, which is here in Winston-Salem, or Forsyth Family Services, there's so many good organizations going on, Smart Start. But we need more of those. So our social workers do have relationships with the agencies within our area that we can send people to, but we also want to encourage community self-healing and give that education to them.

Very well said. So what are adverse childhood experiences, also called ACEs, and how do they impact adult health?

Adverse childhood experiences or ACEs are potentially traumatic events that occur in childhood before the age of 18. So from that zero to 17 years. They include some main categories like abuse, neglect, and pervasive household dysfunction, Now underneath those categories you're going to have subcategories such as in abuse you may have sexual abuse, or physical abuse. In neglect it may be physical neglect, or emotional neglect. Then in household dysfunction, it can be examples such as a parent who has an unmanaged mental illness, substance misuse, interpersonal violence within the home, incarceration. All of these things can be impacting that child's brain development. So that's why we're calling them adverse childhood experiences.

These traumatic events again create this latency period to the onset of poor health outcomes later in life. These adversities, we now know that by the time there are six or more of those categories that I just spoke to, in the original adverse childhood experience study those patients that had six or more of those, their life expectancy was 20 years less than children who had none of those adversities. So we really want to understand that these patients had this 20 year reduction in life expectancy. But even before that, they were already having chronic illnesses, health issues, behavioral challenges, substance misuse, social issues, and these are things that again we want to be able to repair and help each patient build their own resilience. And as we've learned about adversities, there were those 10 original adversities from the adverse childhood experience study, but we know those are not the only things that impact children or they're developing brain.

So for example North Carolina has developed the North Carolina resilience community, has developed a tree that has four dimensions of adversities. The first one is going to be your adverse childhood experiences that I just discussed. The second will be the adverse community experiences. This is what's impacting our population – poverty, structural racism, community disinvestment, police violence, lack of affordable housing, lack of opportunity and economic mobility, discrimination, disconnected relationships, unemployment, and deteriorating built environments.

The third area of the tree is adverse climate experiences. These include examples such as climate change, wildfires, droughts, hurricanes, earthquakes, environmental injustice, pollution, floods, and COVID-19, which is very critical for our healthcare system. We were addressing the pandemic as it was occurring, but while it was occurring all of these adversities were impacting these children, which means there's a latency period that we're going to see in our future, whether that's 10-20 years, of an influx of these children who were experiencing these traumas in their homes when they were not at school, when no one was watching, or when their parent had to go to work and leave them there, maybe without food. So there's all of these challenges that's coming from the pandemic which is under the adverse climate experiences.

Then there's also atrocious cultural experiences. There's impact with macro and sociohistorical conditions, like slavery, genocide, colonization, segregation, forced family separation, removal of property, and then just a political and social mistrust. So our children who have gone through atrocious cultural experiences, they are impacted through their environment and their community and then that carries over into the next generation.

For the provider, how can adverse trauma experiences be identified in their patients, and how should this information impact a treatment plan?

As clinicians or providers we don't necessarily aim to identify specific adversities but we do walk into every situation, again, utilizing that universal precaution. The vast majority of people have experienced adversities and this is a very different understanding than what we once believed. We historically believe that adversities were rare or children were resilient with no lasting impacts, but now since we know differently, we just walk into every situation wondering what's happened to them instead of what's wrong with them. So a provider should always have trauma at the forefront of how they engage. They should consider how trauma has impacted this patient neurologically, psychologically, socially, and biologically, and again going back to looking at what's happened to them instead of what's wrong with them.

Having this knowledge and this approach alters every action in our treatment. It changes how we engage to minimize triggers. It helps us resist that retraumatization. It changes the questions we create in order to obtain our differential diagnosis. It changes what labs or treatments are to be considered. How we respond to the patient's beliefs, fears, and behaviors. Then we also begin to collaborate differently with other providers and just be cognizant of reporting to each other in a trauma informed approach. Helping a patient, again, can be very simple. Is walking in with this lens of what trauma has done to us and then just making sure that we are not retraumatizating them, that we're working with that patient. And then that approach and that lens impacts every step of the journey through a patient’s health process, whether it is maintaining, improving, or in some cases, even in Hospice care, we want to make sure that we're giving them a trauma informed care approach at every point in time.

Laneita, how can health systems prepare to care for the next generation of patients with adverse childhood experiences?

Make sure that you have a road map or a toolkit in place and different milestones. So you may, for example, have five milestones. The first would be conduct a readiness assessment. Is your organization ready to shift to that trauma-informed care lens. Do you have the leadership buy in or are the leaders actually helping you move trauma-informed care through the organization. You want to define your clinical roles and tasks, who's responsible for what. You want to gather your resources, get to know your network of care. Who around you is also working on the same types of approaches but may not be falling completely under trauma-informed care, but once they learn about it, it brings everybody together to have a better framework. Consider that financing and technology needs. What is needed? Is it that you have financing for trainers in every division or every department, or that you have enough technology to have an Intranet build in your system where your employees and staff can go and look for resources you know who to contact to schedule trainings. And again, you want to monitor, evaluate, and continue to improve you know your processes as you move forward.

Healthcare systems absolutely do need to listen and learn from their communities though, that is first and foremost. We need to discover our communities specific history, take those steps to repair any historical trauma through a trauma-informed care lens so that our healthcare systems will be utilized by those patients who have had mistrust, for very valid reasons. That will help break the cycle of that intergenerational transmission of ACEs into the next generation.

Well what can a provider do starting today to begin to address these behavioral health needs for their patients?

So oftentimes one of the questions that I get from providers is that I love this information you know it makes sense but what do I do with it? And what I tell the providers is that it's important to learn how to respond to someone that either shares that they have a history of trauma or that has been triggered. So the first thing that you can do is say we now know adversities in childhood can impact our adult health, how are body works, and how we cope. How do you feel any adversities in your past may be impacting you now? Often times that allows the patient to open up to share or to express a concern. Typically, they don't because it's such a private moment, they're not going to share a lot, and that's another thing that providers are worried about is the time. Most of the time they will just share something small. But when they do you thank the patient for sharing, validate their strength by stating I'm amazed at how you came through your trauma and are trying to take care of yourself, and then you know once you've asked how they're impacted and you’ve validated them by sharing that you’re amazed how they came through it, you can usually move forth in your treatment plan. They’ve shared something, you validated it, and it gives you the knowledge that you need for that next step of where to go in your treatment plan.

Outstanding! Laneita Williamson, thank you for joining us today on the move to value podcast

Thank you so much it was truly a delight to be here.