Trauma Informed Care (Lund, 3/26/2025)

  A recording of this presentation is available HERE. 

Thanks so much to Dr. Erin Lund for a very impactful presentation this week on Trauma Informed Care. I have to confess that I have seen this presentation (or a previous version) before, but I DO need to hear and rehear and rehear this topic. 

If you remember nothing else, take pearl in: In our daily work should use "universal trauma principles" with ALL patients and then add "extra carefuly trauma informed care" with those whom we KNOW have had extra trauma. 

This includes things like asking for consent, empowering patients over their own bodies and histories, and resisting retraumatization.

I love/hate this image she shared, reminding us of the context of trauma that extends far beyond a person's individual experience. The medical trauma many of our patients have experienced primes them to respond in particular ways to our care provision, and we need to be prepared, but the collective and structural trauma is also ever present.

© Lewis-O’Connor, A. 2015 © Rittenberg, E 2015 © Grossman, S. 2015 UPDATED, April 2020, Feb 2022

Trauma abounds. 

Many of us are well-versed in the original Adverse Childhood Events (ACES) study, which found that 61.7% of CA adults had experienced at least one ACE, and 1 in 6 (16%) had experienced 4+ ACES. You can see the most common ACEs in the image below.

But trauma doesn't end in childhood. Adult traumatic experiences are also common; these include: intimate partner violence, gun violence, sexual assault, incarceration, birth trauma, accidents, racism, sudden loss of a loved one, and more. 

The actual "traumatic experience or incident" matters much less than how we respond to the trauma. What are our resources? Do we have resilience? What are our protective patterns? Do we have time to recover?

The image below is a schematic of a stress trigger, the natural response, and then what follows. Note the time of calming down, depletion and recentering. If we have the tools to pass through these stages, we can recover from the trigger. If not, we may not be able to. Traumatic experiences can lead to developing toxic stress physiology. And repeated stress can impact our neurodevelopment, interfering with executive function

www.dovetaillearning.org

Toxic Stress and Caring Adults - KABOOM!

 
A local non-profit does trainings/workshops to promote resilience. In their workshops, they teach us that our protective patterns, which we develop over time, can be helpful and keep us safe. But when overused or used in incorrect situations, they can be harmful, self-destructive, and inhibit connection with others. Those patterns are seen in the slide below:

SAMSHA (2021) says that to be trauma-informed we must 1) Realize the widespread impact of trauma and understand potential for recovery 2) Recognize the signs/symptoms of trauma 3) Respond by integrating this knowledge about trauma into policies and procedures and practices and 4) Seek to active Resist retraumatization. 

We can create a safe context, restore power, value individuals. We can use universal trauma precautions and stay patient-centered. Being trauma-informed in the medical setting involves empowering patients, giving choice when we can, collaborating, offering safety and trustworthiness. In addition, get curious, learn the back story, listen to patients' fears. Ask yourself and the patient, "How can we help you get through this?"

Resilience is protective. I very much recommend you listen to Dr. Lund's presentation, where she goes on to really talk about heartfelt listening, growing empathy to connect, not defining people by their trauma, and making a real difference through trauma-informed care. 

She ended her presentation with a seminal paper on Trauma informed care in the ED from Ashworth et al (2023). A link to that paper and very helpful tables is available HERE. 

Reflection and Connection: Surviving Residency and the Start of Personal and Professional Development Groups (Addison, 1/29/25)

See a recording of this session HERE. 

Many thanks to Dr. Ritch Addison, long time behavioral health faculty and foundation layer for our Personal and Professional Development (P&PD) Groups that still run every Thursday at Santa Rosa Family Medicine Residency. 

He spent his time with us on Wednesday morning reflecting on the experience of residency training: the constant pressure, the feeling of never enough time, too much to do with the time, dying patients, asking for help vs. not asking for help, learning the ropes and the conflict and contradiction of ideals/values and visions with every day practices. 

I cannot do his 40+ years of wisdom justice with a summary here (just watch the recording), but I do want to highlight and remind us of his model for Surviving Residency:

1) Covering over> the focus on mastering the procedures of medicine, which requires putting on blinders so that you can do what you have to do to get through your day/rotation/year/training.

2) Over reflecting>> too many reflections, filled with painful self-doubt, feelings of imposter syndrome, Did I make the right choice?

And, as Ritch stressed, neither state is stable. In fact, it's the jarring motion between the two modes that is what is so challenging in residency. "You need time to unload one experience and load the next, and you just don't have time". 

The answer? Ritch says, is connection. A place where you can do just this -- unload the conflictual and unconscious feelings, take a step outside those jarring moments>> P&PD. 

Strategies to Build Resilience and Happiness: The Art and Science of Gratitude (Lo, 4/27/2022)

I am personally feeling very grateful to Dr. Onna Lo for a really lovely presentation this week on Gratitude, Happiness and Resilience. I have already integrated some of her techniques. . .priming my day and granting myself a "celebration" list (what I have accomplished in the last 24 hours) rather than a "todo list" (all the things I feel bad about not accomplishing).

If you are interested in watching her presentation-- and you should be --  it is available HERE .

Here are my notes. sorry they are brief:

Dr. Lo encouraged us to start every day and  every encounter with the ABCs:

A: Awareness (ground yourself)

B: Body/breath (be in your body, find your breath)

C: Connection (with your surroundings, yourself, your patients)

People are struggling

• 36% of Americans are cognitively tired
• 44% of Americans are physically tired
• Depression rates have increased over the last decade from 8% to 22% to 32% in 2022

Something to strive for -- Dr. Lo recommends in our own lives and for patients. To be: Empowered, Engaged, Excited, and Embodied

Some definitions:

• Reactive gratitude: appreciation for a gift received
• Active gratitude: seeking out gifts occurring in life that are appreciated
• Happiness: enjoyment of the present good
• Hope: desire for valued future
• Resilience: the ability to prepare for, recover from, adapt in the face of adversity, stress or challenge

Lesson #1: A positive mindset sets you up for better learning

A positive mindset leads to better learning, improved performance, better problem solving

In  The Happiness Advantage, author and researcher Shawn Achor, proposes that personal happiness leads to professional success (not vice versa). Happiness is a choice. Happiness spreads. Happiness is an advantage. Read more about his work here. 

The happier you are, the more successful you will be (Horn & Arbuckle). 

Gratitude predicts hope and happiness more than forgiveness and patience.

How can YOU build happiness? 21 days in a row x 2 minutes >> 3 gratitudes, positive journaling

Lesson #2: Our brains tend to get stuck in negativity

Half glass full or half empty?

Dr. Lo showed us a series of sociological experiment in which people consistently chose the negative response consistently after being primed with a negative response, even when the outcome was quite positive. If primed with the positive response, people were more likely to choose positive. 

We can unstick ourselves by "priming"-- that is, retraining the mind first thing in the morning with gratitude. That is, starting the day positive allows for the day to be more positive.

Exercise: Draw a triangle, write down 3 gratitudes (these must be heartfelt!)

1) what I am grateful for in myself

2) what I am grateful for in others

3) what I am grateful for in my current situation

Exercise: Draw a triangle, write down 3 wonderful things that you accomplished in the last 24 hours (this is your celebration list)

Exercise: Draw a triangle: write down 3 things that will make today great

Lesson #3: There is science supporting positivity and gratitude

Coherence=optimal coordination between the heart and the mind ==> heartrate variability is a really beautiful sinus curve in someone who is completely in a coherent state. Being in this mindset is better for your whole body.

Much more information about coherence and Heart Math at the Heart Math Institute Website found here. 

Exercise:

1) Heart focused breathing: 5 breaths in/5 breaths out (requires nothing more than the breath)

2) Inner coherence: use positive emotions or feelings of gratitude to establish a coherent beat (using heart math monitor)

And finally, keep a gratitude journal. Even in these hard times, there are big and small things to be grateful for.

Mental Health Disparities in Latinx (Flores, 7/29/2020)

A big thanks to CEDAWG and Dr. Yvette Flores, clinical psychologist and professor of Chicano/a studies at UC Davis, who gave a powerful and heartfelt Grand Rounds presentation this week on how to consider and approach the mental health of marginalized groups, particularly Latinx , in this time of COVID. Again, it is hard for me to give her words justice in summary, but the following is my attempt.

Dr. Flores started with "stating the obvious": 1) That racism, sexism, homophobia and other forms of discrimination affect the mental health of those who experience them, 2) That stress affects well-being and 3) That yes, in fact, we are all in this together.

If I don't wear a mask, I affect you.

If my grandchildren don't wear a mask, it affects me.
We are all a little anxious, depressed, and experiencing past traumas as we live this pandemic.

We all need to be in this together, including in mental health.

Dr. Flores spent some time reviewing the important effects of stress on mental health.

Social stress: stress is produced not only by personal events but also by the social conditions that surround us-- and for all our patients, their intersectional identities (gender, class, nativity, immigration status, length of residence in the US). 

Minority stress: high levels of stress faced by members of stigmatized minority groups (race, gender, sexuality, linguistic ability, physical/mental abilities), including:

• lacking proper social supports
• socioeconomic status (SES)
• interpersonal discrimination

Marginalized status affects physical and mental health.

Good stress vs. bad stress: a little stress has been found to improve performance, but a lot of stress can become problematic. In what ways is minority stress a risk factor? And how may minority stress also be a protective factor?

I love considering the possibility that the very minority stress our patients are experiencing may make them simultaneously vulnerable and resilient. 

What has COVID-19 Revealed?

1) Health disparities have been made more visible

2) Xenophobia and hate crimes against Asian Americans

3) Disregard for these disparities from politicians at the highest levels

4) People of color disproportionately work in front line jobs

5) Disproportionate unemployment rates for Latinx and African Americans

6) Ageism (are old people important enough?)

How can we translate scientific data in a way that people can understand?

How do we frame the message?

"There is no one to blame here, but we all have responsibility."

Role of Gender: For the working class, life and work are often synonymous. How does unemployment affect men? How does unemployment impact women who are single parents and have to work? People of  color will often go to work despite the risk because of their gender or cultural mandate that it is their obligation to provide. But this is also a class issue (always need to think intersectionally).

What are the protective factors in communities of color that might mitigate the crisis?

1. Resilience: Immigrants are tremendously resilient. It takes incredible courage to make the journey that many immigrants (particularly undocumented immigrants) make.
2. Stoicism:  coping, "it's alright, I am fine", challenging for healthcare professionals to care for someone who says they are fine (when they clearly aren't). Dr. Flores' rec: Bring in partner if there is one/
3. Religious faith: "Si Dios quiere" God willing. Can be frustrating because seems fatalistic but is also protective. How can we leverage this?
4. Networks of support:  Overcrowded and/or Multi-generational households, which make them more vulnerable are also the very support structures that allow people to survive. How do we mobilize the 
5. Positive ethnic, racial and gender identity: reaffirm their identification (whatever they may be). Call them what they want us to call them. 

Remember that mediational factors may ADD to minority stress

• Internalized racism
• Controlling images (often propagated in the media-- more serious and perverse than stereotypes), many are gender specific (angry black woman, loud Latino, Latino male as criminal or rapist). How does this affect internalized perception of people of color?  How are people in power speaking about these controlling images?
• We must uphold the identities of the people with whom we work: we need to counter these controlling images (mental health workers)

And finally, on coping: how to potentiate coping, so we can be better healthcare providers and caretakers. 

Dr. Flores called this digging into our ancestral well: we have all learned lessons from our family that can help us to serve our patients. In times of crises, we can draw from the stories/legacies that the elders and ancestors have shared with us (and with each of our patients), which can help transform our fears into opportunities

Where do you draw your strength to continue to care for your patients?

Self care is essential during COVID-19:

It is important for us to promote self-care and resilience as we do this work.

Gendered expectations (nurture ourselves in order to refill the well)

Remember to check out and disconnect in order to connect to ourselves 

Cultural traditions can offer balancing and healing: including prayers, smudging, meditation, mindfulness, exercise, baking, cooking