Trauma-Informed Care: A Podcast with Mariah Robertson, Kate Duchowny, and Ashwin Kotwal

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:04

And Alex, we have somebody in the room with us.

Alex 00:07

We do. We have Anne Kelly, who’s back with us today. She is a guest host and she’s a palliative care social worker. Welcome back, Anne.

Anne 00:14

Thanks. Happy to be here.

Eric 00:15

And we have three guests to help us talk about trauma informed care. Alex, who do we have with us on Zoom?

Alex 00:21

I’m delighted to welcome Mariah Robertson, who’s a geriatrician and assistant professor at Johns Hopkins. Mariah, welcome to the GeriPal Podcast.

Mariah 00:29

Glad to be here.

Alex 00:31

And we have Kate Duchowny, who’s a social epidemiologist and assistant professor at the University of Michigan, where it is freezing cold. Kate, welcome to the GeriPal Podcast.

Kate 00:40

Great to be here. Thanks.

Alex 00:41

And returning we have Ashwin Kotwal, who is a palliative care doc and geriatrician and assistant professor at UCSF. Ashwin, welcome back to GeriPal.

Ashwin 00:49

Excited to be back.

Eric 00:51

So we’ve got a jam packed episode today. We’re going to be talking about trauma informed care. We’re going to be linking to two important JAGS articles that our guests wrote just recently in JAGS. But before we get into that topic, we always start off with a song request. Kate, do you have the song request?

Kate 01:09

Yeah. I requested Tears in Heaven by Eric Clapton.

Eric 01:14

And can you tell me why you chose Tears in Heaven?

Kate 01:17

Yes. So when I was a kid, I remember this being played probably. Well, actually, my dad played it on guitar, but my parents were big Eric Clapton fans. And so it was kind of in the background in my house growing up, only for me to learn later on in life that it’s a. A very heavy song about Eric Clapton’s son who died by falling out of a window in a New York City apartment building. And so, apropos of our podcast, I think it really, both in melody and in the words, captures I think what anyone would agree is probably the deepest form of trauma, which is losing a child.

Alex 01:56

Yeah. And for those of you who are listening live on YouTube, you get me on guitar. And for those of you who are listening to the podcast audio only, you get my son Renn, who went a little crazy with the instrumentation on this one. Here we go.

Alex 02:25

(singing)

Eric 03:26

Yeah. When you listen to that way, it’s such a heavy song.

Kate 03:29

Yeah.

Eric 03:35

Well, let’s get into the topic, and I’m hoping that one of you would be willing to take on my first question, which comes from a very naive place, is even before we talk about what is trauma informed care, how should we define trauma?

Mariah 03:51

I like the SAMHSA definition as sort of a guiding definition for it, and I’m happy to read it. The SAMHSA defines trauma as an event, series events or set of circumstances experienced by an individual as physically or emotionally harmful or life threatening, with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual. Well, being a pretty comprehensive definition.

Eric 04:19

Yeah. So there’s an event or a series of events. There’s the experience of those events, which I’m guessing can make it traumatizing or not traumatizing, and there’s the effects of those events that may last the rest of your life, is that right?

Mariah 04:37

Exactly. And you can’t really predict how each individual might react to the same experience.

Alex 04:42

It’s very individual, so it’s highly subjective in some sense. And one experience that might be traumatizing for one person is not for another.

Kate 04:53

As well as how they cope with that event.

Eric 04:55

Does it need an experience directly? Is something that happens to you directly or could you experience indirectly? I’m just thinking we all went through a major traumatic event in 2020 and the subsequent years. So we all went through a pandemic. I guess that’s an event. You know, we may have known people, we may have cared for people who were dying.

And we often do, as healthcare providers, care for people who are going through traumatic events, through just being sick in the hospital or a home or dying at home. Like, does that indirect? Is that also a trauma?

Ashwin 05:39

Yeah, I think there’s a lot of different types of traumatic events. Some of them are really deeply individual experiences. But you can also think about the collective trauma that we might experience from kind of these big world events, like the pandemic, from major wars or disasters. Certainly a lot of communities we’re thinking about LA right now and the collective trauma that they’re experiencing from the fires. So there’s a lot of different ways to think about it.

The DSM criteria also list out a lot of the traumatic events that we generally consider traumatic, like the loss of a child or other events. So, yeah, many different ways to think about these experiences, but they’re ultimately subjective.

Anne 06:25

And it sounds like the impact can affect us across multiple domains of our life. Is that what I heard you describe, Maria?

Mariah 06:32

Yes, absolutely. And it can be. Yeah, it can be Sort of smaller, I guess. One of the things that’s been transformative for me and my understanding is that that the size of something, the event, like perceived size of it, does not necessarily mean that it’s not traumatic or is traumatic, meaning that very small, seemingly small things can be quite traumatic for an individual and be carried through a lifetime with them and impact them across all those domains.

So it’s a humbling thing when you realize sort of the ways in which it can manifest and how difficult it might be to wrap your mind around what the things might be that cause trauma.

Eric 07:07

It kind of reminds me of our Nature of Suffering podcast where we had BJ Miller on and Naomi Sachs. Like this whole idea of sometimes we try to gradate suffering or compare one person’s suffering to another person’s suffering. Am I getting it? It’s somewhat similar. You can’t really compare the trauma event of one person to another person or compare the degree of trauma because it’s such an individual experience.

Kate 07:35

Yeah. And I’ll chime in as the sort of. More the social epidemiologist, survey researcher of the group. I think that’s one of the inherent challenges about really thinking about how we capture traumatic experiences across individuals, but also across populations. How we do that in our survey research, I think is completely open for critique because we don’t necessarily do the best job. We do the best job that we can do given the number of people that we’re surveying.

But it’s a pretty coarse way in which we do that. And certainly we could dive into the challenges around how we assess trauma, at least at the population health side of things, because I think there’s lots of room for improvement.

Eric 08:13

Yeah. So what do we know about that? What do we know about the prevalence of trauma? And you just published, right, Kate, with Ashwin on the as the senior author, a paper in JAGS looking at was it the prevalence of trauma in older adults?

Kate 08:27

Yeah. And how that relates to numerous health outcomes at the end of life. Exactly.

Eric 08:32

So what did you do in your study?

Kate 08:36

Ashwin and I, which, by the way, was just such a delight to work with Ashwin. We worked on this paper together over the course of a year and it was just really so fun and fascinating to dive into what the survey research says on trauma. And our paper specifically looked at those at the end of life in the last four years of life, what their own accounts were of life course trauma. So those events that happened early in childhood, before the age of 18, but also those cumulative life events, those traumatic events that unfolded throughout one’s life course.

And essentially what we found that was actually really alarming is how prevalent trauma is. So in our study, again, this is relegated to decedents in HRS. So this is around 6,500 individuals, 80% reported experiencing at least one traumatic event across their life course. And that’s, you know, regardless of class, of race, of, you know, all sorts of socioeconomic indicators. And I think there’s lots to dive into in terms of the main findings of the study and certainly how it relates to health. But I think if there’s one major takeaway as listeners, as they read the study or as we sort of talk today, is just how pervasive trauma is, and it cuts across all aspects of different aspects of life, and that you can’t sidestep it. It happens to everybody, essentially.

Eric 09:56

Well, that’s the question I have then, Kate, because when I hear the SAMHSA definition of trauma, it seems like I can’t imagine somebody not having trauma in their life.

Ashwin 10:09

Yeah, absolutely. And our study used a relatively simple scale. It was just asking about 11 commonly experienced traumatic events in people’s lifetime. Of course, people, our scale didn’t really get at things like sexual trauma or racialized trauma or a number of other events that people can have. But even with that relatively simple scale, we picked up, you know, four and five older adults. And. And one thing I learned from Kate is that it’s not just these individual events, but you can experience, you know, greater and greater burden of traumatic events over your lifetime. And we found that one in three people had three or more traumatic events over the course of their lifetime.

Kate 10:52

That ties into a principle in life course epidemiology that we draw upon a lot, which is this idea of training of risks. And so this idea is that as you traumatic events, especially earlier in your life course, that that begets other life events, that makes you more prone to experiencing other negative, potentially traumatic events. And so we see this play out in our study just by what Ashwin was talking about, in that there is this sort of chaining of risks that’s unfolding that sort of puts people potentially on an alternative trajectory by having experienced these early life traumas.

Anne 11:23

And when you say more prone, is that to suggest that they’re more. They’re in situations that may be more traumatic, or they’re prone to experience difficult situations as trauma. What do you mean by that?

Kate 11:33

Yeah, I mean, definitely more indirect pathways than direct. So thinking about, you know, if you are in sort of a home where you’re more likely to Experience childhood abuse that may potentially limit your education trajectory and your ability to attend school. And therefore, because you don’t obtain a high school degree, then you may be less likely to get a higher paying job. And so it’s just this accumulation of risks that can occur that then puts you in situations that are precarious and vulnerable, in which case you may be more likely to experience additional traumas.

Eric 12:07

I got another question, Kate, for you. And this is, I’m going to go a little wonky just for a second because like looking at the 11 things that you looked at for trauma events, some seem like pretty universal trauma events, like having a life threatening illness, a child of yours who died being physically abused when you were young. Some seem like risk factors for trauma events, like did you have to repeat a year of school? Which may not be necessarily traumatizing. Everything may not be. It’s like it’s going back, it’s all an experience.

Kate 12:42

What Mariah was saying about, you know, with that definition around the subjective experience and Alex that you mentioned is that what may be traumatizing to one person may be something that’s a non event for another. Right. It’s all around sort of your mindset and your ability to cope. And certainly this idea of resilience and how folks are able to internalize and make sense of what has happened to them that really sort of differentiates how folks proceed on after they experience a traumatic event or what may be not a traumatic event.

Mariah 13:12

I was going to say that it’s also hard, I think, because societally, I think we sort of have an idea of what trauma is and what it isn’t. And some people don’t even recognize that they’ve had or experienced trauma over their lifespan and retraumatization over their lifespan, cumulative trauma. And so even being asked, you know, like, it’s very hard for an individual to feel, to say, yes, I’ve had recurrent trauma in my life and that’s affected my mental health, my physical health, my cognitive health, et cetera.

It’s not like societally we make that understanding clear. I think we have clear understandings about maybe like military experiences and PTSD and trauma that might be related to that. But I think there’s less nuance and understanding in the general population or even in healthcare providers, honestly.

Anne 13:57

So difficult events, I think I’m hearing you say is like difficult events may be impacting our experience or affecting us not even consciously. Sometimes we may not have even recognized the impact something had in our lives. And yet it’s there the echoes of it are still there.

Kate 14:12

I mean, certainly it’s been interesting being at a major sort of public university where there’s a huge undergraduate population here. And even just the way in which the word trauma is used in sort of daily vernacular of like, oh, this is traumatizing, where you’re like, well, what is the event? I didn’t see it as such. I mean, I think there are, like, even generational divides around how we collectively talk about trauma. And I would say to probably a. It’s a good thing.

I mean, I think that there’s always these pendulum swings, but I think there’s so much more freedom and empowerment around talking about trauma that, you know, that’s sort of probably a larger conversation about how the definition of trauma is evolving, because that certainly will inform the type of survey research we’re doing. But I think that there’s been a lot of evolution to how we even talk about what is a traumatic event.

Mariah 15:00

In books and literature that’s out in public, like the body keeps the score is probably one that many people have heard of, but there are others that I think talk about it more now than has been in the past. And I think you’re right. It’s generationally more discussed in some generations.

Alex 15:15

Speaking of generations, in your study, Kate, you did some interesting work dividing your cohort into generations. I wonder if you could talk about that or.

Kate 15:26

I’m happy to. I’m also happy, Ashwin, if you want to chime in at any point. Yeah. We leverage the Health and Retirement study, which has this really unique study design where they did recruitment to recruit and refreshers of the HRS by cohort. So looking at specific cohorts of older adults that were part of the baby boomer generation. And then we have children of the depression and different cohorts. And so we’re able to segment out by birth court cohort how these different groups may have differentially experienced certain types of trauma.

And what we found was not unsurprising, but it was certainly interesting to sort of differentiate across these birth cohorts that those who, you know, the children of the depression. So these are folks born, you know, in the. In their 20s and 30s, and then the baby, you know, the early baby boomers, that those folks who were more likely to go to war have experienced combat, that they were more likely to have either fired a weapon or been fired upon. And then also things like whether or not you’re more likely to report experiencing a death of a child.

And so certainly we’ve seen major advances and in health care and being able, I mean, incremental, I should say, but certainly better than, you know, the 30s and 40s around, you know, being able to have life saving interventions for, for in childbirth. So we saw that for folks who were born earlier, around the turn, you know, the 20s and 30s, that they were more likely to report, specifically women, I should say there were notable gender differences. They were more likely to report a death of a child as well.

Ashwin 17:00

And I think that just plays into how we should be thinking about this clinically. Right. I mean, when you see someone in the clinic who may be experiencing a serious illness, somebody who’s in their 80s that you’re seeing now might be very different than, you know, a couple of decades ago in terms of the life and kind of world events that they may have experienced. I mean, one thing I was pretty struck by in our study was that for people who were born before the 1940s, about one in five women reported the loss of a child. So really common. And it was still pretty common in more recent cohorts, about 1 in 10 people. So just something to keep in mind that this will continue to evolve as these generations experience different events and advancements in science.

Eric 17:55

Let me ask you this, because we were talking about the event itself and we’ve been talking about the experience. What are the consequences that you found from these traumatic events in the older adults near the end of life?

Ashwin 18:08

These are things that we often see from a clinical standpoint. And I think there has been a lot of push to incorporate this into the guidelines and our general approach. So we did want to see if this was borne out in the data. So we took a look at three different domains of quality of life that are relevant to end of life care. Physical symptoms like pain, dyspnea, fatigue, psychological symptoms, depression, loneliness, and then some of the social experiences as well, like social isolation. We found that trauma was, especially when people experience more and more traumatic events over their lifetime, was really strongly tied to all three of these domains. Pain was far more common. I think it was 2/3 of people who experienced five or more events had significant pain at the end of life, compared to less than half. So you kind of saw the stepwise increase in all of these different symptoms at the end of life.

Alex 19:12

And what’s the clinical takeaway from that? Like, how can our clinician listeners use that information to improve care for older adults nearing the end of life they’re caring for?

Ashwin 19:23

Yeah, I’d be interested in Mariah’s thoughts as well. What we see in clinic is Typically those symptoms, right as we’re seeing the pain, we’re seeing the dyspnea, we’re seeing potentially depression and other things. What we may miss is the underlying causes that are driving some of these symptoms or deeply intertwined with these symptoms. I think this is an opportunity, it’s really an opportunity to think about enhancing quality of life in a different way and potentially a way that may be a little less comfortable for both clinicians and many of the patients that we see. So thinking about addressing trauma as part of our management of other symptoms can be really helpful or at least taking a trauma informed lens to our medical approach.

Mariah 20:13

I completely agree. For me, I think it’s revolutionized or at least been a little bit transformative in the way I think about the ways my patients are suffering in their final years of life. And I think that I love this paper you wrote because the audience or the patients that you focused on in the last four years in particular also in a Venn diagram, like many of the same patients I care for in home based primary care. So just by the nature of prognosis there, and I think, you know, this, this is really where I think the, the value of an interdisciplinary team, which we do so well in geriatrics and palliative care, is important in thinking about approach to these patients because perspective.

Much of my training has been in, in sort of the medical management and symptom management of a patient at the end of their life and thinking about how we do that. And also of course this, the psychosocial support we can, can give. But our social work colleagues, our other team members really bring the lens and understanding for how we might be more holistic in thinking about a patient at the end of their life who’s struggling or suffering, who, who may have had cumulative trauma over the lifespan and how we can really be sensitive to and supportive of that. And, and so I think, you know, I’m often, always, I’m often thinking about how can we really leverage our team to do this, this care better and to really acknowledge the potential cumulative trauma this patient has had.

Kate 21:34

Go ahead, I’m just going to chime in. What I really, really loved about writing this paper is just how readily applicable it is in terms of, you know, I’m often thinking about my work like what’s the intervention? What’s the intervention? And I do a lot of social policy thinking about these really sort of large scale structural problems and how to intervene upon them. And that can be really tricky, especially when you’re thinking about like neighborhood problems and how to intervene on built environment features, et cetera. But what’s nice about this work and the through line through all of the. A lot of the trauma work that I’ve been reading as I got into writing about this is there is this readily applied intervention of really the translational aspect of how it can be applied in clinical care. I think that’s actually a really kind of uplifting note on something that is a pretty dark subject that there is something that we can do about it. And that I think has been a buoy in working in this area.

Eric 22:29

So let me ask you this because one of the take homes I got from the article was trauma is even on a limited number of questions asking about trauma experiences, it’s super common and if you use the expanded definition, it’s universal. How should we just universally just treat everybody? Kind of the same as we think about trauma informed care or should we be screening for trauma? But if we’re screening for it, is it really screening if everybody has had probably traumatic experiences in their life?

Mariah 23:02

Right. I’m going to be. I’ll come out and say that I’m in the camp of universal trauma informed approaches to care. I think we run the risk of bias and bringing our own lens to what we think is the right person to screen or when we should screen, you know, and also re traumatizing someone or bringing up a story or a history that that’s harmful in the moment. Right. Knowing what the trauma was or how many traumas someone’s experienced or how hard it’s been is not necessary to being trauma informed in the way we approach the care. So. So for me, and I think really that’s vetted in a lot of the literature and work too is just universally bringing this approach across the team and really everyone kind of understanding how we show up in a trauma informed way.

Ashwin 23:46

Yeah. And I think that universal approach to trauma informed care is really important. And I think there’s ways that geriatrics and palliative care can kind of add an additional layer to that because we’re unique in that we can draw on the expertise of an interdisciplinary team. Most many people I don’t think would want to re engage with their trauma or want, you know, sometimes it might be unwelcome to start digging up these prior traumatic experiences, but in other cases, sometimes it can be helpful especially if you have kind of the resources of an interdisciplinary team to do it in kind of a structured, careful way. There’s actually some evidence that this late life re engagement with trauma can help to build Meaning coherence kind of re engage in positive ways with their prior trauma. That often happens in life review or legacy sharing that people do.

Eric 24:46

Let me ask you this because both of you also included the same table when we think about like what is trauma informed care? And in that table it mentioned six different approaches, approaches, categories.

Anne 25:01

A framework.

Eric 25:02

A framework?

Mariah 25:03

Yeah.

Eric 25:04

What is Trauma Informed care? What is that framework?

Mariah 25:07

Yeah. So I again, SAMHSA has been sort of leading in the.

Eric 25:11

Can I ask what SAMHSA is?

Mariah 25:13

Substance Abuse Mental Health Services Administration, saa.

Eric 25:16

Okay.

Mariah 25:17

Thank you for asking that. I always have to remind myself the acronym.

Eric 25:22

I just don’t know.

Mariah 25:23

Yeah. So kind of lead the way in understanding and thinking about how we think about trauma informed care. The six principles I can read out and I think when I started to explore this, I was thinking about my own care of patients and how I could do this in a more team and patient centered way. And it feels like it’s really the crux of it is this idea of centering the individual and their own comfort and their story and always kind of revisiting and asking and being sure we’re being true to what they’re comfortable with in the way that they want to engage with us. But the six, the six principles, the guiding principles are safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, cultural, historical and gender issues.

And I think as an educator it’s been really important in particular to focus on that final, that last one. All of them are important, but in educating and teaching, like as we talked about before, different generations living through different generational experiences and traumas and why certain life events and current events could be re traumatizing for certain people from certain generations. For example, understanding cultural history and story for our patients helps us really be able to show up in an understanding and inclusive way. Because really just being non inclusive can be traumatizing and feeling like you’re not safe can be traumatizing. So yeah, those are the six principles to let others speak.

Eric 26:52

So how about this? Go ahead.

Ashwin 26:54

I like those principles and I’ll just point out that the center to Advanced Palliative Care also has a really nice toolkit for people who want to get their feet wet with this and figure out how to do it in a more structured way.

Eric 27:08

I’m going to also call out Mariah’s article in jags. We’ll have a link to it on our show Notes Applying Trauma Informed Approach to Home Visits, which I also love because it makes sense, like in other homes that people have like nursing homes which I think it’s a mandate to provide trauma informed care in nursing homes per cms. And I love the structured approach. I’m wondering if we can think about that structured approach if I just present the case and how you all would think about it from a trauma informed.

Alex 27:43

Is that a tongue twister?

Eric 27:45

Yes. Trauma informed. Trauma informed care approach. So you ready?

Mariah 27:49

Let’s do it.

Eric 27:50

So we have a 60 year old veteran with advanced Parkinson’s disease who’s estranged from his family, ex wife and three children, generally struggled with friendships all his life, admitted to your home based primary care service, generally has good conversations with the male physician but to largely other female interpersonal team including nurses is air bill demanding, insisting the staff know his routines. He wants it exactly the way he wants it but doesn’t even want to talk about how he wants it. And he’s often verbally abusive, making people cry left and right. That’s the story. That’s all you get. Which is not an uncommon story I think in our patient population.

Mariah 28:32

It’s definitely not.

Eric 28:33

What’s the trauma informed care approach?

Mariah 28:36

I mean I think this starts with what we already think about all the time in geriatrics and palliative care, which is thinking as a team about how we can best serve this patient, leveraging what we all understand and know about their story, but also letting him tell us a bit more about his story if he’s willing. And I’m curious a bit about for him in particular, like if he feels like he has. If he feels like he has a voice and choice in his care or if there’s something about the way we’re providing care or communicating that is making him feel unheard or unseen. Often find acting out or feeling frustrated or aggressive with team members regardless of gender board, even maybe with specific genders of team members or different demographics comes from a place of some hurt or some experience that is playing out.

So I think I’d want to understand a bit more alongside my team what this patient’s if they’re feeling heard, if their voice is feeling heard, if they’re feeling attacked in some way or unsafe in our care and how we can maybe modify that as one approach. There’s a lot of other ways to begin to think about this. I’ll let others share.

Ashwin 29:44

Yeah, I love the focus on team. Bringing in the team to brainstorm together, think through how to address those needs, making sure he has a voice and some choice in his care and then coming back to some of the things we were talking about earlier Just being aware that some of those events that he might have experienced earlier in his life might be influencing how he’s acting right now. You know, and some of our work related to loneliness and isolation. We sometimes think about. Sometimes people are isolated because they’re just not very nice people. And it can be really hard to get along with them.

And that plays out in the, you know, all of these different care settings all the time. And those differences in personalities or social interactions, they don’t occur in a vacuum. They might be the result of a whole host of different prior life events. So just coming at that situation with a lot of empathy and awareness that it’s often not personal. This is something that people are processing over.

Eric 30:52

And this also reminds me of Dani Chammas article she just published in Annals of Internal Medicine. Annals of Internal Medicine. We’ll have a link to it. Talking about this idea of countertransference.

Mariah 31:01

Yes, I was just going to say that.

Eric 31:03

Oh yeah, because she wrote this beautiful article about kind of the feeling that you have in the labels that we had a difficult patient. You can assign this patient as a difficult patient, or you can kind of think about the countertransference that you’re feeling. Like I’m feeling very frustrated in the care I’m giving to this patient.

Ashwin 31:23

Like.

Eric 31:24

Like trying to dive more into our own feelings when we’re approaching a patient like this, rather than just giving that label difficult patient. You were thinking of the same, Mariah?

Mariah 31:34

Yeah, absolutely. I just did actually a whole session with my fellows on countertranspurine because I think it occurs dramatically in home environments and in nursing home environments, like when you’re in someone’s space, there’s just so much more input for which to maybe have an emotional reaction to. So I think it’s super important to be keenly aware of what feeling both. Sometimes you feel a special, like a kindred connection to a patient that may make you treat them differently also. Right. So it’s not just both the like, oh, I feel some sort of anxious anxiety or worry in this moment. What is the reason?

But also like, am I too connected or over connected to one patient over another, for example? It’s so important. And also I think that ties in with the idea of checking in with the team members for whom this patient may be a little bit rougher with, has been verbally aggressive with. Because recognizing that we too, as team members are not immune from trauma, recognizing the pervasiveness of trauma in acknowledging that that could also be really traumatic for team members or re traumatizing for team members. And so it goes both ways as we think about approaching the patient and really creating a safe space and brave space for everybody involved in the care for the patient wherever we can. So, you know, in the house calls, for example, we don’t always have the value of only one provider seeing the patient and picking who goes out, but trying to really be cautious about keeping people feeling psychologically safe on both.

Kate 33:03

One thing that it makes me think about is where do we go from here and how do we improve? And I think this is an opportunity. How do we change practice? How do we influence policy? This is where I come back to survey research as potentially being sort of the kickoff on how we do that of like creating that evidence base around like what respondents are saying as a way of then, you know, feeding back to clinicians around, you know, asking respondents in hrs, has a, has a physician or a clinic, has a clinician or a social worker, has anyone ever asked you about your trauma?

And then looking at the intersection around the reporting of events, of how many events they’ve experienced, then also their health outcomes, it would be interesting to think about just the act of naming it and validating and acknowledging that this happened to you, I think is so powerful. So I think this is where, if clinicians were able to do this on a regular basis and patients are seen by their provider in this way, how would that in and of itself be an intervention and improving health? Just by the sheer acknowledgement, of course, recognizing that there’s even the opportunity to go much further around connecting to care and digging deeper, if folks are interested.

Anne 34:16

I think one of the things I’m hearing you guys describe collectively between some of the interventions you’ve described and SAMHSA’s framework is tasking us all to really have an attitudinal shift if we know that trauma is prevalent. Let’s assume that people have been through hard things, even if we don’t know what those are, and to sort of approach it with the compassion and curiosity around that as opposed to trying to over medicalize something or create solutions without understanding sort of the bigger picture. Am I hearing that right?

Mariah 34:49

Absolutely. It’s like a radical revisiting of assumptions. We might be bringing and bringing more curiosity to, to everything we do because we recognize, gosh, we’ve all, we’ve all been through it in some capacity and we, we should be humble in that recognition and then the care we provide.

Anne 35:06

With a wider lens.

Alex 35:07

I’m still a little confused about whether we should ask about it. I’m going to be the confused listener, because I’m hearing that we don’t want clinicians to be the arbiter of what is trauma, what is not trauma, or to stereotype based on highly prevalent historical events or observed characteristics of patients. And yet we also want clinicians to be mindful that most, maybe all, people have experienced some sort of trauma, and that may be connected to the ways in which they express to us pain, frustration with treatment, demoralization, depression, feelings of loneliness. And so I’m kind of caught in there, and I wonder if you could help me out of this. Like, are there ways in which clinicians could ask about this that are more sensitive? Or, like, I’m just kind of stuck here?

Mariah 36:02

I wonder if it’s really about getting to know the patient and their story, as part of which I think is what we do in geriatrics and palliative care quite well. It’s just curiosity to the core of somebody’s journey and story and what’s driving whatever might be the thing we’re concerned about, like, getting to the root of how we can help support them. But I guess it would be a little bit hard to really, truly have a screening tool and be like, trauma, yes, trauma, no. But I think in the way we show up with curiosity and understanding, we may get to a place where we’re like, wow, that sounds like a really traumatic thing you went through.

Or it sounds like you’ve. In my practice, I will say things like, oh, it sounds like that was really traumatizing or really hard and overwhelming. How did you get through that? My gosh, you’ve been through a lot of hard events across your lifespan. I can see why you feel xyz afraid of medical care, for example. So I think it’s not that we’re not affirming and hearing about it, but it’s really just showing up with the safety, the psychological safety, to let a patient feel comfortable sharing those hard experiences where they’ve happened and help them recognize that that could contribute to why they feel that way.

Eric 37:11

And I remember listening to a Curbsider episode on Trauma Informed Care with Megan Gerber, and she used this line, which I liked a lot, which was, have you ever experienced anything that makes seeing a doctor difficult or scary for you? So you’re not asking them to divulge all of their stuff. They’re leading just like everything. They’re leading the story, they’re leading the discussion. We’re getting consent from them, but we’re just asking, like, inquiry.

Ashwin 37:36

Yeah, absolutely.

Eric 37:37

Curiosity.

Ashwin 37:38

I like these open ended questions as well. One of the questions I saw from the CAPSI toolkit was also open ended. It was difficult life experiences like growing up in a family where you were hurt or where there was mental illness or drug addiction, alcohol issues, witnessing violence, those things can affect our health. Do you feel like any of your past experiences are currently affecting your physical or emotional health? And so just kind of a really open ended way. There are these really structured, validated scales that people can use as well. And sometimes people may feel more comfortable writing something down rather than just diving into a conversation about it. And those scales might be helpful in a palliative care or geriatric setting where you really do have a lot of resources that can kind of help to address those.

Anne 38:31

My clinical brain, my sort of very practical clinical brain is sort of kicking in as I think about this because I think even as I hear we us use language to identify screening questions, I can imagine many people, depending on the relationship will be self disclosing and answer some of those questions. I can also imagine people who have had significant difficult life traumas or events who don’t want to disclose that or, or don’t feel comfortable disclosing that in the moment and just acknowledge we’re not entitled to know that or and not to assume that just because someone says no that that’s the whole truth and the full truth, but to assume that there’s probably still something there we just may not have. We may not be have the privilege to know it.

Kate 39:13

And to that point I think if you don’t have the data, you can’t act. How you act is up for discussion, but I think no data, then there’s no place to go. So I’m always partial to more screening and from a data gathering endeavor that if you don’t have the data then it’s hard to really even have those next step conversations on what to do about it. So.

Eric 39:39

So let me ask you this as we’re coming close to the end of the hour, if we can think about practical tips and I’m going to go back to the article on home based care and trauma informed care. What are some practical things that we can do around safety? Because the other thing I remember from that podcast was simple things like as we do a physical exam, don’t saying open your mouth for me when you want to look at the back of the throat is actually describe what you’re doing, get consent for it. In order to evaluate why you’re having a sore throat, I need to look at the back of your Throat. Is that okay? Rather than open your mouth for me, which could be re. Traumatizing. Yeah.

Alex 40:16

And Megan has a nice example of that. Instead of saying, show me your body part, say, in order for us to treat you, it would be useful for me to examine the arm. Would you mind rolling up the sleeve so I can see the rash?

Eric 40:28

Mariah. Mariah. Megan was the person on a pipe. Mariah, what others safety things could we do?

Mariah 40:34

Yeah. You know, so I want to give Megan, like, lots of credit. Megan was my mentor on this paper as well and was one of the ones who sort of supported the idea. You know, she had created some work in the virtual space. And then we were thinking, wow, the home is similar. Right. But I think, gosh, we enter spaces in geriatrics and palliative care that most medical people, medical providers do not. And that offers us an opportunity to be really generous and thoughtful about how we do that. And so I really think it’s just deference and recognition that we are putting ourselves into a space that’s quite private and personal to a person, whether they’re also in the hospital. Right. You’re still in their personal space. And so I think about everything that I have on my person and whether I’m putting it in their space in a way that makes them uncomfortable, how I approach them. So just being cognizant of what you would want if someone came into your. Your home or your space and was asking things of you.

Kate 41:32

Yeah.

Eric 41:32

Yeah, I love that too, because it applies in the hospital, I think Ann’s told me this before, like, don’t move the tv.

Anne 41:39

Knock before you come in.

Eric 41:41

Knock before you come in.

Alex 41:43

I’m so confused.

Eric 41:44

Maybe not close the door on everybody without their consent first. Anything else, Ann, that I do that triggers.

Alex 41:52

I do all those things.

Anne 41:53

I think about that all the time. I think about knocking on the door. May we come in? I don’t close the door unless I ask. It’ll be okay if I close the door because it’s noisy outside. I just. Right. So for some people, having. Knowing what’s happening in the hallway or having a way out feels important. So just having con, like mutually agreed upon plan for even the environment can be useful. I’ve found a stool.

Mariah 42:13

I have a stool. I always bring being like lower to the ground, not like looming over someone in their bed. That’s like quite an uncomfortable. Beds are a very intimate space. Like the oddity of us, like, how often we’re in someone’s room and they’re in bed and we’re Doing things, that’s like a very uncomfortable space for, for many people. So just recognizing where positioning and buttoning people’s things before they, like you’ve asked, like untying their gown before you’ve even asked, you know, those kinds of things are really important.

Ashwin 42:44

And a lot of this kind of draws on those geriatric principles too. You know, just trying to make the hospital or these care settings as normal as possible, you know, because critical illness, being hospitalized can trigger people’s prior traumatic experiences. So, you know, restraints and being tied to the bed and, you know, the sleep, wake cycle, all those things, even just being delirious, many people have seen clinically that that can kind of trigger a lot of those prior traumatic experiences. So being aware of that, applying geriatric principles, I think can be helpful.

Mariah 43:22

I searched to see if it was studied, but I have a feeling and believe that we call white coat hypertension just like nervousness with your doctor. But I think it’s a trauma response to medical care in some way. I have not found any studies to show that for sure, but we always just note like, oh, your blood pressure’s high when I’m here. I wonder how much of that’s related to trauma.

Kate 43:44

Seems like there’s a HRS paper there because there you go, there’s data on it.

Eric 43:50

I love it. You just go straight back to the data. Like, we need data.

Kate 43:54

Well, I mean, you know, underlying this conversation, I think is just a basic realization of just our shared humanity. And I think that’s something that I really try and remind myself as someone who works with large scale data sets, that especially it’s no different than Ashford. Our paper is that, you know, yes, these are 6,500 data points, but when you really start delving deeper, these are people. These are people with real life stories. And I think that, that this paper really connected me to the HRS participants, despite the fact that I’ve worked with these data many times over, that underlying this. Right. Are just people who have gone through really tough things. And that is something that connects us all.

Eric 44:31

Well, I want to thank all three of you. I didn’t realize. Is it Megan?…was the author of this paper and was also on the Curbside Podcast. So I’ll have a link to that podcast. I want to thank all three of you. But before we end, maybe a little bit more of Eric Clapton.

Alex 45:04

(singing)

Eric 46:05

Well, I want to thank all of you for being on this podcast and we’re going to have links to all of the papers, the Cap C stuff, everything on our show notes, so please check it out. But a very big thank you to everybody for joining us on this podcast.

Mariah 46:20

Thank you so much.

Ashwin 46:21

Thanks.

Eric 46:22

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.