Episode 330 - Michael John Cusick, "Trauma-Informed Care, Part 1"

Welcome to another episode of "Restoring the Soul with Michael John Cusick." In today's episode, we'll explore the critical concept of trauma-informed care—a term that's become widespread yet is often misunderstood. Originating from clinical and research settings and gaining broader cultural awareness, trauma-informed care prioritizes understanding the comprehensive life experiences of individuals to improve their engagement and outcomes in care settings.

Michael shares personal stories that underscore the importance of this approach, illustrating the profound impact it can have on patient experiences and outcomes. We'll delve into practical ways organizations can create sensitive environments for those with neurodiversity and sensory sensitivities, the significance of establishing clear protocols for consent and empowerment, and the necessity of training staff in trauma-informed practices.

Join us as we discuss how integrating trauma-informed care can lead to better engagement, retention, and overall health outcomes, transforming the way we approach care in both medical and therapeutic environments.

Transcript

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Hi everybody, I'm Michael John Cusick. Welcome back to another episode of the Restoring the Soul podcast. Today our topic is trauma informed care. Now, we therapists, psychologists, psychiatrists and psychiatrists use this term a fair amount. And over the last several years, particularly during the pandemic, the words in the phrase trauma informed care have taken root all across culture. I hear this used a lot and, and I think it's interesting that it's used frequently but not very well understood. So today, in part one of a two part podcast on trauma informed care, I wanna talk about what trauma informed care is, why it's important to understand it. And then in the second podcast, I'm gonna circle back around and talk about five pillars of trauma informed care. First of all, it was the year 2018 and Dr. Bruce Perry, who has written a number of books and one of which he's co authored with the famed Oprah Winfrey called what Happened to you? Conversations on Trauma Resilience and healing. In 2018, Dr. Perry was with Oprah on a special about childhood trauma and childhood adversity. And he for the first time used this phrase in a mass context on Oprah called trauma informed care. And his outtake in that program on childhood adversity and trauma was only a couple of minutes long. But I believe it was there that this term really began to catch on. Now, prior to that, it was used in clinical settings and in inpatient settings and in research settings to talk about an overall approach to patient care and to client care. And this idea of a trauma informed approach is not just what a therapist does with you in a counseling session, but an overall way of thinking about providing care and access to people in light of their childhood experiences, in light of the adversity that they've gone through. And as a result of this trauma informed care, there's a set of emerging best practices that therapists certainly try to integrate, those who specialize in work with trauma and childhood adversity and abuse. But it's also ways that organizations can set up care, access to care, and everything from the lighting in your office to what people experience when they walk in. So as we talk about trauma informed care, the emerging best practices prior to the five pillars that I want to present are really in the face to face clinical counseling situations when a person goes to receive care, and then the other are organizational ways of thinking about, proactively about trauma informed care. And I'm going to give a couple examples of that from even some recent tests that I underwent at a cardiac clinic to deal with some palpitations, or rather to get some assessment about what was going on with these palpitations that ended up being caffeine and probably a little bit of stress. The thing about in trauma, trauma informed care is that the research is showing us that when there is trauma informed care, that it improves, number one, whether people engage with treatment and in that engagement, whether they continue and stay with the treatment that's needed for particular issues like trauma, abuse and childhood adversity. But it also produces better outcomes. Trauma informed care determines whether people engage in therapy, whether they continue in therapy. That's what we mental health professionals call client retention. In other words, if people will stay throughout the course of treatment, that's needed and most mental health is not, here's your problem, that'll be 3.5 sessions and then you'll be on your way. It's an unfolding process. So client retention is important. And then finally, trauma informed care improves client outcomes. This approach actually impacts whether or not people will be helped and to what degree. Now it's important, as I keep using the word impression, approach or care. Trauma informed care is not a modality. It's not a way of doing therapy particularly, or a model of therapy like cognitive therapy or EMDR or gestalt therapy, or psychodynamic therapy, or interpersonal therapy. It's a broader lens and approach that can allow other forms of therapy to kind of come in underneath it. So typically when a person has trauma that could be abuse, neglect, life threatening events. But as I like to define around here, that trauma is most simply defined as any experience, event or environment that overwhelms the individual, including their central nervous system, and leaves them without caring, loving resources to cope. I'll say that again. Any event, experience or environment that overwhelms the individual, that leaves them without loving, supportive resources to cope. Now this can also include in light of that environment. And this is really important to say that trauma in terms of environment can be persons of color, minority persons, people that are in poverty situations, people that are experiencing discrimination. So there are systemic issues that those like myself, a Caucasian privileged male, may not think of. People living in and under discrimination or in lower socioeconomic status with fewer resources to food, to education, to going from month to month to pay their bills. Those kinds of situations can be chronic stressors and be part of or actual factors in causing trauma. There can be so many realities that cause trauma in environments as well. For people who grow up with a family member with mental illness. For people who grow up in a family where there is substance abuse or alcoholism. You know, oftentimes people will say in the therapy offices that I've been in over the last 30 years as a professional and I've had my fair share of being in them as a client as well. You know, I didn't have any specific abuse. I wasn't sexually abused, I wasn't physically abused, I don't think I was emotionally abused. But just the environment of growing up in a home where there's mental illness or some kind of significant addiction that can be a history of trauma. So we know that there's massive evidence that where there is an environment of trauma that that exposure to trauma, especially in childhood, increases the likelihood of health risks long term over the person's life. There's a wonderful ted talk by Dr. Nadine Burke Harris. She's a physician and she has done a lot of great research, but she's one of the people that has popularized the ACE test, which is used to measure adverse childhood experiences. That's what the acronym stands for. And here at Restoring the Soul, that's one of the assessments that we give. It's one of the broadest assessments. But the data that supports this very simple test, I think it's eight questions is the higher your ACE score is the greater your adverse childhood experiences, the likely higher level of trauma you are? And with or without a trauma diagnosis, the higher your ACE score, the more likely you are to have health related issues and health risks that are seemingly unrelated to psychological or mental health reasons. And so again, I would encourage you for a compelling and concise explanation of childhood adversity to visit ted.com for Nadine Burke Harris TED talk entitled specifically how Childhood Trauma Affects Health across a Lifetime. So what is trauma informed care? I've been talking a lot about the overall approach. It's an understanding of how life experiences shape the individual and how that life experience impacts how a person experiences their care. So my life experiences have affected me, my nervous system, my mind, in terms of my cognitions, how I see the world, whether I'm hypervigilant, whether I'm not, whether I'm even open to receiving care. You know, over 30 years, three decades in the mental health field, I've seen a lot of different kinds of people. And there's a category of person that for 30 years they've never been to a doctor. And I'm not judging that. If you can do that and you don't have to go to a doctor, great. But it's oftentimes this reluctance of I don't want to go and depend on anyone. I don't want to go and find out if I'm vulnerable for advanced testing or screening. I don't want to find out if I've actually got some kind of disease and if I'm sick. So there's this avoidant way of relating to healthy care that this person might even have insurance to receive. So it's not a financial issue. And that avoidance of care is actually a result of how their life experience has shaped them and therefore how they relate to receiving and accessing care. I've worked with so many people over the years who as a result of their trauma, they say I'm really great at helping others, but I'm not so great at. At taking care of myself, and I'm not so great at receiving. How can you help me to receive? And oftentimes it's not getting out a book called you know, how to receive, or go to howtoreceive.com, it's an issue of looking at the person's nervous system and how they have shut down or closed themselves off to that vulnerability. And it might seem like an obvious thought, but that they never were able to receive grace growing up or in their earlier childhood experiences because that was too vulnerable. They were shamed, they were punished for being needy or for receiving, or that they simply couldn't receive because there was nothing there to give them. Nothing was being poured into them in terms of their basic developmental needs. So there are a number of organizational competencies that trauma informed groups use. Generally speaking, those are going to be hospitals and larger clinical settings. But at restoring the soul here we have started to think through what are the core values that we want to put in place for how people will relate to us, what are the kinds of protocols that we'll put in place? And we've done, I think, a pretty good job about this. From when people walk in, you know, we don't have fluorescent lights. We even did a remodel. And we don't have LED lights which have a certain still not fluorescent, but kind of intensity to it. We have a lot of ambient lighting. And I'm going to come back to things like that more and more. But a part of trauma is often neurodiversity or sensory sensitivity in terms of touch, taste, sight, smell, sound. There's sensitivity there. And we have to be proactive and thinking about how clients will experience those kinds of things. There's also a number of guidelines. And today I want to spend just a little bit of time talking about some of Those guidelines as it relates to these five pillars. Before I wrap up this particular episode, I want to talk about some key ingredients of what trauma informed care looks like in an organization and then in a clinical setting. And the first thing in an organization is that, let's just say a hospital, a dentist office, and then a physician's office. Those three typical points of contact and care, which outside of the therapy office may be the most common, the first key ingredient is for the organization to communicate and lead their patients and clients in a process of transformation. Now, what does that mean at the dentist? That means that in light of understanding trauma and childhood adverse experiences, that from the time that the patient walks in to check in at the dentist office, till the time that they sit down in the dentist chair, to the time when the dentist starts drilling or the hygienist starts doing what they're doing, to the time that they check out, that they're proactively thinking through what is the outcome that's desired here today and what might we be needing to think about in terms of serving people well so that they can a not simply be comfortable so that they come back and remain our patient, but so that they will not be activated, dysregulated, or even traumatized by this experience. Now, nobody likes going to the dentist, but after I was diagnosed in 2003 with complex PTSD, which was a 7 to 10 year process of overcoming, I remember a number of times when I had some major dental work done and prior to going to the dentist office, I had some major triggering. There's something about laying down in that chair and they tip it back and you may put your sunglasses on and they just kind of start in and if they're not aware of trauma, that can be very dysregulating. And I remember because there was, as I've talked about so often on this podcast, sexual abuse. As part of my story, and part of that sexual abuse involved photographs being taken of me as a child. The dentist and his assistant wanted to take photographs of my tooth for the before and after they did this implant for where one of my teeth was knocked out. And I remember sitting in the chair all the way back and they put this big retractor in my mouth, so my mouth looks like it's about 6 inches wide. And, you know, there's everything just wide open. And without asking my permission, without having me sign a release of information, they took those photographs and then they were posted on the website as a before and after example of this doctor's excellent care. Now, I Think that was around 2007 or 8, somewhere back in there. I don't know what the ethics were at that time in dentistry. I don't know if the Health Insurance Portability act, known as hipaa was in place place at that time. But I would say that at the very least that dentist and or the assistant should have had a policy in place that said, hey, this is your mouth, these are your teeth. This is an incredibly vulnerable situation to be in. A, laying in the dentist chair, B, having your mouth open with this retractor, C taking a picture of your face, albeit not identified because it was just my mouth on the dentist's office website of no tooth with this big gap and then one with the tooth in place. And we'd like to ask you to consider being on our website as a before and after. Now, here's a particular struggle with this, and this is why this conversation is so important, is because if I'm laying in that chair and if I've had trauma and abuse and if I'm a people pleaser and I happen to be on the enneagram personality type A2, which is I'm a helper and a giver, it's really hard for me to say no, and particularly to an authority and especially when I'm in a place of vulnerability. Do you hear how this is working out? There's no proactive protocol or communication about this process. They're just acting perhaps ethically with what works for them. So they might have said beforehand, before you sit down in the dentist chair, or we'd like you to take this one page form and review a practice that we ask clients to participate in. And here's all the parameters of it. Here's what will and will not happen with the photographs. Do you hear how this is all about empowerment and it's about giving me choice or giving the patient or the client choice. It's about giving control, if you will. So I can say no, but I have the opportunity to say no sitting in the lobby when I'm not in a vulnerable position with the retractor in my mouth. By the way, how does one with a retractor in their mouth go? All right, you take the picture, that's not going to work, right? So this is a really good example outside of mental health, about a clinical setting. So that is communicating about transformation and being aware and proactive. And in the dentist's office, the transformation is how do you go from your tooth knocked out to having a tooth and leaving the office after however many sessions, appointments or treatments and be satisfied with that outcome for many, many, many months. I was very uncomfortable and even had to go and talk to my therapist about what this stirred up in me to have these photographs taken. And you know, I considered filing a complaint and ultimately I made the decision to not go back to that doctor's office. Now why did I make that decision? Because they did not have, even though I didn't know the phrase at the time, they did not have a trauma informed approach. As a result of that, my therapist re engaged with something that she used to do long before this moment at my dentist's office. But my therapist used to go to doctors and dentists and educate them back in the 1980s in the early 90s about how to work with clients with abuse and trauma and sexual abuse and physical abuse in particular. The second key ingredient for organizations is helping clients through involving them in the planning process. So walking them through and saying here's all the different ingredients of what's happening and it's all about power. Or rather it's about empowering the client in the midst of the vulnerability of care and allowing them to plan. Okay, rather than doing your treatments three days apart because you can't do it any sooner, would it feel better to you to have this a week apart, two weeks apart? Would it also be better for you to, in a dentist's office to have nitrous oxide, you know, where you're semi conscious, or would you like to be awake? A lot of people, they would with trauma and abuse and childhood adversity, the last thing they would want is, is to be out of control. And on nitrous oxide and others, they don't want to be awake for that. So all of that is just consideration. And you may be thinking, wow, this would take a lot of extra time and energy and thoughtfulness on the part of these caregivers. And I would say yes, that's correct. But remember, the evidence suggests that the outcomes are better outcomes in terms of engaging in treatment, being retained in treatment and the outcome. The third piece of this trauma informed care for an organization is training for key staff members, both clinical and non clinical. That would be the person at the check in when you come and say, hi, I'm here for doctor dentist appointment. If you're really nervous, they might say the doctor will be about 15 minutes. We're so sorry that they're running behind as opposed to that nervous or anxious client sitting in the lobby and just waiting, wondering when they're going to come out. They may say if there's something in the client's chart about a history of trauma. They may say, you know, we have another section of the waiting room or if you'd like to step inside, here's an empty room where the lights are lower and it's a little bit more quiet. Would you be more comfortable sitting there? So sometimes clinical training allows for the employees and the caregivers and non clinical people to engage in other ways that are extra intent. By the way, years ago I had over a period of about three or four years, I had nine kidney stones and some of those involved surgery. And I remember going to my doctor, the urologist, and telling him, I am in the midst of healing from trauma, an extended course of therapy regarding sexual abuse. Can you please put a note in my file? And the doctor took a deep breath and he exhaled and he said, thank you for telling me that. Let's deal with this right now. And he literally stood up, invited me out of his office, walked over to this big room that was the medical records section. And he very kindly and gently spoke to this young woman that was the medical records specialist. And he said, we're going to put a label on the outside of this chart and at the entry point when people click into it. And I'm not sure if this was a policy that they had at the time or if the doctor just initiated this, but I remember being so touched. The doctor wrote history of trauma and childhood abuse. And then there were certain things of awareness where I wanted to have certain kinds of medication. I wanted to be basically anesthetized fully as opposed to just a mild sedation for kidney stone treatment because of how that could be re traumatizing. And to think of not having that, it really became a big deal. And I'll just share this because it's what happened. But I remember spending many sessions over a period of weeks and weeks talking with my therapist about whether or not I was actually worthy of requesting this certain kind of care. So you can again see how important this is not just at the organizational level, not just at the clinical level, but in terms of how people can self advocate and how the invitation is there for this. Overall, organizationally, a trauma informed approach is about creating a safe environment from what I call soup to nuts, from beginning to end of the experience. And that is really to prevent secondary traumatization from staff that are not intentionally doing this. That means that with certain people they're going to have information ahead of time or to anticipate or simply to have a way of relating and being in the office so that there's not ongoing trauma that happens as a result of policies and practices. Another example from the dentist office. And if anybody wants to hire me as a consultant to work with dentist office to give my opinion, I'm half kidding about that. But so I've been in the dental chair and they come after drilling and examining and doing an exam and they say, so would you like. No, they'll say, it's our policy to give you the financial information about this. So while laying back with these sunglasses on, completely vulnerable, they come and they bring a clipboard and they start reading numbers and figures about how much this is going to cost. So it's going to cost$2,500, let's say, to repair your tooth. Would you like to go ahead and do that? Now, I would suggest that that's not only not trauma informed, but that that has the potential to be re traumatizing. I mean, if I was at a car dealership and the salesman said to me, would you, you know, like to take that car home with you today? I would feel pressured and maybe anxious and I'd want to leave that situation or at best say, hey, I need some time. Let me go to lunch with my wife. And we're going to come back, we're going to think about it. But in the dentist chair, with the power differential of expertise, with that vulnerable physical position, I don't think it gives people the ability to make good choices and good decisions. So the trauma informed perspective is about creating safety in a way that prevents secondary trauma from staff. The clinical aspect of trauma informed care, this is what it would look like specifically in medical situations, in the face to face at a level lower than the 30,000 foot organizational level. And it's involving people in the treatment process. So it would be the dentist, the hygienist, or even the medical assistant where I recently had a physical who comes in and says, I'm going to put the blood pressure cuff on your arm right now. Are you ready for that? Is that all right? And you prefer left or right arm? That may happen. But then if they need to ask you to take off your shirt or your top, you know the blood pressure cuff isn't going to work over that sweatshirt or over that flannel shirt. So I'm going to need you to take your top off. Would you like me to step out and would you like to have a gown on? Because what happened at my office was they said, take off your shirt and I'm sitting there from the waist up with bare chested and in ever so subtle a way they could have said or may have had a proactive stance that was more anticipatory, proactive and considerate of that situation. Now, in that instance, it didn't traumatize me, but I know many, many people that that would traumatize. And I've sat with people over and over and over again and said, what would it have been like for you to speak up in that moment? And those the person says, I never would speak up, I wouldn't possibly speak up in that situation, even though I felt ashamed, embarrassed and terrified. The second thing, and this is just so obvious, but it doesn't happen. And that is screening for trauma. At my particular doctor's office, there's two assessments that you get when the minute you go into the examination room and they say the doctor will be here shortly, they hand you a clipboard with the PHQ9. That's the patient health questionnaire. And we use this at restoring the soul on the first day of every intensive because it's like taking vital signs. It's like taking pulse, respirations, blood pressure. And it's just a simple way of finding out people's level of depression and anxiety. And then we give a trauma inventory. And that is somebody might have filled out the paperwork one, two or three months ago. But this allows there to be a fresh report and a way of screening for this. That even if a person doesn't have post traumatic stress disorder or something that significant, we know whether there are adverse experiences in their life that might make it important to relate to them in a particular way. At the clinical level, it's important for staff to be trained in specific treatment approaches. So in therapy this would be things like emdr, brain spotting, which is a popular trauma treatment, although we don't do that at restoring the Soul. Somatic experiencing, somatic interventions, attachment work, polyvagal work, interpersonal neurobiology, cognitive therapy and spiritual kinds of interventions. All of these approaches would be about helping understand a person's nervous system as it relates to their life experience, with the assumption that they have the potential to be activated or dysregulated in a situation where they're vulnerable. The final aspect of trauma informed care at the clinical face to face level is knowing lots of resources so that if you are not a shotgun, one size fits all kind of mental health clinic where you can deal with everything, let's just say that you specialize in sexual abuse or in addictions treatment with trauma as part of that background. Having referrals is we can't help you, but we know a really great resource that will and oftentimes people will make referrals in mental health. For I saw this person's name on a website and it says that they do trauma. So I'm referring you there versus a referral that can be made. We have a specific relationship with this particular person and we know that they're safe. We know that they're going to respect your trauma, understand your trauma and help you get the care that you need. So that is trauma informed care from the 30,000 foot view, from this overall approach to patient care. And in our next conversation, we're going to talk about the five pillars of trauma informed care as it relates to restoring the soul. We'll talk to you next time.