Understanding trauma and resilience through research, real stories and reality… my reality

I’m sure you are all well aware that social factors affect health. This framework was not unfamiliar to me when I first started working at Mountain Area Health Education Center (MAHEC). I understood that social experiences can influence health, but I didn’t realize to what extent until I began a research project at MAHEC on childhood trauma.

You might be wondering how traumatic experiences from childhood are related to clinical medicine? Trauma lives in not only the mind, but also the body. There is a rapidly growing body of evidence to support this. In 1998, Drs. Anda and Feletti published a study, which found a significant correlation between health outcomes and childhood traumas (referred to as “ACEs” or adverse childhood experiences”). Adverse childhood experiences include physical, sexual or emotional abuse, physical or emotional neglect, and household dysfunction, such as losing a parent or immediate family member to death, witnessing domestic violence, or having a parent with mental illness or substance abuse. Even when controlling for variables like socioeconomic status, the researchers determined that a person who has more than three ACEs has an increased risk for liver disease, diabetes, chronic obstructive pulmonary disease, and heart disease among other medical conditions.

After reading the 1998 ACE study, I asked myself, how does this happen? How do childhood experiences from 30 years ago have such a lasting physical imprint on a person? My curiosity prompted me to dive into the medical literature. I yearned for a scientific explanation. Luckily for me, since the initial 1998 study, scientists have made tremendous progress in understanding the physiology and neurobiology of trauma. A lot of the research has explored the role of the fight-or-flight response, which, as many of you probably already know, is an adaptive system in our bodies to help us in threatening or dangerous situations. This response sends energy to your muscles when you need to suddenly slam on the breaks to avoid a car crash. It increases your heart rate and respiratory rate when you see a bear in the woods and need to run. But imagine if that bear was your physically abusive father… imagine if you felt a sense of danger every night when “the bear came home from work,” explains pediatrician Dr. Burke Harris in her Ted Talk on ACEs. When a child is repeatedly exposed to trauma, his or her system of alarm will be continuously activated. The expert psychiatrist Dr. van der Kolk states, “Long after the actual event has passed, the body may keep sending out signals to escape a threat that no longer exists”. These excess hormones, like cortisol and adrenaline, can cause toxic stress and have a lasting impact on the brain and the body. ACEs are both a social issue and a medical concern.

Learning about ACEs flipped a light switch inside of me. I reconsidered my approach to medicine and  began to think about addressing the underlying cause of disease, which involves addressing trauma in many instances, instead of only treating the symptoms. I started seeing connections between childhood trauma and many other public health issues. During my time at MAHEC, I have witnessed the devastating impact of the opioid crisis on individuals, families and communities in western North Carolina. After I learned that opioids and other substances act on receptors in the brain and essentially numb the neurobiological effects of trauma, I began to examine our opioid epidemic with a different lens. What if we also have an ACEs epidemic?

My research on ACEs greatly influenced the way I approached my clinical work at MAHEC. I began to comprehend why people engage in certain behaviors. My mentality shifted from “what’s wrong with you?” to “what’s happened to you?” I began to ask patients more questions. I made a deliberate effort to learn about their backgrounds, to listen to their stories in order to understand. Hearing patients’ personal narratives transformed my abstract understanding of trauma into a tangible reality. ACEs were not a phenomenon in an academic journal anymore; they were real, raw human experiences.

After listening to some truly astounding stories, I felt overwhelmed and helpless. What can I do to address trauma? There isn’t a miracle medication to erase the past. Although there is no magic pill, I learned that experts have developed many specific strategies that can boost patients’ resilience and reduce the effects of trauma. There is currently a movement in public health to teach doctors and other allied health professionals about how to promote resilience strategies and provide “trauma-informed” medical care. Through MAHEC, I learned about an innovative approach called the Community Resiliency Model, which aims to educate not only the patient, but also the surrounding community about the effects of trauma and empower them with the techniques and skills to boost resilience. Some of these resilience techniques can literally reset the nervous system, mitigating the physiological effects of trauma. The Community Resiliency Model is based on the notion that “it takes a village” not only to raise a child, but also to heal one. Helping an individual recover from trauma requires bringing together community members to create a trauma-informed, resiliency-focused support network.

Several months into my fellowship, I gained a new perspective—a highly personal one— on trauma after my own adverse experience. During the fall of 2016, my older brother passed away very suddenly and unexpectedly. When I received the phone call, my fight-or-flight response was activated before my brain could begin to process what had actually happened. Trauma lives in not only the mind, but also the body. As I heard the words “he’s gone” uttered, I felt my heart rate rapidly accelerate. I began to hyperventilate inside the Asheville Target. It was the strangest thing because I had learned all about the physiology of trauma from my research on ACEs. I knew exactly what was happening to my body, but I couldn’t do anything about it.

The weeks that followed my brother’s death are still a blur to me. But one thing I distinctly remember is having a loss of words. When I tried to speak, nothing came out. There weren’t words that could fully capture the horror of what I endured. I thought back to something I learned from my research: when experts used neuroimaging techniques to analyze traumatized brains, they saw that Broca’s area, the part of the brain that controls speech production, was shut off. This happened to me. My brain physically could not produce words (on a side note, I have found writing this blog post to be an empowering way to reclaim my words).

I was a living example of everything I had learned about through work. As a result, I was better able to grasp patients’ experiences of trauma. I felt a deeper sense of empathy for them. I had an urge to tell all of my patients, “Your pain is valid. I recognize and understand your suffering and I’m so deeply sorry for your trauma.”

When I returned back to my life in Asheville, I struggled… a lot. I could barely concentrate on simple tasks at work. It felt like my brain was surrounded by a fog of trauma. My grief felt like a heavy backpack full of bricks, an unbearable weight that I carried around constantly. I would frequently break down crying during the middle of the day. Whenever it happened, I would say to myself: Get it together, Natalie. Control yourself. But I couldn’t always. Trauma and grief are incredibly powerful. I felt overwhelmed. Above all, I needed support from the people around me, but I felt guilty and embarrassed asking for help. I prided myself on doing things independently. I can make it through this on my own, I thought. I was also very accustomed to helping and taking care of others, so it was deeply uncomfortable for me to become the patient, to acknowledge that I needed to be healed and cared for. However, once I admitted this to myself, it made all the difference.

With the Community Resiliency Model in mind, I began reaching out to the people around me—to my community in Asheville. Once I asked for their support and help, my trauma became less overwhelming. There were more people to help me carry my heavy load of bricks. Why did I ever try and do this on my own? My community has been unbelievably supportive and kind. I will never forget the compassion I received during this time. I also started using the resilience techniques that I learned about on myself. Over time, it has become easier to breath. Although I am still profoundly sad about my loss, I feel more resilient and connected because of my supportive community. It took a village to help me on my path of healing.

My raw pain is now the underlying force that fuels my passion for medicine, health and healing. After learning about and living through my own trauma during my Davidson Impact Fellowship, I understand that both health and healing are complex processes. Given that social realities impact these processes, I recognize that my situation is one of privilege. It greatly disturbs me to think about the fact that there are so many people, especially young children and socially vulnerable individuals, who experience horrific traumas with less resources and support than I had. I am more determined than ever to combat this injustice and serve as a supportive resource to vulnerable patients; to be present with them on their journey towards healing.

Ultimately, this year has left me inspired to provide trauma-informed care to my patients and to educate my peers (why I chose to write about it in this blog post), colleagues, family and friends about ACEs and resilience. I hope that by spreading this message throughout my medical career, I can help my patients and my community become more resilient. It really takes a village—a resilient, supportive, connected village—not just a person with a stethoscope, to help people heal.

 

Simple, but Powerful Medicines: Patience, Listening and Trust

By the end of my time at Davidson, I had become so accustomed to immediate results. After a long evening session in the library, elegant graphs, lengthy Spanish sentences, and even chapters of my thesis would appear before my eyes. It was so satisfying to see my ideas and efforts rapidly crystallize into a tangible product (a metaphor for my organic chemistry professor, Dr. Stevens).

Thus, when I first began my fellowship at Mountain Area Health Education Center (MAHEC), I myopically assumed that I would instantly see “results” in all of my projects. I thought to myself, “I am going to make a radical impact, immediately”. How idealistic of me! My sense of time was completely skewed. It can be very difficult to change an individual, a community, a culture or a system. Difficult, but still possible. Through both my research and clinical roles at MAHEC, I have learned to embrace my work with a new sense of patience.

As a research fellow, I am involved in two projects. One project is a community education program for long-acting birth control, which aims to reduce unintended pregnancies in two surrounding rural counties in western North Carolina. Since the topic of birth control can be controversial, we recruited 15 local community members to help us design a culturally-sensitive birth control message and figure out appropriate ways to spread it. Although designing our own campaign is much more time-intensive than distributing existing posters from an established birth control campaign, our thoughtful approach will hopefully have a long-term impact because we are developing a culturally-specific message that will actually resonate with the people in our target communities. This project has shown me the vital importance of patience. My other main research project is a study on childhood trauma and the social determinants of health. I appreciate this research project because it has enhanced my understanding of the psychosocial factors and human behaviors that affect health.

As a community health worker, I get to apply what I’ve learned in my research and address some of these psychosocial factors and behaviors with actual patients. In essence, I help patients follow their treatment plans and engage in behaviors that positively impact their health. Helping patients adopt a healthy behavior, such as eating a more nutritious diet or quitting smoking, usually entails changing a deeply ingrained unhealthy habit. This aspect of my work has tested my patience in a new way. It may be one of the most challenging things I’ve ever done, given that humans are creatures of habit. During the first few months of my fellowship, I felt frustrated. I kept asking myself: “Why am I not seeing results? How do I motivate my patients to change their behaviors? Where does motivation even come from?”  I contemplated this last question for a while. When I asked Cathy, my wonderful boss and mentor, for advice, she encouraged me to take time to learn more about my patients’ interests, activities, goals and dreams. So, I started listening.

I learned about my patients’ lives. I listened to their stories. I learned what brings them joy and meaning. Although listening seems like a simple task, I have found it to be one of the most crucial clinical skills. After learning what things are important to to my patients, I am more effective in helping them adopt healthier behaviors because I can encourage and motivate them in a personalized way. This approach requires more time and patience, but it’s worth it. Additionally, I have observed a powerful side effect of listening — it builds trust; it demonstrates to patients that I am invested in their stories, instead of merely being interested in their medical progress.

I am especially grateful for my impact fellowship because it has enabled me to understand these lessons before I enter medical school and begin my career as a physician. In my medical school personal statement, I wrote the following sentence: “I grasped the power of listening and the importance of making patients feel heard.” From my work at MAHEC, I have learned that it is so crucial to not only listen, but also to make patients feel heard, recognized and validated; to bring compassion and to be really present with patients in the midst of their vulnerability, pain and illness. That is how a lot of the healing happens. Listening, trust and compassion are some of the most powerful medicines I’ve seen.

Adversity Against Adversity

When I walked through the doors of the Education building at MAHEC, I wasn’t sure what to expect. I had never done an employee orientation of any kind before. ‘It’ll just be an extended series of PowerPoint presentations… right?’ Well, little did I know that said presentations would have such a great impact on my future goals. The very first presentation focused on the mission, values, and structure of MAHEC and began with one phrase – Your Doctor. Your Teacher. Your Advocate. Contemplating these words over a matter of weeks struck me sufficiently enough to lead me to shred my first medical school personal statement and write something entirely new – a piece largely influenced by this simple statement. Yes, really… the root of my motivation to go to school for yet another 4 years had transformed by observing the essence of this statement first-hand every day.

My very first day of actual work began with a 2-hour discussion with Dr. Letson, my supervisor, and former Davidson Impact Fellow/new MAHEC employee, Cate Hendren. We went from Medicaid expansion to neonatal abstinence syndrome, then to the unique academic life at Davidson, off to ‘best-practice’ pun delivery techniques, back to Dr. Rishi Manchanda and upstream medicine… and back again. Needless to say, it was a relaxed and friendly conversation on the surface. But I’m sure my new colleagues could see the whirlwind behind my eyes, as though I was literally screaming, “There is so much to be done! Where could I possibly begin?!?!” Even now – three months in – narrowing my focus has not helped much in the complexity of these important problems. What has helped is meeting people who have dedicated their lifelong careers to trying. How do we end sexual assault for good? Completely eradicate the rampant spread of HIV in the Southern U.S.? Find a sustainable and effective way to close the health outcome gap between races and ethnicities? Well. You simply start by trying.

In my opinion, I am meeting the most extraordinary people this nation has to offer. A woman who goes to work to raise money for Planned Parenthood, knowing she will likely be met by an adamant pro-life protestor. A man living with HIV who leads community engagement to ensure access to medicine and frequent rapid testing to stop the cycle of transmission. A health system innovator who says that her work is informed by her deepest personal values. Almost every day, I meet a new person who inspires me to consider the breadth of what I could do as a Davidson Impact Fellow and (fingers crossed) as a future primary care physician. Instead of simply being a doctor, why not be a doctor AND teacher AND advocate each time I enter an exam room? Holding the responsibility of charting symptoms and advising treatments was never my dream job – it has always been more than that. I want to make people healthier and sustain healthy states, not merely cover-up symptoms. Most will need medications. Others will require knowledge on how to manage their chronic illness. And every patient deserves an advocate who will stand in their place in front of the legislator, the landlord, or the peer physician when their voice is being silenced.

I am exciting about my current projects and initiatives here at MAHEC and beyond as an advocate for women’s and children’s health and well-being. And I could not be more grateful that this opportunity has directly informed my future as a primary care physician.

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