Public Health
HEALING THE HEALER Changing the Way We Understand and Respond to Trauma Kenneth Epstein, PhD, LCSW, and Emily B. Gerber, PhD As health professionals, we live during a time and in a place with unparalleled access to evidence about what is required for healthy development and well-being across the life span. And yet even with this understanding, the
gap between the science of healing and practice remains. Why is it so difficult for patients, practitioners, and service systems alike to make changes that improve our ability to prevent or ameliorate diseases that continue to disproportionately impact so many? It turns out that trauma is a likely barrier that can impede our ability to heal and be healed. While the idea that something that happens in our minds may also impact our bodies is as old as civilization, a watershed study published in 1998 by Drs. Vincent Felitti and Robert Anda and their colleagues drew a clear empirical connection between childhood adversity (Adverse Childhood Experiences, ACEs) and long-term health consequences in adulthood (e.g., heart disease, cancer, stroke; Felitti et al., 1998). Most surprising was the high prevalence of ACEs in study participants (middle to upper-middle class patients), with nearly two-thirds reporting at least one ACE, and more than 12 percent of participants reporting four or more. We now know that the more ACEs experienced, the higher the risk for social, emotional and behavioral problems in childhood and adolescence and poor psychological and health outcomes in adulthood. Clearly, childhood adversity is not only a “mental health” problem, but also a complex mind-body problem that needs to be addressed by multiple fields including medicine. Trauma is a pervasive part of human experience and histories, one that we all share. It’s something that can happen to a soldier in Afghanistan and to a family walking to a corner store in San Francisco. About 90 percent of us will experience a trauma at some point during our lifetimes, with exposure to multiple traumas as the norm. Clearly then, the prevalence and the lifelong consequences of trauma throughout the lifespan, is a clarion call-to-action to assure the conditions in which individuals can be healthy (Blodgett, 2012, citing IOM, 1988, 2002). In San Francisco, we recognize that a new response is needed —a comprehensive, multi-level public health approach to the devastating effects of trauma on individuals, families, communities and service organizations. This includes tertiary, intensive, trauma-informed care for those who need it, as well as primary and secondary interventions that prevent trauma from occurring, promote health and well-being, and facilitate early recognition for at-risk populations. These interventions must then be translated to family and community level interventions that increase capacity and resilience. However, similar to individuals, trauma also imperils the health of the systems providing this care. Ultimately, the effectiveness of our trauma interventions with families and communities may hinge in large part on our ability to counter its impact on our healthcare organizations and workforce. WWW.SFMS.ORG
By infusing trauma-informed principles and understanding into day-to-day leadership and staff practices, policies and operations, the City of San Francisco is leading the nation by developing a traumainformed public health system that fosters wellness and resilience for everyone in the system. The Initiative has based its change efforts on the Trauma Informed System’s Principles and Competencies including: • Trauma Understanding • Cultural Humility & Responsiveness • Safety & Stability • Compassion & Dependability • Collaboration & Empowerment • Resilience & Recovery These six principles provide the framework for the foundational training curriculum as well as the starting place for considering our programs and policies, staff-to-staff and staff-patient relationships. Training is now underway with the entire DPH workforce (approximately nine thousand DPH employees), from clerks to providers to administrators, with the goals of creating a shared understanding and language about stress and trauma, as well as providing guiding principles and practical tools to support the DPH staff in working more effectively within the context of a chronically stressed and traumatized system. This “101” training is an important first step in a relationship-based systems change process that is being informed by implementation science. However tempting it is to embrace training as the solution, it is never enough. Our initiative uses a multi-pronged approach to develop and sustain learning and change by utilizing the principles of implementation science to insure that knowledge is transferred into and sustained within actual structures, practices and supports. These include baseline and continuous evaluation of trauma’s impact on organizational and staff work life, commitment to change, embedded program champions to lead change efforts, development of growth and healing plans, policy alignment and regular consultation with subject matter experts, and those with lived-experience. To improve care, implement practices that rely on evidence and achieve sustainable improvements in healthcare, we must make these critical investments in a healthy workforce and organization. By actively counteracting the “dis-integrating” effects of trauma on our systems and services, we will more effectively meet the needs of our families and communities by developing healing organizations that support reflection in place of reaction, curiosity in lieu of numbing, self-care instead of self-sacrifice, aligned rather than competing initiatives and collective impact rather than siloed structures. Kenneth Epstein is the Children’s System of Care Director for San Francisco County Community Behavioral Health Services. Dr. Emily Gerber is Assistant Director of the Children, Youth and Families System of Care and a Licensed Clinical Child Psychologist. MAY 2016 SAN FRANCISCO MEDICINE
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