Distress after ACE training

We had a similar experience a few years back, at a local training for the staff of health and human service providing agencies. (public and non-profit) Since this was an audience for whom ACEs was not a new topic, I think the planners did not expect the reaction to be so intense. First, people were really astonished that the audience scored well above that of the general population (both in total numbers and number of ACEs) and second, it brought to the surface issues that people felt they had resolved, or more likely, had never fully resolved.

We actually had to stop the presentation and help some folks deal with their feelings. (Luckily, we had lots of trained counselors available!) While I was neither the planner, a counselor or an affected person, I think there was some comfort in realizing that you were not alone. Rather, if there was ever a time or place to acknowledge the effect of ACEs on your life, you couldn't do much better than in a room with lots of others with high ACE scores who knew exactly the mix of emotions you were experiencing.

Since then, we acknowledge before we start the test that people might be disturbed by the findings and try to have at least one trained counselor available in case someone needs a person to talk to.

For me, it's a great reminder that while we tend to use impersonal and distancing language in our professional personas, we are talking about things that cause some people ongoing pain and anguish. And sometimes we are those injured persons.

That's really useful, thanks Allen.

Andrew Turner posted:

Hi all,

Advice sought please! We are a public health team in a UK local authority, and have been raising awareness of ACEs and trauma-informed interventions for some time, with some success. We have recently been made aware of an issue around ‘ACE training for enquiry’ and in particular the impact for those staff who would ask the ACE questions.  We have a local centre that specialises in helping women experiencing domestic abuse (along with a wide variety of other complex needs and generally high ACE scores). Many of the staff at the centre are volunteers and some have had similar experiences.  We have received feedback that learning about ACEs and their impact has caused distress to some staff – we have reports of some feeling guilt about having ‘passed on their ACEs’ to their children, especially having learned that this could potentially have been prevented.  Obviously, these staff were taught about ACEs in order to be able to help their clients in a more trauma-informed manner, and the last thing we wanted to happen was for them to be upset themselves. We will be looking into this further to understand their perspective, but I was wondering whether any of you have had similar experiences and how you tackled any negativity or distress  arising from education around ACEs. Many thanks.

I think if you check out my previous post regarding the proposal from NHS Scotland (now attached), you'll see a number of different levels. I think this can be used to structure a set of guidelines for preparing people for this sort of work,at whatever level they feel prepared and comfortable. If you've seen posts of talks by Anda or Felitti, there's nothing unusual about finding sets of helpers in their audiences with levels of ACEs "above the norm" -- meaning that in the Kaiser studies. But such groups also tend to have resilience resources above the norm, including time spent de-sensitizing to the material, and "vicariously" dealing with it. For most, victim and "therapist", this sort of work might best be done by older or wiser souls -- look at the demographics of those who make use of the call line for the Blue Knot Foundation in Australia -- typically in their fifties or older -- you need a certain amount of real-world strength to get into it, your own or others histories.

So, the level of support etc needed depends on the person's degree of involvement with the issues. On the one hand, it appears relatively "easy" for primary care doctors to conduct screening evaluations (ACEs Q, PTSD screen), and refer people on. On the other hand, those who choose to go further with the material, who aspire to become involved as "therapists", or as "educators" need to be better prepared, personally as well as professionally. Many would say "don't do the work if you ain't done the work" -- do the work on addressing the leftovers from your own history if you want to approach doing this work professionally -- I don't treat fellow workers / speakers "with kid gloves" "just in case" -- if they haven't acted responsibly to do their work, then they shouldn't do it, pure and simple -- they'll be hurting not only themselves but putting their clients at unnecessary risk. This view is shared by many others, for example, see McPherson's resources, the book "Victims No Longer" by Mike Lew etc etc.

Thus. this field really is no different from any other "peer support work" in mental health in these regards -- have understanding supportive management; fellow supports nearby for debriefing; if you're speaking, your own pre-prepared "script";  personal and professional boundaries sorted out -- AND RIGIDLY MAINTAINED as necessary. There are guides around in the MH field for responsible use of "lived experience", and this is just one particularly common form of "lived experience".

Good morning.  we at the Illinois Chapter American Academy of Pediatrics(ICAAP) have witnessed and experienced the same reaction to ACE training.  Therefore we have incorporated some training and coaching that includes information of building resilience, self care, "ghosts in the nursery", and compassion fatigue, with very positive results.

We have created materials and tools based on SAMSHA/CDC work and if you contact me at jbrewster@illinoisaap.com I will gladly send information and discuss with you.  there is no denying that there is a cost to caring .  please take care.  Juanona Brewster, Senior Director, ICAAP

I too have had the experience where providing ACEs training caused much distress in my audience.  So, I no longer provide ACE training without also providing resilience training. 

I usually do this by making a comparison between ACEs and car safety.... when I was young, there weren't seatbelts, let alone carseats and boosters and people in my generation survived.  Now we have a lot more information, we 'know better' and we put kids in carseats and boosters and they're surviving better (safer, less deaths, less significant injuries) than before.  With ACEs, just like with car accidents, we can't ever  stop them all, but researchers are learning that there  are things we  can put in place, like seatbelts/restraints to decrease the detrimental impact of ACEs.  

Hope that's helpful.

Our organization is sensitive when conducting trainings for a family recovery program that serves families with a parent in early addiction recovery.  Many staff and volunteers are attracted to this work because of great intention and compassion.  Some of that is rooted in issues in need of personal recovery and self care because of their own family environment and upbringing.   Some of these well intended are not aware they are ACOAs, or have not admitted to encountering trauma in other ways as a child.  The training and work in serving children and families dealing with trauma can be triggering, and we try to bring awareness of this issue to program directors.  With the concern of compassion fatigue, we encourage trainers and facilitators to model self care, and discuss the importance of providing appropriate breaks in between program cycles so that the facilators can rejeuvenate.  This type of direction is important for healthy adults, but even more important for those who have not dealt with childhood trauma and do not practice self care.   For the good of the program, we can appreciate that adults in need of healing themselves, who do not maintain healthy boundaries, and do not practice self care, are a concern when working with families who really need strong centered  support and direction.  We too need a stronger response when the triggering happens and facilitators identify with the need of their own healing.   It's good to see your post as this has been on my "I really need to do this" list but never actualized into a goal.  It's too important to not do.  I would encourage you to look to Dr. Tian Dayton, who is exceptional on this topic.  While she provides a plethora of material, a great start is with her book "The ACOA Trauma Syndrome."   

Mary Beth Colliins posted:

Our organization is sensitive when conducting trainings for a family recovery program that serves families with a parent in early addiction recovery.  Many staff and volunteers are attracted to this work because of great intention and compassion.  Some of that is rooted in issues in need of personal recovery and self care because of their own family environment and upbringing.   Some of these well intended are not aware they are ACOAs, or have not admitted to encountering trauma in other ways as a child.  The training and work in serving children and families dealing with trauma can be triggering, and we try to bring awareness of this issue to program directors.  With the concern of compassion fatigue, we encourage trainers and facilitators to model self care, and discuss the importance of providing appropriate breaks in between program cycles so that the facilators can rejeuvenate.  This type of direction is important for healthy adults, but even more important for those who have not dealt with childhood trauma and do not practice self care.   For the good of the program, we can appreciate that adults in need of healing themselves, who do not maintain healthy boundaries, and do not practice self care, are a concern when working with families who really need strong centered  support and direction.  We too need a stronger response when the triggering happens and facilitators identify with the need of their own healing.   It's good to see your post as this has been on my "I really need to do this" list but never actualized into a goal.  It's too important to not do.  I would encourage you to look to Dr. Tian Dayton, who is exceptional on this topic.  While she provides a plethora of material, a great start is with her book "The ACOA Trauma Syndrome."   

just emphasising the important need for careful selection, training, and "supervision" of people in human services -- "supervision" in brackets only because it has a range of meanings in different settings / disciplines --- meant only in the least judgemental, most supportive manner

Russell Wilson posted:

Andrew Turner posted:

Hi all,

Advice sought please! We are a public health team in a UK local authority, and have been raising awareness of ACEs and trauma-informed interventions for some time, with some success. We have recently been made aware of an issue around ‘ACE training for enquiry’ and in particular the impact for those staff who would ask the ACE questions.  We have a local centre that specialises in helping women experiencing domestic abuse (along with a wide variety of other complex needs and generally high ACE scores). Many of the staff at the centre are volunteers and some have had similar experiences.  We have received feedback that learning about ACEs and their impact has caused distress to some staff – we have reports of some feeling guilt about having ‘passed on their ACEs’ to their children, especially having learned that this could potentially have been prevented.  Obviously, these staff were taught about ACEs in order to be able to help their clients in a more trauma-informed manner, and the last thing we wanted to happen was for them to be upset themselves. We will be looking into this further to understand their perspective, but I was wondering whether any of you have had similar experiences and how you tackled any negativity or distress  arising from education around ACEs. Many thanks.

I think if you check out my previous post regarding the proposal from NHS Scotland (now attached), you'll see a number of different levels. I think this can be used to structure a set of guidelines for preparing people for this sort of work,at whatever level they feel prepared and comfortable. If you've seen posts of talks by Anda or Felitti, there's nothing unusual about finding sets of helpers in their audiences with levels of ACEs "above the norm" -- meaning that in the Kaiser studies. But such groups also tend to have resilience resources above the norm, including time spent de-sensitizing to the material, and "vicariously" dealing with it. For most, victim and "therapist", this sort of work might best be done by older or wiser souls -- look at the demographics of those who make use of the call line for the Blue Knot Foundation in Australia -- typically in their fifties or older -- you need a certain amount of real-world strength to get into it, your own or others histories.

So, the level of support etc needed depends on the person's degree of involvement with the issues. On the one hand, it appears relatively "easy" for primary care doctors to conduct screening evaluations (ACEs Q, PTSD screen), and refer people on. On the other hand, those who choose to go further with the material, who aspire to become involved as "therapists", or as "educators" need to be better prepared, personally as well as professionally. Many would say "don't do the work if you ain't done the work" -- do the work on addressing the leftovers from your own history if you want to approach doing this work professionally -- I don't treat fellow workers / speakers "with kid gloves" "just in case" -- if they haven't acted responsibly to do their work, then they shouldn't do it, pure and simple -- they'll be hurting not only themselves but putting their clients at unnecessary risk. This view is shared by many others, for example, see McPherson's resources, the book "Victims No Longer" by Mike Lew etc etc.

Thus. this field really is no different from any other "peer support work" in mental health in these regards -- have understanding supportive management; fellow supports nearby for debriefing; if you're speaking, your own pre-prepared "script";  personal and professional boundaries sorted out -- AND RIGIDLY MAINTAINED as necessary. There are guides around in the MH field for responsible use of "lived experience", and this is just one particularly common form of "lived experience".

Thanks Russell.  Can you point me towards the previous post you mentioned please? 

Juanona Brewster posted:

Good morning.  we at the Illinois Chapter American Academy of Pediatrics(ICAAP) have witnessed and experienced the same reaction to ACE training.  Therefore we have incorporated some training and coaching that includes information of building resilience, self care, "ghosts in the nursery", and compassion fatigue, with very positive results.

 

We have created materials and tools based on SAMSHA/CDC work and if you contact me at jbrewster@illinoisaap.com I will gladly send information and discuss with you.  there is no denying that there is a cost to caring .  please take care.  Juanona Brewster, Senior Director, ICAAP

Thanks Juanona, I'll be in touch!

The timing of your question is great as I am in Finland at the Interpersonal Violence Conference (IPV 2017) doing two presentations on the intersections between domestic violence and ACEs based on research I did with domestic violence shelters here in Finland and in Alaska!  As an aside, there are a number of participants from the U.K. here!

I appreciate that you are addressing what I consider to be a critical gap in the ACEs work--bringing domestic violence and ACEs together.   Our population-based data in Alaska mirrors what we have seen in the national data; childhood exposure to domestic violence is the strongest predictor of other ACEs. My experience in the U.S., Canada and several other regions is that the domestic violence movement and the ACEs movement, which are so different in their origins and orientation, have remained separate and there is a pressing need to bring information about the intersections between DV and ACEs to DV advocates and service providers.

With regard to your question, I have many thoughts and will share a few here. My first comment is only relevant if the ACEs questionnaire is provided during the training.  Informed by our work with home visitors and developing ACEs curricula for other types of frontline service providers, we learned that whatever your position is on assessment for ACEs, it should not be done during training.  There is a lot of groundwork on trauma-informed practices and support that needs to be in place before asking questions about ACEs. While in the right circumstances with appropriate support, answering these questions can be useful, in a training it can be highly stressful and push people into survival brain mode, feeling traumatized and unable to focus and learn.   

 I do talk about and provide validated assessment tools for resilience (for adults and for children) as I have found that often people are not aware of these tools and we stress the importance of identifying strengths.  In settings where ACE assessment is being done, I think we have a duty to also ask about strengths/protective factors given what we now know about resilience.

In developing curriculum and resources on DV and ACEs, we have learned to be very sensitive, trauma-informed in our approach and the language we use.  As someone who specializes in the neurodevelopmental implications of trauma, I have seen the damage done when people perceive the information on toxic stress as ACES=damaged brain forever.   Emphasizing that we are talking about potentially traumatic events, that neuroplasticity continues across the lifespan and the amazing capacity of the brain to heal, discussing the growing sciences of post-traumatic growth and hope and using a resiliency framework that highlights the fourth generation of resilience research and clearly communicates that DV and ACEs do not define our destiny are some key points.

In closing, here are a few additional thoughts based on the training we do on ACEs for domestic violence service providers and advocates:

• Start and end with resilience--build a "resiliency sandwich" including content to interactively practice resilience promoting skills
• Focus on the ACEs data that is relevant to the DV community--the intersections between DV and ACEs
• Facilitate group discussions about implications and concerns about the ACEs data, identifying culturally relevant factors that buffer the effects of ACEs and opportunities regarding how DV advocates and organizations can use ACEs information in their work to support clients, build partnerships, seek new funding streams etc.
• Incorporate simple strategies for self-care and healing

Hi Andrew, 

From my experience this is so common - that might be a good place to start with your folks, letting them know how difficult this work can be and that it's not uncommon to feel the effects of trauma from simply hearing other people's stories. (My experience is that sometimes people feel shame or embarassment that they're feeling this way).

I've done a lot of training on this topic and one resource that I absolutely love is Laura van Dernoot Lipsky's book Trauma Stewardship. I recommend it to everyone I know and I have some training materials I've developed based on the principals in the book. Her TEDtalk is a nice primer on some of the concepts in the book as well. 

If you think it would be helpful, please feel free to contact me and I can share more with you about the training I've developed on this: kaleigh@k-cornelison.com 

Linda Chamberlain posted

 My experience in the U.S., Canada and several other regions is that the domestic violence movement and the ACEs movement, which are so different in their origins and orientation, have remained separate and there is a pressing need to bring information about the intersections between DV and ACEs to DV advocates and service providers.

Perhaps you could tell us why, if the fields have remained separate for so long, why no one (?!) has thought to benefit from the decades old research of Donald Dutton (the Canadian!) who found the link between being abused as a child and increased adult propensity for perpetrating domestic violence? 

This brings up a couple of ideas or questions for me.

- I think it is important to put a "warning label" on all talks that address ACES and trauma.  Something like: We are going to talk about adverse experiences/trauma and many of us have had adverse experiences. Even though we won't do anything surprising, just talking about it will wake up ghosts.  It is important to take care of yourself during the talk and later today. Even if you don't think you've had adverse experiences, most of you work with people who have and /or you've been in a position of caring for another human being when you were powerless to help that person... that impacts us too... and those ghosts can wake up too.

Then it is also important to frame the conversation away from blame.  Trauma get's passed from one generation to the next. It is passed socially and epigenetically.  It is important to remember not to blame the parents and grandparents we work with as they also had parents and grandparents with adverse experiences.  It is important to not blame ourselves. Like others we are doing the best we can with what we have.

I also wonder: Why would anyone talk about ACES without talking about resilience? It is easy to understand how ACES impact us, and how prevalent they are. Most of us have a sense of resonance when we hear the information. Long convincing isn't very necessary. The really important information is what to do about it. Dr. Felliti talks about his survey and how he spent time interviewing folks who were resilient.  He concluded that resilience comes "from the deep belief that at one time you really mattered to another human being."  You can't just tell someone that... you have to be that.  And because it is doable, it is a source of hope. And there are lots of short frames that can be used to teach people skills they can use the next day.

I am between clients and wanted to respond quickly with this - Any training or learning community about ACES is best followed by information/training on Resiliency.  There is a questionnaire - similar to the ACES - to find your Resiliency Score - which 'ends' or completes the training with HOPE!!!  Anecdotal evidence points to greater hope and decreased distress or secondary traumatization, when ACES trainings end with the hope found in our Resiliency! 

Andrew, and other folks, I hope you're reading all these responses while keeping an eye on the background / context of the respondents. There are some clear differences depending on the perceived target audience - - service providers or general public. My response, sorry, was primarily directed at service providers, mainly. 

Making Evidenced Based Practices Fun and Accessible:

Happy to talk and share the Strength-Based Trauma-Informed Leadership Programs Model (SBTILP) that has evolved over 20+ years.  It answers the question I once heard someone ask -  what do I do?  SBTILP  uses a three step hierarchical model that builds Safety, Grounding, and 29 (and growing) Social Emotional Competencies leading to improved outcomes and positive transformation.  

There are many moving pieces to how ACES are used.  Those moving pieces Include who is; leading and their clinical and Trauma-Informed background, the audience and their resiliency, coping skills and protective factors, the goals of the presentation, availability of long term support, etc. etc.

Best,

Judy Nelson, MSS, CP, LCSW

For myself being a "victim" as a child. I know the effects it has and had on my life. The choices I made to mask the pain and the people I hurt to feel in control, came from not feeling safe and protected. Betrayed in other words, I felt it was something I asked for. Until there are laws put into place that let childern or adults feel safe, people will try to protect them self, try to hurt others, do drugs, drink, break the law etc..... because they were never showen as a child how to cope or that the law will protect them against all who are at fault. So if an adult tries to help others because they "survived" it don't mean they are able to. They still are crying out for help. Most hurt people want to help because it helps them. Just like people that have known hunger, want to feed others. But dont NOTHING is going to change until we say thats ENOUGH. People who harm childern, regradless of why or what they went through need to be held accoutable. Rapest, child molestors,abusers, murders etc, should not ever be able to hurt another person. If there is a disease spreading you don't try to  put a bandaid on it and hope it heals. You cut it off, to save the rest of the body. I am a mother and I have seen the effects my poor me, excuses have on my childern. I dont blame no one, what is done is done. I cant cry about it. I can only make sure I raise good childern and protect them with my life. They will only see a strong mother. Not a "victim".

Thanks for a fascinating conversation on an issue that we too have struggled with in my organization where we frequently include information on ACEs and other trauma.  Several years ago I tried to capture the things we attempt to do when providing training on trauma and trauma informed practice in a short paper called: Walking the Walk:  Modeling Trauma Informed Practice in the Training Environment.  One of the references for that paper Black, T. (2006). Teaching trauma without traumatizing. Traumatology, 266-71 was very helpful to me.

Hi, Andrew: Thanks for bringing this up. I think it's important that an organization educate its own staff about all parts of ACEs science before educating anyone that organization serves, and then providing the people it serves with the same information. And what I mean by ACEs science is:

• the epidemiology of adverse childhood experiences (ACEs) (the CDC-Kaiser Permanente ACE Study and subsequent surveys that show these experiences are the norm, not the exception);
• the neurobiology of toxic stress from ACEs on children's developing brains and the brains of high ACE-scoring adults;
• the short- and long-term health effects of toxic stress from ACEs;
• the epigenetic effects of toxic stress from ACEs, otherwise known as historical or inter-generational trauma (in addition to the question: "What happened to you?", also asking "What happened to your parents?" To your grandparents? To your great-grandparents? To your tribe, ethnic group, etc.?"
• resilience research, which shows the brain is plastic and the body wants to heal, as well as resilience research that shows how organizations, systems and communities can heal by using trauma-informed and resilience-building practices.

We think it's critical to teach all these together, because no one of these stands alone in our new understanding of why people behave the way they do, or how to change human behavior, whether it's unhealthy, unwanted or criminal behavior.

As others have mentioned in their replies, it's important to warn people about what's coming before they enter the room, to make sure they know that they can step out anytime they want, and to provide time for group discussion as well as individual assistance later. That's just being trauma-informed about what you do.

It's important to note that it usually takes people more than one time to absorb this information, especially if it's new to them, so doing several presentations for people is a great idea.

Also, what I've also found is very powerful is, on the second or third time that a group has heard about this, to do an instant poll of the room (using something like PollEverywhere.com), where people can answer the ACE questions — and a resilience survey — anonymously but see instantly where they are as a group. In the helping professions, the percentages of "yes" are usually higher than the original ACE Study. This is important for the organization to know in terms of whether it has created a safe work place for its employees.

As much as I like to disagree with Jane on some issues ;-D   (tongue firmly in cheek) I certainly must commend her on her clear summary and exposition here; except for two things I'd like to stress -- the list of ACEs on the ACE questionnaire is not complete, and remains open to further research -- such as, but not limited to, the effects for some children of repeated parental conflict -- matters not usually called "trauma" or "abuse"; and Resilience is an ongoing constructive process, not just, but worth considering, what people bring to the workplace -- how do so many people higher in ACEs than the norm manage to work effectively, and to continue to work effectively, in organisations? Because they've had, AND MUST continue to have, resilience-building experiences in their personal and work lives.The recent Treating Trauma Without Drama Summit, of which I've written on numerous occasions, was, and for the next day is, a rich, and free, source of materials for this learning and practice.

Of course, not everyone wishes to learn about all aspects of ACEs Science -- a term only developing due to the good work of this website -- as will be seen when I post later about the recent research of Peña, but it's a rich, though at times complicated, field worthy of serious study. (And the work of Peña might be of some interest to the more hard-headed medicos in your target group).

Thanks, Russell. I agree completely. For the first step, I'd compare apples with apples (the original ACE Study questions), then, as the organization progressed, have the people who work there add those they think are relevant to them and then ask the people they serve to add theirs.

As for resilience surveys, Cissy White did a good overview, and we have a list to choose from in the Resources section. 

Thanks to everyone who has contributed to this rich conversation - especially these last summaries by Jane and Russell.  I'm working on a Call To Action to wrap up my book on dissociation and, with everything evolving so fast, this snapshot is very helpful.

Thanks everybody, this has been a really useful discussion!