Promoting better outcomes instead of "trauma-informed"?

I think you've (unsurprisingly, given it comes from SAMHSA) hit upon an important concept -- recovery can happen (almost?) independently of clinical outcomes -- which really challenges clinical service researchers,  and those reviewing their research, to include recovery outcomes and not just clinical outcomes in summative evaluations of treatment program "success". This disturbs me when someone pointed out what therapy approaches may be recommended, as was done recently.

For example, in reviews of Acceptance and Commitment Therapy, if one looks at helping people with chronic pain (and lots of people with ACEs have such problems), including "pain reduction" as an outcome would be grand, but given that CBT/ACT can bring about, even in those with the most "disabling" pain, meaningful, valued, lives, pain reduction almost becomes irrelevant (look at Lance McCracken's work, for example). A similar conclusion can be drawn for those with psychotic symptoms -- almost like the idyllic outcome as seen in "A Beautiful Mind". 

So one should be careful in reviewing "randomised clinical trials" if a narrow range of outcomes are included -- should one be happy if a patient's psychotic symptoms are reduced if they also suffer disabling side effects from the medication, and thus their "quality of life" is still pretty poor -- the way things often were in the past, when Haloperidol would tan your hide, and Melleril would turn you blind, and ... (etc).

Unfortunately, because your post uses fairly global terms, it leaves me unsettled and questioning -- is this true for everybody, in every situation, with every "problem" ?, although no exceptions spring easily to mind.

something else people might be interested in checking out is how the use of metaphors in "medicine" can influence patient-physician communication, with the ongoing effect on what patients choose to do to promote their own physical and mental health -- read through the passage and you'll see how it's applied to ACEs and recovery practices -- an opinion piece in the Journal of the American Medical Association

http://jamanetwork.com/journal..._campaign=11-04-2017

Russell & Corinna:

Thank you both for great discussions and links to stuff that keep me thinking. I'm not always sure what is meant by trauma-informed when it's used. It's sort of everywhere and I appreciate the intent of many people and organizations using it but am not always clear when it's clinical, a buzz word or signals a real change in approach, communication, collaboration and community.

I don't mean to sound so critical. I think some of this is what happens when there's big changes away from one model (say, the medical model or the prevention only model). But I hope to learn more about what didn't work in older working models and change those things so we're not only using new words but doing things mostly the same individually and organizationally. Cis

Being a bit of an old f*)& (disturbing that I came across the attached paper as a postgrad!) gives me some early insights -- Engel's BioPsychoSocial model is still not widely followed in medicine -- especially, perhaps due to the way "the old language" is still used -- curiously enough though, the person who did much to try to push for it, George Engel, showed how it could be used in physical medicine, not just in mental health (the modern euphemism for "psychiatric services") -- but see the attached, where he applies it to myocardial infarction -- not always an easy paper to find!

interestingly, again, he refined his thoughts from an earlier 1951 paper of his

Hello,

This has been on my mind for a while now particularly as I hear more and more people talking about being trauma or ACE informed as if that is the aim of the learning journey - I want to say and what next?  What will you do differently, how will your practice change, do the systems and processes reflect this change.....

We have been training and supporting organisations in becoming informed AND changing practice for over 4 years now - learning a lot as we have gone along.  There was a moment recently when we visited an organisation we had worked with previously and a new team member said 'we want all the same training and development - they think differently to us' when referring to more experienced colleagues working in family intervention.  When I asked what that meant she said 'they use different language, they are interested on what the family thinks is impacting on them and not what the professional thinks, they help the family to change what they want to change and support the journey' - defining their own success.  Being able to work in this way does need financial support in terms of not having time limited interventions but in the longer term delivers much better outcomes.  This of course relates to the time old question in relation to what does good or success look like (relates to the comment above about recovery outcomes) and will organisations be given enough time to evidence what works, so often good practice is lost due to not having ongoing funding.

This is a cool research article where a guy went to a psych hospital and trained the staff and the patients together. They did a one hour talk on, "We're sorry you got sold the disease model or the bio bio bio model so hard. It's not really as scientifically supported as all that. There's other ways to look at this stuff that actually have stronger evidence."

After this one hour intervention, a year later, staff treated patients a lot nicer, and the patients had higher recovery rates.

What I find is that clinicians like trauma-informed care because it's the honorable way out. They can say, "We found out this new info so that we don't have to admit we've been so horribly wrong all along."

Like saying, "You still have this illness (that gets me paid), but it may have been caused by trauma instead."

Sometimes people do a lot lot better if you sweep away the BS first instead of piling good info on top of bad info.

Like, "Hey, maybe you weren't as sick as you were led to believe, maybe your life situation was misdiagnosed as a permanent illness and really it's not. Maybe all you need to do is build better community supports, maybe it's the community around you that's the problem and you are just the canary in the coal mine..." ETC.

I've always though trauma-informed care meant, "Now I know that it was trauma all along, so I didn't even need your "care." "

Corinna:

I think you are on to something. I think there was a lot of bad treatment, a lot of trauma even to hurting people who were not only NOT helped but hurt by the medical model. And until and unless that gets acknowledged, a lot of people are going to be pretty suspicious and with good reason. A lot of us didn't only not "feel heard" when we said, "Hey' this isn't working,' we actually weren't heard. Or worse. And that's not been acknowledged. There's lots of people who got secondary trauma or terrible treatment or both that compounded things.

David Morris talks about how evidence-based doesn't necessarily mean much in his book The Evil Hours: A Biography of PTSD and even how a lot of evidence-based approaches are not based on evidence of effectiveness but more mean they are insurance eligible treatments and even how some "evidence-based" treatments have caused some veterans to lose their lives because they caused harm as opposed to not only not helping. So some of us are eager and hopeful for change but wanting to make sure it's more than words changing. I don't feel the same hearing 'trauma-informed' as you do, but I can appreciate what you are saying. My response is more neutral and observant and wanting to make sure trauma-informed is always informed by trauma survivors. 

Sometimes I feel the good info. piled on top of bad and worry some people are not totally getting it (trauma, ACEs, symptoms) - or seeming to from my point of view. But also, I know I'm not totally getting it all of the time either with a lot of stuff. 

My response is more neutral and observant and wanting to make sure trauma-informed is always informed by trauma survivors.  I really want to be sure it's more than words changing and that's why I love these discussions in the comments which often really stretch me in the best way. 

And thanks for always sharing links and resources, too. Cissy

SAMHSA has defined what trauma-informed means -- here's a link to the report in which they did so. It's a good guide; whether and how organizations use it is another matter.

And something else to consider: the trauma-informed/resilience-building approach is also being used in education, with early measured and remarkable results; juvenile justice, with some early stunning results; criminal justice, with stunning results; communities, with stunning results; corrections; pediatrics; business; etc.

At the foundation of using trauma-informed/resilience-building tools is ACEs science (science is not medicine or a medical model, by the way). ACEs science includes:

• the epidemiology of adverse childhood experiences (the ACE Study and subsequent surveys that expand the types of ACEs),
• the effects of toxic stress from ACEs on children's developing brains (neurobiology),
• the short- and long-term health consequences of the effects of toxic stress from ACEs,
• the effects of toxic stress from ACEs on our genes (epigenetics, leading to historical and intergenerational trauma),
• and resilience research that looks at the effects of implementing trauma-informed AND resilience-building practices on individuals, families, organizations, systems, and communities.

To your great point, Corinna, of other ways to "look at this stuff", there are social service agencies and people in the faith-based community who are educating people about ACEs science. These are people with high ACE scores who are having significant problems in their lives coping with the effects of toxic stress and could have used assistance earlier in their lives but didn't receive it because, also to your point, our communities aren't set up as supportive, self-healing communities. Many of these people are in the most dire of circumstances: in prison or just out of prison, in a rescue mission, etc....in other words, society's given up on them, is blaming them for their troubles, and they've given up on themselves. When people learn about ACEs science, they learn four important things:

• They weren't born bad.
• What happened to them as children wasn't their fault.
• They coped as well as they could (alcohol, meth, violence, food, etc.), given that they weren't given healthy options.
• They can change.

That's what they say. And with this knowledge, many of them go on to change their lives, and live happier and healthier. That doesn't mean that practices such as EMDR or somatic therapies or yoga or gardening or volunteering at a food bank or joining a singing group or equine therapy or SuperBetter tools aren't useful, but people are in a better place ("I can change...what I experienced was normal...I don't have to feel this way the rest of my life") to try different things that help build resilience in their lives or help them get unstuck. And they can contribute to building the community supports that are necessary to create self-healing communities.

I agree that our traditional models of medicine, including psychiatry, and psychology focus too much on managing an illness (just as any other sector focuses on managing problems instead of creating and managing solutions) and not enough on healing and improved outcomes, and, the good news is that they're starting to change, and that healing is being integrated into every sector of our communities. I've heard people in every sector (education, faith-based, pediatrics, family practice, psychiatry, youth justice, corrections, etc.) who have learned about ACEs science say: "I've been doing it all wrong...". One of the important changes is that the healers who are changing understand that they bring their own ACEs to any interaction, and they understand that assisting and empowering someone to heal themselves has better outcomes.

Jane:

I think this is one of the best, most concise and persuasive pieces of writing on why ACEs science matters, what it means and how it can be used in reference to trauma-informed initiatives. It shows what's working, what's yet to be transformed and how practices/approaches/tools can help even more when a person's overall thinking and philosophy shifts.

That's what I experienced in my own ACEs "aha" moments and it has changed everything. But this has helped me with the much wider perspective and to put together some missing pieces. I'm printing this out.  I hope others read it, too.

Thank you!

Cissy 

We now have gathered about 10 events of ACES science messaging vs reslience/overcoming messaging.  I'll email the spreadsheet to anyone who feels like crunching the data for us. 

Mmmm...how did you differentiate between ACEs science and resilience/overcoming messaging, Corinna. ACEs science includes resilience/overcoming messaging.

The ACES handout talks more about neurobiology and the resilience handout has more "how to" on building resilience and helping people in distress.

Jane, how did you decide that those 5 pieces of info were the magic ticket?
Have you done any kind of research that showed that when people possess those 5 pieces of biology info that it actually connects with the actions or outcomes you suggest?  Ie, promoting individual level resilience supports and community level resilience supports?   So this is your theory.

Like maybe telling people how to build individual and community level resilience will go farther than giving people 5 magic pieces of neurobiology info [that science has been shown to be somewhat disempowering] and expecting people to magically make the jump into individual and community level resilience building.

Anyways, we have empirical data testing this theory now. Telling 5 magic pieces of neurobiology vs telling about individual and community level resilience.

BTW, our artists were all appalled by the green cards. None of them wanted to use them.