Our blog article entitled, “Public Health 3.0 or Public Health Modernization: What is it and What Does it Mean? (Part 2)” touched on ACEs, or Adverse Childhood Experiences, and how public health departments can strategically head off poor health outcomes by addressing the root cause (such as addressing ACEs) early on.

In March, I had the opportunity to attend a webinar on that topic, hosted by the Northwest Center for Public Health Practice out of the University of Washington (they host an excellent series of webinars, by the way!). The presenter was Karolyn Holden, BSN, RN, Director of Grays Harbor County Public Health & Social Services, Washington State, and her presentation was entitled “Trauma-Informed Practice – A Rural Perspective” (You can access the webinar slides here).

Karolyn Holden shared Grays Harbor’s experience in learning about trauma-informed practice and coming to grips with the widespread influence of ACEs on their community’s health. Grays Harbor educated themselves and changed their approach in addressing their community’s health. Here I’ve compiled a bit of the information Karolyn shared.

Part 1 of this article will focus on the science behind a trauma-informed approach and the reasons why it is effective. Part 2 will focus on how Grays Harbor employed their trauma-informed approach and offer practical steps for how you can too.

Understanding the Basics:

NEAR Science and the ACE Pyramid

“It feels like there has been a massive confluence of information related to Neuroscience, Epigenetics, Adverse childhood experiences, and Resilience in the past few decades… it’s resulting in some powerful new ways of looking at what leads to health disparities. Those fields of study are foundational to the work I’m going to describe.” — Karolyn Holden

NEAR Science says that stressful events that happen in our early years of development affect us in ways that last our entire lives.

Science tells us that from our birth, our brains are growing and adjusting to our environment.

Whether that environment is:

  • Traumatic
  • Friendly
  • Threatening
  • Soothing

Our experiences get wired into our biology.

We learned about NEAR, which stands for:

  • Neuroscience
  • Epigenetics
  • Adverse Childhood Experiences
  • Resilience

The Near Pyramid demonstrates how Adverse Childhood Experiences can affect later life.

Grays Harbor ACE Pyramid

The ACE Pyramid from Grays Harbor County Public Health & Social Services

During Karolyn Holden’s presentation, webinar attendees were then asked whether they used NEAR Science and the ACE Pyramid regularly.

The responses from the webinar attendees (about 40% of whom were local public health departments) indicated that NEAR Science and the ACE Pyramid are used by:

  • 23% daily
  • 20% weekly
  • 13% monthly
  • 44% not at all

It was surprising to see that almost half of those asked responded that they aren’t employing NEAR Science or the ACE Pyramid yet, especially since these are such powerful tools for health departments to use in addressing root causes (or enacting upstream interventions) in their community.

Characteristics of Trauma-Affected Individuals

The characteristics of trauma-affected individuals include:

  • Inability to integrate experience
  • Hyper-arousal
  • Lack of emotional regulation
  • Too much or too little memory
  • Misinterpretation of reality
  • Triggers
  • Re-enactment

Re-enactment involves the use of coping mechanisms developed in response to loss of safety in the past, that persist though they are no longer helpful. There are three potential roles in re-enactment:

  • the Victim
  • the Perpetrator
  • the Rescuer

If you find yourself playing any of these roles, you will often find yourself caught in a destructive cycle of alternating between the three roles with the other players involved. Healthcare workers need to find a position outside of the triangle to interact with the trauma-affected individual in order to effectively address the issue.

Why Employ Trauma-Informed Practice?

Grays Harbor shared that they have 38% of adults aged 18-64 with elevated ACE scores greater than 3 in their community, compared to the Washington State Average of 26%. This data gave them an epiphany; they realized that anybody could be affected by a childhood trauma, not just children or those displaying immediately obvious signs. Grays Harbor realized that in order to effectively address health concerns in their community, they needed to come at the issue from a trauma-informed perspective.

They also recognized that observed problematic behavior could be linked to a traumatic childhood event, and those observations could be used to better engage people and better understand their behavior. They began to ask themselves…

What if…

  • …we operated under the assumption that anyone could be living with the effects of unresolved trauma?
  • … we considered the possibility that the problematic behavior we observed might be related to that?
  • … we used those assumptions and insights to inform how we engage people and interpret the meaning of their behavior?

“I went through nursing school during the early years of the AIDS epidemic… The healthcare system responded really logically to that epidemic by creating a new approach to infection control, called ‘universal precautions’. In essence, we were told to stop  basing our behavior on what was known about an individual’s HIV status and to take the right precautions, like using gloves, that would prevent HIV transmission, with every patient. A corresponding approach, in my mind, to the pervasiveness of trauma, is to approach every person as if they might be living with the effects of unresolved trauma, whether or not we know it to be true. In this way we can avoid inadvertently causing additional trauma through insensitive or inappropriate engagement.” Karolyn Holden

“… approach every person as if they might be living with the effects of unresolved trauma, whether or not we know it to be true. In this way we can avoid inadvertently causing additional trauma through insensitive or inappropriate engagement.” Karolyn Holden

So How Do We Do That? The Triple Focus

“Ensuring safety is a really foundational construct in trauma-informed work. As we use it in this context, the definition of safety is broad… we consider emotional, psychological, and moral safety.” — Karolyn Holden.

It can be overwhelming to consider this broad application of the idea of safety. Grays Harbor managed to organize their approach into a “Triple Focus” approach to their efforts in their community:

  • Client interactions: the way they interacted with the clients they served
  • Physical Environment: the physical space in which they provided the services
  • Workplace Culture: the culture of the workplace that influences the people who were performing the services
Grays Harbor Conceptual Framework Diagram

The Grays Harbor Conceptual Framework has a triple focus on Client Interactions, Physical Environment and Workplace Culture

This “Triple Approach” is based in deep respect for people and preventing situations that push people into behaving in ways they are ashamed of.

This Trauma-Informed Practice helps to:

  • Avoid re-traumatization
  • Build therapeutic relationships
  • Improve outcomes

Karolyn delved a little deeper into each aspect of Grays Harbor’s Triple Approach…

Client Interactions:

“We focus on client interactions because the fundamental goal of becoming trauma-informed in the first place is to be as effective as possible in the help and the support that we provide, and certainly to do no harm in the process. The nature of our work makes it likely that we are engaging people who have a higher than average likelihood of significant trauma exposure, and government and health services often involve environment and processes that can be confusing and overwhelming, even to those of us who live inside them.” — Karolyn Holden

“The nature of our work makes it likely that we are engaging people who have a higher than average likelihood of significant trauma exposure.” — Karolyn Holden

When it comes to client interactions, healthcare professionals need to remember that:

  • Trauma exposure is pervasive and clients are particularly vulnerable
  • We’re here to help, not harm
  • Participating with re-enactment interferes with therapeutic relationships

Physical Environment:

“We focus on the physical environment because people who are in a state of emotional hyper-arousal can almost feel paralyzed with uncertainty about what to do in unfamiliar situations. That can make it difficult for them to pick up the cues in the environment that help them feel a sense of control and know how to navigate. They may feel intimidated or overwhelmed by too much noise or visual stimulation. And supervising children in such situations can really intensify anxiety. We believe that providing a space that takes these possibilities into account, can help people feel safe and confident in engaging our services.” — Karolyn Holden

When it comes to the physical environment, healthcare professionals need to remember that:

  • People with trauma exposure struggle to feel safe
  • Anxiety may make it hard to read environmental clues
  • Hyperarousal may make it hard to focus and maintain a sense of control

Workplace culture:

“We focus on workplace culture because systems, like individuals, can become trauma-organized. The work that we do often results in bearing witness to the trauma of others. This can result in vicarious trauma that, left unattended, can lead to burnout and negative attitudes about the job and about the people being served. Studies support the premise that, as a group, people who select health in professions can have higher ACE scores than the general population. This can really set us up to engage in re-enactment scenarios without ever realizing that we’re doing it and without the skills to change the dynamic. …We focus on workplace culture because our most valuable resource is human capital. The researchers who carried out the 1998 study, have recently published findings that show a strong correlation between ACEs and problems on the job. Attending to the effects of trauma in a multi-dimensional way  has the potential to improve our effectiveness across the system.” — Karolyn Holden

“Studies support the premise that, as a group, people who select health in professions can have higher ACE scores than the general population. This can really set us up to engage in re-enactment scenarios without ever realizing that we’re doing it and without the skills to change the dynamic.” — Karolyn Holden

When it comes to workplace culture, healthcare professionals need to remember that:

  • Trauma exposure is pervasive, helping professionals may be particularly vulnerable
  • We can’t help if we’re overwhelmed by our own injuries
  • Negative workplace culture affects the quality and efficiency of our services

Conclusion

Grays Harbor took everything they learned about trauma-informed practice and put it into action. They began to ask themselves, “Where does the rubber meet the road?” and were willing to make changes in their client interactions, physical environment, and workplace culture. Part 2 of this article will address those changes and offer practical tips for your health department to begin practicing being trauma-informed.

Next Steps

Karolyn Holden’s webinar presentation was incredibly informative and highly useful. You can view Karolyn Holden’s full presentation recording here (it was excellent!).

To learn more about how Nightingale Notes EHR empowers your health department to evaluate ACEs in your community so that you can begin employing a trauma-informed approach, contact us today!