National Clinical Training Center for Family Planning



Trauma-Informed Care in the Family Planning SettingTranscriptNCTCFP:All right. I have it as one o'clock central time, I guess I should just say the top of the hour, because that'll apply to everyone. So thank you all so much for joining us today for Trauma-Informed Care in the Family Planning Setting. This webinar is now live and being recorded. The webinar will be available for future viewing along with a copy of today's slides. You may type questions for our presenter at any time during the presentation in the Q and A feature. And you may also use the chat feature when there are opportunities for participation. If you do use the chat, please select the two and then select all panelists and attendees so that other attendees can see your discussion. And now I'll do next slide.Nkem Ndefo:I was a little ahead of myself there.NCTCFP:No problem. Yeah, we're all eager. This webinar offers 1.5 contact hours. After viewing this live webinar, you'll be directed to a survey link for evaluation and CE. You will also receive an email tomorrow with the evaluation link. Certificates will be emailed within three to four weeks. There's no commercial support for this presentation and UMKC and ANCC do not approve or endorse any commercial products associated with this activity. Next slide, please.NCTCFP:The speaker and planning committee have disclosed any conflicts of interest. The speaker has nothing to disclose. Jacki Witt and Kristin Metcalf-Wilson serve on the Afaxys advisory board, which has been resolved and the rest of the planning committee has nothing to disclose. This presentation is supported by a grant from HHS, OASH and OPA. The contents do not necessarily represent official views of these groups.NCTCFP:Next slide. AAFP and the ANCC's commission on accreditation have reviewed this presentation for credit. Next slide.Nkem Ndefo:We're done.NCTCFP:Yeah.Nkem Ndefo:Do you want to talk about CNEs?NCTCFP:Nope. If you are looking for more detailed information, you can find this on the slides, but I just wanted to give a quick summary.Nkem Ndefo:Great. All right.NCTCFP:All right. I'd now like to introduce our speaker, Nkem Ndefo. Nkem Ndefo is the founder and president of Lumos Transforms and creator of the Resilience Toolkit, which is a model that promotes embodied self-awareness and self-regulation in an ecologically sensitive framework and social justice context. Licensed as a registered nurse and nurse midwife, Nkem also has extensive post-graduate training in complimentary health modalities and emotional therapies. She brings an abundance of experience as a clinician, educator consultant and community strategist to innovative programs that address stress and trauma and build resilience for individuals, organizations, and communities across sectors, both in the US and internationally.NCTCFP:Nkem is known for her unique ability to connect with people of all types by holding powerful healing spaces, weaving complex concepts into accessible narratives and creating synergistic and collaborative learning communities that nourish people's innate capacity for healing, wellness, and connection. She has served on regional trauma-informed taskforces and regularly provides trauma-informed subject matter expertise to organizations and initiatives locally and internationally, including serving on the Los Angeles County Trauma and Resilience Informed Systems Change Initiative work group, and developing a pilot trauma-informed learning academy for peer support workers as part of Los Angeles County Department of Public Health's Trauma Prevention Initiative. She is currently an advisor to the strategic planning committee of Trauma Informed Los Angeles. So with that welcome, Nkem.Nkem Ndefo:Thank you so much, Shelby. I want to acknowledge Shelby and Carissa on tech here making this all possible, and I'm excited to be with you all for the next 90 minutes. You did a pretty broad scope. I forgot what introduction bio I sent. The thing that I'd like to add is what moved me from clinical midwifery practice, fullscope midwifery practice to focusing on trauma was the realization that trauma and stress were preventing the outcomes to which I had hoped to provide as a nurse midwife, realizing that perhaps being able to work in that space, I couldn't unlock some more potential for the families and the babies, the moms that we serve. And I'm happy to be in the support role to guide this information to you all who are still in the front lines, in the trenches, serving folks in family planning and capacity.Nkem Ndefo:So before we go any further, I do want to say that when we talk about the trauma-informed approach, we have to use the trauma-informed approach. You can't just put it as an outcome, as a goal that you want at the end, it has to be in the process of how we do things. And so to that, we're going to do a little bit of practice to help us be more connected, which you'll see, to be more present and more able to learn and open, which you'll see later, as some of the trauma-informed principles are supported by this little activity we're going to do right now. So it's a little unusual way to start a webinar, but bear with me and maybe you'll have some fun here.Nkem Ndefo:So we learn best when we're more present and open and when we're connected. And we spent a lot of time virtually, especially since COVID, and it can be very disconnecting. So I'm going to invite you into a practice to connect to your immediate environment, which will hopefully help you settle and be more connectable here with me. So just notice right now, using your senses, listening to the sounds in your immediate environment, just get a little quiet. What sounds do you hear, just noticing that for yourself? What do you see in your immediate environment? What are colors and shapes and objects? Really look around using your neck, not just your eyes. When was the last time you looked at your ceiling? The floor, patterns, colors, what catches your eye? Noticing the feeling of your clothing as it falls on your skin, the firmness of what you're sitting on. Perhaps there's a place where your hands are touching, or your legs are crossed where there's contact of one part of your body to another.Nkem Ndefo:And as you notice these things, the sights, the sounds, the tactile sensations. Do you feel a little bit of settling? A little bit more presence, a little bit more awakeness, perhaps, or alertness? A little quieter mind? A little bit more readiness to be here. I hope so. I hope that was useful. And if that is, that's a practice, you can do very, very quickly, orient to your senses and drop into yourself. Okay?Nkem Ndefo:That said, I would love folks, I'm seeing some folks getting in the chat, I'm going to invite even more chat, I know we have over 250 people and so it's going to be a busy chat, is I would love you to type in your name, your location, your role, I would like to know what your role is. And one thing that you noticed in your environment, something you heard, something you saw, something you felt. Let's see who is here and what you all are experiencing. Katie Humphreys in Atlanta, Medical Director of an FQHC, tell me, what are you seeing in your environment? Lucia, what is it? Are you in the clinic? Are you hearing sounds of people talking? Are you working from home right now? What are you seeing? What are you hearing? Marissa in Los Angeles seeing a messy kitchen. Oh, that's probably not too relaxing, I'm sorry.Nkem Ndefo:Joan Henry heard an airplane overhead. Here we go. And as that chat goes through, take a chance to look and see who's with us. That we're here together from all around the country, wanting to learn more about this subject, right? Ray hears a clock ticking, of a vaccine fridge humming right? So beautiful. Hearing an air purifier, we could use that, we have smoke here in Southern California. We have quite a number of fires here. Seeing a snake plant and hearing silence. Someone has hot pink sticky notes. I've got yellow.Nkem Ndefo:What's lovely about this is we become human again, right? We become human. And that's a core tenant that you're going to see running through this theme of this webinar. Okay. Oh, the noisy clock on the wall, hearing my neighbor doing some hard work, Texas, Pennsylvania is in the house. Wonderful, wonderful, wonderful. Welcome everybody. You might even like this with your team, if you like, just a quick one of those. I hope you like that mindfulness exercise, it's a quick one to do with your team. Okay.Nkem Ndefo:So let's get in here and let's do objectives and Shelby, folks are getting the slide deck, yes?NCTCFP:Yes, definitely. We will send it out afterward. Also, we might have sent it, I did send it before, I'm not sure if everyone got it, but we'll make sure everyone gets it afterwards.Nkem Ndefo:Okay, fantastic. So we're going to do a little bit of history. I think it's important to know where things come from. We're going to talk about the impact of trauma, trauma-informed goals and principles, and what are the developmental stages for an organization that's trying to move to this approach? And then a little bit of linkages about how your own wellbeing is tied up in the ability to provide trauma-informed care. Okay.Nkem Ndefo:So I want to start that really the trauma-informed movement was kicked off by the ACEs study, the Adverse Childhood Experiences study, which is pretty well-known at this point, but there are details that I think are useful that I'd like to review, that this was done in the nineties in San Diego. And it was in a weight loss clinic, okay? So it was a weight loss clinic for people who were doing medically supervised weight loss. So to lose many hundreds of pounds.Nkem Ndefo:And what Vincent Felitti discovered, this doctor, is that there was a super high incident of childhood sexual abuse, so much so that it shocked him because he was never taught about that in medical school and he thought he was prejudicing somehow the disclosures and stepped out and asked other clinicians to ask the questions and saw the same high incidents of childhood sexual abuse. And so he presented this information at a conference on obesity, and frankly, he was ridiculed. He said there, "I'm not sure what it is, but it's such a high incidence that it seems like there's some kind of connection or correlation," but in the audience was Robert Anda from the Centers for Disease Control. And they talked and he said, this seems plausible, what would be needed? And Robert Anda said a very large study, you're going to need a very large study. And thus the ACEs study was born.Nkem Ndefo:And so this was done between 1995 and '97 in Kaiser, San Diego here in California and over 17,000 HMO members, right? So they're insured, that tells you something, who were receiving physical exams, they completed a retrospective questionnaire about their childhood experiences. And this was then compared, Kaiser is wonderful for comparing just they have that huge treasure trove of health data to compare the results too. The participants, and this is noteworthy, were mostly wight, were mostly middle-class and upper-middle-class, they were college educated and obviously if they were in Kaiser, they all had health insurance. And so what did they ask about? They asked 10 questions and it was just, yes, no, it's a binary. You would get one point if this occurred not how many times it occurred or how severe it occurred. Just one point yes or no. Right?Nkem Ndefo:So there was the abuse, physical, emotional, sexual, neglect, physical and emotional and household dysfunction, anything from caregiver mental illness, domestic violence, an incarcerated parent or caregiver, substance abuse, separation, and divorce. So we know this isn't an exhaustive list of adversity, but just for these 10, just for these 10, what did they find? First off, they found that ACEs were incredibly common, okay? Remember the population we're talking about here, almost two thirds of the study participants reported at least one ACE, okay? And more than one in five reported three or more ACEs.Nkem Ndefo:What they also found is that ACEs cluster, right? And so if you have one ACE, you're more likely to have others. And you could imagine if you have a substance abusing parent, or if there's domestic violence, you could imagine there's probably neglect, right? You can see how they would cluster. And what they also found was that there was an incredible correlation, almost unheard of in public health, that revealed a graded dose response relationship between ACEs and negative health outcomes. The more ACEs you had, the worse your health.Nkem Ndefo:And typically we would say four, on the original ACE of 10 adversities, a score of four or more is considered the sort of a threshold for serious problems. But new work is hinting that two on that traditional study is enough to trigger negative health outcomes, especially for certain populations. And we'll cover that in just a moment. So what kind of health outcomes are we talking about? So it's the behavior. So lack of physical activity, smoking, alcoholism, drug use, right? A lot if we think of that is coping mechanisms to deal with some of the adversity that people have, and then the physical and mental health, obesity, diabetes, depression, heart disease, cancer, stroke, even fractures. Even fractures, right? So this is a quite something. The CDC continues ongoing surveillance of ACEs of these original study participants. There have been over 80 studies published on this original data set.Nkem Ndefo:But there are some limitations here, right? So this really helped us bring trauma up in front of our eyes about, wow, how is this impacting people on such a serious level? But there were limitations. And so there's been a proliferation of studies to remedy some of those limitations. The Philadelphia Urban ACEs Study acknowledged that there was a lack of people of color in that original study, right? And so this captures the experience of vulnerable people of color in community. And this was with 1700 adults and what they did is they took nine of the original ACEs, they took out divorce and separation, but they added what they called five urban ACEs: experiencing racism, witnessing violence, living in an unsafe neighborhood, living in foster care and bullying. So they came with a total of 14 ACEs, right?Nkem Ndefo:And here they found a much higher incidence of the original ACEs except sexual abuse and emotional neglect were comparable. And here, 81% experienced at least one of the 14 measured ACEs and 45% experienced at least one standard and at least one urban indicator. So this is prevalent, right? This is prevalent. The National Survey of Child Health, what this was was the difference here is the original ACE study was retrospective. This was to catch the occurrence as it happened. And this was again surveying parents though, and nearly half of all children nationally and in most states have experienced at least one adverse childhood experience.Nkem Ndefo:And so you can see, I'm not going to go through this slide, if you want to go through it in more detail, you'll obviously have the slide deck to look at your particular region and you can see the breakdown by race, non-Hispanic and Hispanic. And you can see if there's yellow shading that the percentage is higher at a statistically significant level. If it's blue, it's lower at a statistically significant level. So even at the state level, at the state and regional level, that these disparities still persist.Nkem Ndefo:Then we have Hughes. This is a 2017 study, and this was a metaanalysis. So now we're looking at a much larger group of data, includes 37 studies with more than 250,000 participants in 20 countries. So now we've zoomed out and looked at an international context, right? And what they found is that if you had four or more ACEs, look at the odds ratios here, one and a half times diabetes, look at cardiovascular, look at cancer, look at violence, victimization, and perpetration, and look at substance abuse. Look at those odds ratio. So we know in correlation in this kind of research, we can't say it's causation, but wow, that correlation is something else. Look at suicide.Nkem Ndefo:So the question is, what connects these traumatic experiences? What connects these traumatic experience to these types of outcomes? So what are the mechanisms here? First off, having these experiences in childhood disrupts neurodevelopment. And I'm going to say it's really more than that, it's a disruption of system-wide physiology. System-wide physiology. We're really looking at multi-system alterations. Oh, we got a little neurologic, there's a little typo on that or a little formatting thing on that slide. So what happens neurologically is we see brain changes, prefrontal cortex inhibition, so that's implicit of the impulse control. Hippocampal atrophy, so we're looking at memory learning capacity. Changes in the nucleus accumbens, this is where the pleasure reward center is so people need more stimulation for a similar effect. So you can see this may be correlated with risky behavior, addictive behavior. Immunologic, right? Chronic inflammation, increased inflammatory markers, impaired cell mediated immunity, more likely viral infections. Something we want to think about with COVID. Endocrine disruptions, HPA access dysregulation, where we see sympathetic dominance. We see folks in a persistent adrenalinised state. Inhibition of thyroid hormones, and even genetically, telomeres shorten, ages, premature aging. And we see epigenetic changes.Nkem Ndefo:So profound system-wide disruption from the experience of childhood trauma and adversity. And we can see, right, based on that you're going to see social, emotional and cognitive impairment. It's not a surprise. So what happens from this? Here, we see people adopt health risk behaviors. And I think this is where we're really seeing in your context where health risk behaviors might really be coming into play.Nkem Ndefo:I think back to hearing Felitti speak many years ago, and he said something that really, really stuck with me. He said that we, as clinicians, focused on these behaviors, the smoking, the multiple sex partners, unprotected sex, we see these and we're trying to manipulate and get people to shift at that level without really seeing what's underneath it, that this is the result that this perhaps is this person's best solution to a problem we did not even ask about. I'm going to repeat that, that what you're seeing, the smoking, the overeating, whatever you're seeing may be the person's best solution to a problem we didn't even ask about.Nkem Ndefo:So I want to pause here and offer a reflection point because so far I've been speaking very generally. I want to bring this onto you. I'm inviting you to think about the patients that you see, and if you don't see them directly, the patients in your clinic, perhaps you're an administrator, or have another role to think about the patients that are coming through your site, your context, and what are the unprotected, what are the risky behaviors, the health risk behaviors that you see? Just really think about patients in particular, what are you seeing? And I invite anything want to put in the chat at any time is welcome and also questions and answers are also welcome at any time. I'll try to answer them in flow, but there'll definitely be dedicated question and answer time at the end. So thinking about the patients that you're seeing, what are their risk behaviors?Nkem Ndefo:The patients that you're seeing, what are their risk behaviors? Have you ever stopped, paused to think, or if you haven't, I'm going to ask you now that the behaviors that they are showing might be their best solution and that we're not asking about what's happening underneath. When you think about that for this moment, how might that shift? Does that shift your perspective when you think about your patients? And I'm going to invite people into the chat right now, what are the health risk behaviors you're seeing? Type them in? Are you asking about what's happening underneath? Have you thought about it? Type it in?Nkem Ndefo:So Ann says adolescents who smoke cigarettes, drink alcohol, unprotected sex and, no, they're not planning pregnancy. Recurrent sexually transmitted infections. Right. patients who use while they're pregnant. Jenelle, seeing patients who have multiple sex partners, unprotected sex. Yeah. Cheyenne is a powerful statement that these behaviors might be their best solution. Suicidal thoughts.Nkem Ndefo:So is it a shift for you? Is it a shift for you to think about what might be underneath? I know we're busy. When I worked in family planning, particularly those settings, it's very, very busy. Aah. Katie, people who are seeking narcotic meds for purpose of abuse, multiple sex partners, sex workers. Yeah. Children in the foster system because their parents are neglecting their children. Recurrent STI's is from the same partner. Yeah. So what happens when you actually think about what might be going on underneath? What happens inside of you as the clinician, inside of you as the administrator? Is there a shift? You can say yes, no, haven't thought about it, don't want to think about it too much for me now.Nkem Ndefo:Felina that mean.... Katie, change from frustration and irritation to sympathy. Frustration sometimes. Just wanting to say, "You can do better." I know that feeling. Jessica, a shift to more compassion. Susan, it feels like it minimizes my burnout. Elizabeth, it's not a new concept, but it isn't always why they are there to see you. So it seems like too big of an issue to fix. I can give you an antibiotic for chlamydia. I can't fix childhood abuse in my STD clinic. Elizabeth, you are so right.Nkem Ndefo:The trauma informed approach. Let's see what we can do to come up alongside, because I understand as clinicians, we already feel overwhelmed. I know that feeling another paper, another screening, another thing I have to fill out in the same amount of time, and who's going to hold this with me. And that's why I'm taking some time to do a whole approach. You are included.Nkem Ndefo:Rachel, I think it's part of the whole person concept. We forget to do it sometimes. Yeah. Yeah. And just pausing. Think about how busy your day is. Just that we can pause for a moment and even reflect on this, make a little space around this. I think honors some of the experience of the patients that we're seeing. Angelica, I get upset because I see that so much in the black and brown communities is rooted in racism and the symptoms are addressed in mostly punitive ways as opposed to addressing the root issues. Yeah. Yeah. And the trauma informed approach definitely includes addressing race and race equity. It's not separate. April, I see your question about assessing resiliency and we're going to get to some of the applications at the end. Thank you.Nkem Ndefo:Okay. Right. So thank you for your reflections and taking that time to pause. Katie says, I find ACEs as a very powerful bridge for folks who often don't get the opportunity or tool building of a trauma informed lens, but the focus on ACEs can often become dehumanizing in larger settings. Absolutely. And this is why we're starting it at the beginning. And then we're going to zoom out and back in and look at the whole system. I appreciate that comment, Katie.Nkem Ndefo:So it's not a surprise when we come back to this pyramid and we see the disruption of the neuro development and system-wide in the physiology all the way up, right through the social, emotional, cognitive impairment, people adopting health risk behaviors. Where do we see? We see disease, we see disability, we see social problems and they compound each other and we see early death.Nkem Ndefo:Yes. If you have a question, please do put it in the Q and A. There's the ribbon at the bottom of your Zoom window. You just hit the Q and A and then that will end up in a separate Q and A, and if I can address it in flow I will, otherwise I'll pop it into the Q and A at the end.Nkem Ndefo:All right. If the ACEs study kicked off the Kaiser-CDC, the ACEs study helped kept kickoff the trauma informed movement. I do think it's important to address a little bit more of... When you understand where something comes from it helps you understand its impulse. It helps you understand its potential biases and its strengths. And it also helps us be more adaptive going forward. So I'm a big fan of understanding lineage. So this confluence of a number of different events and bodies of works that really added momentum to the movement. I want to say that there's an online community, if you're not a part of it, called ACEs connection and that really started connecting people around the ACEs study in cross-discipline and cross-region.Nkem Ndefo:The work of Nadine Burke Harris. She was originally at a clinic in San Francisco and now has her Center for Youth Wellness. She is charismatic and was able to really spread the news about the ACEs study. And she's currently in the California state government spearheading an ACE screening initiative statewide. At the same time, yes, Glen says, "Burke Harris has a great Ted talk, highly recommend."Nkem Ndefo:Psycho neurobiology research really exploded to help us understand better the experience of trauma being not just a cognitive experience, but a whole body experience. And I think it's specifically of the work of Stephen Porges and helping us understand the neurology and the autonomic nervous system response and Bessel van der Kolk of understanding some of the central nervous system responses. The Body Keeps the Score, fantastic book. If you want to know more about that. And then we started seeing a growth of trauma healing modalities that was based on this new science and these were somatic experiencing, sensory motor psychotherapy. These were holistic trauma treatments that moved away from the cognitive only model. At the same time, there was an explosion of research on trans generational mechanisms of transmission, transmission of transgenerational trauma. I think specifically of the work of Rachel your hood out of Mount Sinai, starting to find biomarkers, epigenetic biomarkers, and also a resurgence in culturally specific trauma healing practices like Latinex, indigenous practices, Afrocentric practices, really seeing a resurgence in those at the same time.Nkem Ndefo:And so we have to look at the movement from all of these angles as a confluence of events. And all of this is shifting that famous paradigm from what's wrong with you, it's a disease focused paradigm, to what happened to you. So understanding the antecedent. I think of Bessel van der Kolk saying that you'd be hard pressed to find any mental health diagnosis that does not have trauma as an antecedent. Now think about that. So perhaps we're just looking at different varieties of the way trauma manifests. So all of this is asking us to go upstream. It's asking us to recognize the impact of trauma to both prevent it and heal it, both prevent it and heal it. Okay. So I think back to the question here about Elizabeth, her comment about, "I can give you an antibiotic for chlamydia. I can't fix childhood abuse in my STD clinic, but we can prevent more trauma. That's something we can do." So there is some hope here. Okay.Nkem Ndefo:So I want to move to talking about a public health model of trauma prevention. Thinking back to school, if you remember, maybe it's been awhile, there's primary, secondary and tertiary prevention. Right? So primary prevention is that's what's upfront. Right? That's where we prevent the societal concerns that affect health, then wellbeing. This is where we foster resilience. This is where we build protective factors. Right? And they're proactive by definition. Primary prevention's proactive by definition and it should generally be aimed what, not at individuals, but at populations time. So this is the safe housing. This is living wages. This is access to quality, physical, and mental health services. This is community connectedness. Right? The conditions here that support the most research protective factor. Let's say the most research protective factor is a stable bond with a protective and well-functioning caregiver, a stable bond with a well functioning and protective caregiver. And so what are all of the larger factors that support that? That's trauma prevention at a primary level.Nkem Ndefo:And then secondary prevention we're in the thick of it. Right? Here we're talking about early detection and prompt intervention to control the problem or disease and minimize poor health outcomes. So here we're talking about trauma screening, DV screening, for example. Right? You're catching it in the thick of it so that you can do some intervention. That you can do in an STD clinic. You can do it and you can refer.Nkem Ndefo:And then there's tertiary. And this is the aftermath. This is where we reduce further complications of an existing disease, an existing, something going on through treatment and rehabilitation. This is about trauma healing. The thing that's very interesting about this model, we can say in public health that all major health issues have been solved at the primary prevention level but when you come to trauma, let's say smoking, so we've decreased smoking by and large through primary prevention efforts, taxation messaging, all kinds of things. [Inaudible 00:12:23] laws about where you can and can't smoke and we've seen decreasing rates of smoking, but trauma's different than smoking because the thing about traumatized people will traumatize other people. And so there's a cycle here. There's a cycle. Primary prevention isn't enough, that we actually have to do tertiary prevention. We have to do trauma treatment to break the cycle so that the trauma doesn't go around to the next generation. And I can see some of you, there was a couple of comments about seeing kids in foster care, seeing the neglect, the substance abuse and seeing that cycle.Nkem Ndefo:So in trauma, tertiary prevention is primary prevention and this is a unique feature of trauma. And so while public health, and I think it's important that we look at all the levels. We can't just look at our one-to-one interaction, because if you look at just our one-to-one interaction with the patient, we feel all the weight on us and it shouldn't be all on us. The weight needs to be distributed across all of these prevention levels and know that we are doing our part in a larger system. And I think that's reassuring as well. So what we do need is linkages between the interpersonal, between the one-on-one and the systemic, and really how do we do that? It's about becoming trauma informed. That helps us with that linkage, this trauma informed approach because it includes all the levels. And as you see, as we work this in here, you'll hopefully get a deeper understanding of what this means.Nkem Ndefo:I want to differentiate the difference between trauma informed care and the trauma informed approach. Big difference. Okay. The codified form of trauma informed services started in behavioral health. So the official trauma informed and the understanding is as we saw from the ACEs and other research trauma is prevalent, it's ubiquitous, and that services should take this into account. We want to use a universal precautions approach. I'm old enough to have, I may not look it, but I'm old enough to having started practice in the late eighties when very different attitude towards HIV. And I remember working in labor and delivery in particular and the older nurses who trained pre HIV still hated gloves. They just hated them. And those of us who had trained just after that line, post HIV universal precautions were kind of horrified and even now, if you're a younger clinician, you couldn't even imagine being a labor and delivery nurse and resisting gloves. Right?Nkem Ndefo:But this idea of universal precautions, it took a while before it became just in our culture and how we understood to move with infection and with COVID, we're going to take that to a whole nother level about how kids are getting used to mask and you watch a movie now, and you'll say, "They're not wearing masks. What's wrong?" Because your whole culture has started to shift. We want this around trauma informed as well. That it's the assumption is that everybody has something. So we're going to use this approach, not just with people who screen positive, but with everybody, universal precautions.Nkem Ndefo:And so when is it trauma informed care? It's trauma informed care when you're in a therapeutic setting. That means you're providing care. So an example would be, you're a doctor, a nurse, a PA, a therapist, you're providing care in that way. That's trauma informed care, but that is different than trauma treatment. Trauma treatment typically happens in behavioral health or maybe a culturally relevant modality. It may be community based. It may be group based. It may be faith-based, but it is specific to the trauma, as opposed to you're in the course of providing services, you are using a trauma informed care within your services, not actually treating the trauma itself.Nkem Ndefo:Again, if you have any questions about any of this, please don't hesitate, pop them in the Q and A, or if you want to make comments, they're welcome in the chat. And I will address them as I can. So what happens in a non-therapeutic setting like a school. They can use a trauma informed approach where they can still acknowledge that trauma is ubiquitous, and we're going to get into more of the goals and principles of being trauma informed but understanding if you're not providing services, you still can use the approach. So in your clinic setting, are there people who don't provide services? Maybe you have a case manager, maybe there's the receptionist, someone who does intakes, maybe the environmental services, people who still are interacting with your patients that they too, even though they're not providing trauma-informed care can use a trauma informed approach. People who are processing insurance, etc.Nkem Ndefo:So because sometimes when people say, "Oh, we're going to move to trauma informed." And they say, "I'm not a therapist. How will I do that?" Saying that this approach can be used in every single role for those people who are not providing care, they can still use the goals and principles in their approach and those who're providing services can at that can use the approach and those who were doing trauma treatment can also use the approach because surprisingly not even all trauma treatment is trauma informed. Say, really? Really. How do we know?Nkem Ndefo:I'm going to go through next talking about what are the goals of trauma informed care and what are the principles? And this is really the heart of the matter. So these goals, originally developed by the Substance Abuse and Mental Health Service Administration, federal level, around behavioral health, have been adapted and used in many different contexts and they hold up. Most people when they adapt them, still use these same ones intact and they're four and they're R's. Make it easy. Four R's. First is to realize the wide spread impact of trauma and the potential for recovery. We've just talked about that. Right? Trauma is ubiquitous, but there is potential for recovery.Nkem Ndefo:The second R, recognize the signs of trauma. Do you know how to recognize when trauma is showing up? Maybe as we talked about a little bit, maybe it shows up in people's behavior. Maybe there's other signs. Three, there are other signs too. Three worst auto somatic complaints. How are things coming in. Three respond by integrating the knowledge of trauma into policies, procedures, and practices. It's not enough to realize, it's not enough to recognize this knowledge base, and it can't just show up in practice. It needs to show up in policy and procedure. So what we're looking at is an institutional adoption of this approach and resist re-traumatization.Nkem Ndefo:If we can do nothing else, but this fourth R really, actually, SAMSHA says actively resist re=traumatization. It takes it out of the R when you put the A first, but if we can do nothing else, can we at least say that we did not traumatize somebody further? And that's not little, You think, "Oh, that's nothing." That's not little, because many times coming into a family planning setting, there's a history, for example, of sexual assault. Can be highly ripe of a situation ripe for trauma triggers and re-traumatization. So if you can say, "I didn't, re-traumatize someone," you did something. All right. Fully trying to again, having been a clinician, understanding that perspective about what's often asked of us sometimes feels unreasonable when we're already so burdened, but there are things we can do.Nkem Ndefo:So I want to talk next about the... If you have any questions, again, pop them in... The trauma-informed principles. And I find these to be super important, almost a blueprint for living. There's six and they're clusters. Some are standalone. Safety being the basis. Without safety, nothing else here happens. Then I would say probably following that is trust and transparency. You can't have trust without safety, but safety builds trust. These are mutually reinforcing. Collaboration and mutuality. And this we're thinking about the relationship between the clinician and the patient. We're thinking about the relation between the administrator or clinic site leadership and line staff. We're thinking about the relationship from the clinic itself, your site to the community. We're thinking if you're in, for example, an FQHC and you have cross-disciplinary. So maybe you have OBGYN, midwifery, and a family practice. What's the collaboration of mutuality cross specialty. And behavioral health as well. Peer support. Peer, it's patient to patient peer but what about your peers? What about your peers? The idea of being culturally, historically, and gender identity appropriate. I prefer the term cultural humility but it's not as well understood.Nkem Ndefo:Cultural humility is an idea rather than the idea of cultural competence. To say that I'm competent in all cultures. I don't know how that's possible. There's cultures and subcultures. Cultural humility, instead, has this idea that I'm in a learning stance. What do I know? What don't I know? Am I humble enough to admit what I don't know? Can I meet you in collaboration saying, "What don't I know about your culture and I'm curious and want to learn." What I also like about cultural humility is it acknowledges that I have a culture as well. If you happen to fall in a dominant group, for example, I am-Nkem Ndefo:Happen to fall in a dominant group, for example, I am cis-gender. I would assume if you want to just go, Oh, I want to learn about trans culture. Wait a second, did I even learn about cis-gendered culture? Or if I'm white, I want to learn about your culture, whatever, you know, whoever it is, this black, indigenous, people of color, but did I learn about my own white culture? And so it causes a more introspection and humbleness that allows us to approach on a more level, collaborative, exploring way than a competence, which is like kind of a sense of mastery, which is a very colonial word in and of itself.Nkem Ndefo:And the last cluster of principles is voice, choice, and sometimes self-agency, sometimes empowerment. I prefer self-agency over empowerment because empowerment often is used, although it means feeling powerful, it can be used in a sense, as we are empowering you, versus somebody is taking their own self-agency, so I tend to prefer self-agency, but you'll see variable choices around this. So these are principles, and if you think about, just imagine, if you lived and worked and played and worshiped in a culture that had these values, that valued everybody's safety and trust and transparency, that we collaborated in a mutual way, we supported each other, we were humble about each other's culture and experience, right? And that people could be heard, and their voices and their choices would be valued, that I want to live there. Does anybody want to join me? Right? That's just a humane set of values, a humane place, and so sometimes when there's, I think, understanding of trauma, Joelle raises her hands. Can I raise two hands? Can I twinkle? Can I snap? Right? So when we think trauma, we think, Oh, we're going to have to be talking about that trauma and trauma trauma trauma.Nkem Ndefo:And then on the other side, it's not just what we're healing or preventing, it's what we're building. We're building something different, we're building a different culture. And so I think when you center these principles, one, it makes people a lot more excited because you can't have trauma-informed services in an organization that is not trauma-informed. I'm going to say it again, you cannot have trauma-informed services in an organization that is not trauma-informed, and we're going to get to some of the details of what that looks like in a little bit more concrete way, because what happens as a clinician, right? You're not being supervised in a trauma-informed way, there's a very hierarchical way, there's a lack of trust, you don't feel safe in your role, there's not a lot of collaboration, and then you're expected to turn around and be trauma-informed for the patient. It's just not, it doesn't work. And also this idea of, Oh, if I'm going to be doing screening, am I opening myself up? Am I hearing more stories? And then turning around and to my clinic and saying, how am I being supported in this new role that's being asked of me?Nkem Ndefo:So I know that these, especially for administrators are probably like, Whoa, these are hard questions. They are hard questions. I'm working right now with the California Primary Care Association, which is the association of our federally qualified health centers on a five month process to help clinics develop their knowledge base and their skills in their journey to becoming trauma-informed, because one 90 minutes is just a little sprinkle. This is really a process.Nkem Ndefo:Okay. Again, so looking at those principles, and here's my little tip, this is a tip that I often use, I use for myself, I run an organization as well, is that when I come up against something that's difficult, an ethical dilemma, just a question or some just challenge a personnel challenge, whatever it is, I come back to these principles as a guide to say, what if I centered safety? What if I centered collaboration more? What if I was more of these? And often that's how I find the answer to the dilemma. So that's one of my little tips. So rules for living.Nkem Ndefo:Okay, so I'd like you all to think right now, we're gonna do a little reflection point, one way, one way, it can be very, very small, that you are centering one of these principles in your practice or at your clinic and put it in the chat, one way that you're promoting a little bit of safety or a little bit of peer support or voice, choice. One way that you're doing this in your clinic with your patients. Let's see what folks are doing, because I believe that you're already doing some of this, it just might not be named this. Let's see what you folks can come up with. What do you think of one way. Shared decision-making. Robert, tell me how you're doing collaboration of mutuality. Tell all of us, what is it? What is the thing that you're doing? Danny: I listen and ask clarifying questions. Great. Elizabeth: I think when I keep information confidential, it lets patients know that they are safe. Absolutely. April: promoting patient centered counseling, which is collaboration and mutuality. Risa: I try to create trust with my patients by ensuring confidentiality, explaining it and making sure it's clear. So that transparency, by being transparent. Joelle: opening up a safe space and personal approach to assessing patients. Shannon: we're providing training that emphasizes collaboration and mutuality.Nkem Ndefo:So some of you are already doing this, right? And so really recognize your strengths. I mean, I trained in the midwifery model, and so much of this is built into the midwifery model, even before we called it trauma-informed, right? About choice, right? Choice in birth setting, and birth practices, and it's a huge, huge piece of midwifery. We just didn't frame it in trauma-informed, right?Nkem Ndefo:Oh, a galaxy note, we don't have your name, so you're Galaxy Note10: depression and anxiety and substance abuse screening tool on all patients. So think about it, which principle is that affixed to? And it helps you understand better what you're doing when you get that level of clarity, you might have it intuitively, you might have it implicitly, but make it explicit. We're doing this because it's related to this principle and this principle and this principle, okay?Nkem Ndefo:Katie: providing choices to the patient in every way, from "do they want their body covered during exam?" to "which restroom would they prefer to use despite gender labels?" Right? So there is choice. Choice, in the sense of self-agency. Beautiful. I love to see this, this really cheers me a lot.Nkem Ndefo:Alright. So we've got the goals of trauma-informed care or approach, you can use it in both. The principles are the same and care and approach, and next we're moving into the domains of implementation. Okay? Boy, there's a lot of words on this slide. I don't generally like to put a lot of words on this slide, but there's a lot of words here. These are the domains where, for an organization to be trauma-informed, this is where we need to talk about, it can't just be, where do we usually see it? We see it in screening, assessment and services, and we see it in training and workforce development. Those are the two places we see at the most. Look at all these other ones, leadership and governance. How are you doing progress and results monitoring? Are you monitoring how trauma-informed you are, how safe people feel, how much voice they feel they have? How are you engaging and involving the community, patients? What about your built environment, your clinic?Nkem Ndefo:I remember it was a human trafficking group that worked with healthcare providers, mental health providers, law enforcement and advocacy, violence advocacy, and how they worked to change the built environment when they were bringing in trafficking survivors, from a very cold and sterile environment to make it much more, and they did it with collaboration by asking survivors what would help them. So another thing is you don't have to think of it all, bring in collaboration on it. Where is there cross system collaboration? That means cross discipline, if you're in an FQHC, you have the advantage of having usually more disciplines there, right? How are you messaging to the community? What is your messaging to your patients, themselves? Policies and procedures, for sure, and even a financing. So these are the domains of implementation. So what does trauma informed implementation look like? And I want to use a developmental framework because people throw around the word trauma-informed very easily, and I find after doing this work for a number of years, that I really don't see much fully trauma-informed, I see fits and starts.Nkem Ndefo:So let's get an organized way to think about how does an organization become trauma-informed. Again, it's very hard to put this all on the clinician, we have to look at the larger ecology around the clinician that supports the person, all of us in the system, really. So I'm going to use a developmental framework and there's different stages here, there's four stages: trauma-aware, trauma-sensitive, trauma-responsive, and lastly, trauma-informed. So trauma-informed is at the end, trauma-informed is at the end, okay?Nkem Ndefo:So trauma aware, let's do this, this is where you're aware of the prevalence. This is often where you have a training, and you learn about the ACEs, and you learn about how much trauma is in your patient population, and you start to ask the question, Wow, I'm really thinking about how this might be impacting our patients and staff. This is where we start saying, Oh wow, there's a lot of burnout and vicarious or secondary trauma among staff, where you're starting to get that awareness. What also has to happen here, in order to deeper into this process, is what I call the abiding why.Nkem Ndefo:The abiding why is the deep understanding that you cannot get the outcomes for which your services are responsible without addressing trauma. I'm going to repeat that again: you cannot get the outcomes for which your services are responsible without addressing trauma. So let's say for decreasing incident of sexually transmitted infections, we just saw untreated trauma, risky behavior, recurrent, repeated, multiple STIs. So when we say, as a clinic, we want to lower the incidence in our patient population, we can't do that unless we're addressing trauma. Just one example. So when we start to understand this on a deep level in our organizations that this abiding why, it's not something extra to do, oh, another checklist, another screening, another thing I have to do, you understand that by doing this, you're going to get the result that you wanted in the first place. In fact, the result that people come to us for, that's the abiding why. It's so important. And I find once that is in there, it opens up the possibility of, we're ready. We want to do this. And even when I described the trauma-informed principles and Joelle said, "two hands up," right? Yes. I want that too. As clinicians as administrators, how wonderful to come to work and be in that kind of environment, how different would our relationship be to ourselves, to each other and to our patients?Nkem Ndefo:So it's good for everybody. So the abiding why is a win-win-win. There's work to get there, but when we have the North Star in front of us, it feels like we want to do it. It feels possible. Okay, so that's trauma-aware, and I would say that's fairly common at this point, though I find uneven and often have to do what we call level setting, where people have the awareness, but we need to level-set the awareness and people definitely need to develop the abiding why. That is often missing in most of these conversations.Nkem Ndefo:The next stop is this idea of trauma-sensitive. Here, it's about developing change-readiness. Are you really ready? Are you committed? Are you, not just you as one clinician, because you can do some stuff, but is your organization, is your department, what's the degree of resolve to see this change through, to successful and sustainable completion, right?Nkem Ndefo:Then there's capacity-readiness, right? So you can be commitment-ready, but not have the capacity, right? Do you have adequate knowledge? Do you have experience, skills, ability, resources, to bear, to really bring those to bear, to support successful implementation and sustainability, and with COVID, you all are pulled in a lot of directions, so to say right now, can we become trauma-informed in the middle of COVID? And then there's some saying, I say, we're in twin pandemics, the pandemic of racism and the pandemic of COVID. Then if we understand that racism is also, if we go back to those principles, if we do those principles, we are being anti-racist at the same time, so can we afford to not address racism, especially with the COVID disparities, health-related health disparities? No, we can't afford to.Nkem Ndefo:So in some ways we're strapped for resources, for capacity, and if we do this work, we're actually probably make more capacity. So commitment-readiness, capacity-readiness, and what's the relationship between the two? Generally they feed each other, as capacity increases, commitment goes up. It's hard to be excited about something when you're overwhelmed. It's just hard. And so by building people's capacity, we can often grow commitment and then the commitment can help you tap other places of other resources, like when people get that abiding why, I find all kinds of resources open up that you were surprised, where does that pot of money come from? So in this stage, you're also identifying champions. Who in the organization can be a champion for change, and how can we resource these champions? How do we build consensus around the trauma-informed principles and the goals? Where do we start having some few ideas and start testing them out, pilots here and pilots there, right? And we're not looking at all the domains. We're not looking at all the domains. We may be saying, okay, we're going to do workforce development, we're going to start here, and then we're going to look also in policies and procedures. We're going to do those first because often we go to screening first without workforce development. I would encourage you, if you're thinking about it, policies and procedures, workforce development before screening. That's, if I can say anything.Nkem Ndefo:Okay, then we become trauma-responsive. Here, you're really getting your implementation, not just in a few domains, you're getting them into more and more domains, right? And you're beginning to assess your progress and results. How are we doing? How can we improve? And by the time you're trauma-informed, the principles are embedded into your organizational norm, they're just part of your culture. You actually don't need champions at this point because you have a leaderful organization, everyone is a leader for the trauma-informed approach. It is built into everybody, and this is not just clinical services, these are including your environmental services, janitorial services, anybody who has patient contact or contact with other staff, because we're all connected. We're all connected. Here, you're having ongoing assessment, you're deepening and improving, where can we improve? My organization, although I would say we are trauma informed, we still regularly, on a regular interval, meet with team members, people do private surveys, anonymous surveys, where do they think we are on house safety and all the different principles, we rate them and give examples of what we're doing well and what we're not doing well, we come together and we evaluate where we can improve. And we're already trauma-informed, but what can we do more? And here you're disseminating to partners, other clinics, other providing templates and sharing your information, so when we think about trauma-informed, that's a much deeper understanding of what that is.Nkem Ndefo:Okay, so thinking about this trauma-aware, sensitive, responsive, or informed: what is your site? What is your site? What is your site? Would you say your site is trauma-aware, trauma-sensitive, trauma-responsive or trauma-informed? I'm going to pop it in the chat and let us know and maybe let's see what, folks.Nkem Ndefo:Trauma-sensitive. Great. Aware, says Karen. Kate says developing trauma-awareness with a need for level-setting among varied staff. Trauma-aware, says Ray, trauma-sensitive, aware, aware pre-COVID and then you got a setback, Joelle said. Yeah, well COVID, I think, has set in many of our dreams on hold. Trauma-aware, responsive. Okay, great. Alright. So you're doing great here. Responsive, sensitive. And my guess is that your organization is probably saying already, we're trauma-informed, and I think it's important just to back off and understand this developmental process and know, even with a clear, articulated plan that is resourced, you're looking at a three to five year, it takes three to five years to shift culture, and that's with an intentional implementation plan and adequate resources. So to take a little weight off of us about this need to be perfect and have it out of the gate like this.Nkem Ndefo:So I see a question from somebody about... I'm going to hold that question, it's a fantastic question about being help staff feel like this is not just another task. You know what, I'm actually going to answer it now, here's the question: what can I do as a program manager to help my sub-recipient be more trauma-informed focused, and help them think like you, that this is not just another task that I'm adding to their already busy schedule, but just to help them be very successful in their work?Nkem Ndefo:I think the first thing is it has to be modeled by, if you're the manager, asking for trauma-informed services, without first looking at your policies and procedures, especially around employment and HR policies and procedures first, is part of the problem, because you really are asking them to do something more without providing them a different approach. So looking at how well are they resourced, looking at how is their collaboration? Does your line staff have a sense of power, a self-agency, and voice in the organization? Is there collaboration on, for example, how their day flows, or some of the other breaks and supervision and some things like this, because as they start to feel that they have more collaboration, that there's more trust and more safety for them, usually their stress levels go down, capacity expands, and then it's easier for them to extend the same thing that's being offered to them, to the patient. So I think you have to go upstream. That's my experience. So if I didn't fully answer and you have a follow up, feel free to pop in another question there.Nkem Ndefo:Okay, that was great, I'm glad that that answered that. So Susan has a question piggybacking on that last question: we are integrating behavioral and oral health, okay, you're an FQHC, how do we train the dental staff without them thinking we are adding more to their plate? So I've actually done some interesting lectures for dental students at University of Southern California, about using the trauma-informed approach. They have to recognize, one: how does trauma impact oral health, right? How does trauma impact oral health? So understanding that stress, right, where people are grinding their teeth, and doing chronic inflammation, so gum disease, and so when we start to see the linkage of, Oh, stress and trauma.Nkem Ndefo:... linkage of Oh, stress and trauma. How is that impacting oral health? They realize that this is also in their domain. It's also important when you emphasize that they're not supposed to be therapists. You're not supposed to be therapists. It's opening up this approach and it may be as simple as... We're talking again about values, shared decision-making. That's part of becoming trauma informed, and I think that's something that can be brought in into almost, we hope, any clinical setting. And if someone has problems with shared decision-making, then we need to go back and do some value of alignment. Value and principle alignment is a really good place to start. So I'm just... If you have formal-formal questions, I'm going to ask you to put them in the Q&A because as people type in the chat, the questions get lost, or can get lost.Nkem Ndefo:So if you can put them in and I will do my best to attend to them. Nicole, I see your question, but I'm going to move a little bit more into the content just to make sure that we get through here and... Yeah, bookmark that. Okay, so what I want to say is this, and I don't usually have quotes on slides, but this one is so important. Trauma-informed implementation is... And I'm going to read this because it's that important, "It is not a program model that can be implemented and then simply monitored by a fidelity checklist. Rather, it is a profound paradigm shift in knowledge, perspective, attitude, and skills that continues to deepen and unfold time." We can not do this through the energy of compliance. This is not an algorithm. These are values. It's a value centered, and so coming back to that value alignment is so, so important and understanding, how do we do change work? What does culture change? I think this is moving us to the culture, a very kind and just, and humane culture.Nkem Ndefo:So when we look at organizational level, you must have leadership involvement. It is very hard to do anything like this if it's just happening at the clinician patient interface. It needs to happen with leadership involvement. And in the slides, there is a reference for... There's a fantastic blueprint we designed together as a team here in Los Angeles on trauma and resilience informed systems change initiative. And we made a blueprint for this type of change, including questions to ask at each stage and starting with leadership. That you need to train clinical and nonclinical staff in the trauma informed approach. Everyone, from the front desk person, everybody needs to be included in this. Engagement models, I highly recommend champions. If you can find a few champions in each department across different levels, and these people are more deeply resourced and can serve as resources for work groups and other ways of bringing change in.Nkem Ndefo:Really create... Having a conversation with your patients. Maybe you do a focus group with your patients. What does a safe, physical, and psychological environment look like? Do a focus group with your staff. What does this look like? Patient engagement at all level, including an organizational planning. I will say that there is a women's shelter here in Los Angeles that includes... Look at this, they included their patients in a signage committee. A signage... Not patients, they're participants. I'll say program participants, though they do have healthcare there. As they were designing new signs for the shelter and clinic, they included patients to say, "What would you like to see?" On those committees, in their evaluations, their quality improvement patients sit, participants sit on those committees, and that is trauma informed.Nkem Ndefo:Prevent and treat secondary traumatic stress and burnout in staff. A burned out staff, a traumatized staff, cannot provide trauma informed care. And so if that is your issue, do you know... Are you measuring, like using, for example, the professional quality of life inventory? Do you know what the levels of burnout and vicarious trauma are in your staff? Find out, and address that before asking people to do more. And evaluate, evaluate, evaluate. How are we doing? How are we doing? How are we doing? At the clinical level, we talked about shared decision-making, collaborative patient relationships, trauma screening, where appropriate. Again before adding that, make sure that you have the resources of where to send people and that your staff is well enough resourced and has enough time in their days to do this in a way that doesn't re-traumatize people. Having the availability of trauma specific, trauma treatment. If you don't provide it at your site, where are you sending people?Nkem Ndefo:So you're engaging partner organizations, and how is your site working at a larger level to enhance protective factors in your community? Housing and the like, what are you doing as an organization to do that? And at the clinical level, where are you making linkages? Okay, let me look at some time here.Nkem Ndefo:Considerations and cautions. What I see in implementation is an over-focus on patients. Again, that clinician patient interface without looking at the larger system. You cannot have trauma... And I'll say it again. This is the third time, maybe fourth. Trauma informed care is not just for patients. It's for everybody in the organization. You cannot be just that at the point of service and delivery. It has to be embedded into your DNA. I do find that clinical providers and administrators need to have a self-awareness and ability to regulate their stress response to embody the trauma informed principles.Nkem Ndefo:Safety is the first trauma informed principle. Can you cognitively create safety in your head? If you can, you are amazing. Please teach us all. Safety comes from the body. Stress reactions will hijack your capacity to feel safe and to engender safety in those people entrusted to your care. Okay, so if we don't know how as clinicians to settle our stress, we become robots. No one feels safe with a robot. As administrators, as leaders, if we don't know how to settle our stress responses, we can become authoritarian, overly directive, non-collaborative, we're not good listeners. So, there's a lot of things that happen. When we become stressed, we're pressured for time, we're reactive, and we're disconnected. Those are antithetical to the trauma informed principles.Nkem Ndefo:So I often use an approach of needing to drop into our... We have to be able to settle our stress to embody. You have to have embodied trauma informed. It's not something we can just do in our head. And interestingly enough, when we're embodied, it actually means we feel ourselves better, and from a neurological basis is when we can feel ourselves better, we actually have better boundaries. We have healthier boundaries and it is a prevention for vicarious trauma because we can be more clear. We're not numb. I can feel myself. I know what my boundaries are, and so I can be in empathy with those people that I am serving without their issues coming into me. And so that's a longer lecture, but just in terms of the neurobiology of embodiment is a preventative of vicarious trauma.Nkem Ndefo:Additionally, if we over-focus on the individual or interpersonal trauma level, we ignore the systems level contributions. Here, I think about the clinic having... ER clinics need to be specifically anti-racist for example, right? If we can't just be... I think of Camara Phyllis Jones, a wonderful physician and public health leader, and she has a wonderful TED Talk on racism, and she talks about racism as being an escalator. It's just moving. And you're standing on it, and if you don't do anything, you just go with it. You just go with it, which means we're perpetuating some of those harms that are on a larger level, and so we need to be anti-racists. We actually have to walk on that escalator. We actually have to walk. We have to move our legs intentionally, and so we can't just look at the interpersonal. We have to look at the larger system and what is our role in it as individuals and what is our clinic and our site's role.Nkem Ndefo:The over-focus on trauma neglects the other side. Remember in the trauma-informed goals is that there's hope for recovery. So we have to also focus on resilience and recovery and healing. And that's why I think focusing on those trauma informed principles brings more of this in than just the negative or the downside. It looks at the rainbow and the pot of gold. And so there's some of us who are arguing that trauma informed isn't even a great term. One I'm using now is trauma informed resilience oriented, TIRO. Trauma, informed resilience oriented, TIRO.Nkem Ndefo:And then we move the paradigm from what happened to you, to what's right with you, and how can we build on it? What's right with you, and how can we build on it? So even as you think about who you're working with, where we also focus on the strengths, not just the problems. Not just in the clinician patient interface, but as a clinic as a whole. What's working? Just earlier calling out when I said, "Where are you implementing some of those principles?" That's what's working, that's what's right with you. So I know it feels like there's a lot in front of you to do. Also realize that you're doing some of it now. All right, so we're going to move formally into questions.Nkem Ndefo:The racism escalator is Camara Phyllis Jones. She's the former head of the American Public Health Association. I think she's based in Atlanta. Okay. April, you've been so patient with this question. There Karissa, thank you. April, thank you for the overview of ACEs. Do you have any insight on the physician's role of assessing resiliency as well or positive experiences that can combat these ACEs? Right on time, April. The Montana Institute has much of the research I've been exposed to about this topic. So what we find is the research is still very, very new about screening. Even about the trauma screen... Even the ACE itself, so one of our oldest instruments is the ACEs instrument and it's being rolled out. It was developed for research setting, and it's being rolled out into clinical settings. And now there's like some, "Oops, we didn't think of that, and what about that?" And there's a lot of questions coming up around that.Nkem Ndefo:So resilience screening is even newer than trauma screening. There's so much we don't know about. I think it needs to happen, and I think it needs to happen just, as you can see by my ending, it needs to happen in parallel and we need to be researching. Absolutely, because there can be unintended harms if we're not careful. Especially what I see anecdotally is in sites rolling out screening without resourcing the people doing the screening. And so I think the research needs to be not just on the patient population, but also on staff. So we're looking at implementation science research, not just on efficacy research. That's what I'm going to say on that.Nkem Ndefo:Okay, Nicole. Staff who suffer themselves from untreated ACEs, which is all of us, more or less treated, I would say. And we're asking them to be trauma informed themselves. This is why start with your policies and procedures in your organization and then your workforce development before you move to the patient side. So when you look in policy, if you know you have staff who have maybe an even higher burden of ACEs, then looking at your policies and procedures, what is your health benefits? What are your mental health benefits like? On a procedural level, how are you rotating staff through difficult assignments? What is the workload like? Are you using reflective supervision? So there's some things that can happen first before asking the switch of them and they will appreciate it, and they will thrive because at least they're not being retraumatized in the work.Nkem Ndefo:So there's my recommendations of going alongside staff who themselves are needing trauma informed approaches and treatment. Yeah. Okay, are there trauma informed approaches that branch out beyond one organization? Like you said, racism is truly a root of all trauma. It feeds capitalism, classism and all other -isms. I feel like TIA and One Health center isn't addressing living wage, housing, for access for to basic needs. Don't we want to address what is causing trauma while also healing trauma within staff and patients? Are linkages to assistance programs enough? This is huge. This is a huge one. And sometimes when we look at the enormity of it, it can feel overwhelming and make us shut down and do nothing, so I don't want to leave with that. This is going to take... I'm going to say, many bodies make light work. Everybody has a role.Nkem Ndefo:Finding what are the places where are your skillsets and where's your passion and doing your work there is so, so, so important. Being able to understand that, although it's really big, that my piece or role is here and I can understand its importance in the larger, asking... These are really... It's a model for living. How am I in all of my relationships, not just with my patients, but with my coworkers, my supervisor, supervisee, my children, every relationship, how am I centering the trauma informed principles so I live them? That is doing the work, and the more and more people that do that... The more and more people that do that, we start to get the shift around all of these things, because this is not going to happen overnight.Nkem Ndefo:How am I aware of my own stress that's making me pressured and disconnected? And am I in more stress than I need to? And can I settle that stress so I can be more connectable? So, think about even how I started this session. Just a moment for us to pause and connect to our environments, to connect to ourselves so we could be more ready to learn. Taking one minute here or there. So when you think, "I'm not doing the whole thing," sometimes that one minute is towards the whole thing. How do you walk a mile? One step at a time. I know it's a long road, but there's my cheerleading for you. That's what I do.Nkem Ndefo:Oops, sorry there. I've got multiple windows and it depends when I'm clicking on here. Joelle, do you think it would be more beneficial to have an in-service with staff to first help address their own biases and/or ACEs? How to approach staff who are not wanting to change shift to population health and addressing disparities and ACEs alike? Same answer, go to your policies and procedures and look at how you're supporting your staff. Ask them in collaboration, "How well do you feel supported? What could we be doing differently as administration, as leadership to support you? How can we be in collaboration with you?" As you start to resource them, they will have more bandwidth and more space to take on these... Because when we're stressed, we get narrow focused and we get selfish, and we can't think about other things, and big things. The better resource they are, the more they can look up and start to connect and do this larger work.Nkem Ndefo:So, put the horse before the cart. Put the horse... We tell people to put the oxygen mask on themselves. We talk about self care, but we are not creating the conditions for them to put the oxygen mask on themselves. So I think about a colleague, we teach together, and she told me about being on a plane. And on this plane, they had the oxygen masks came down and all these things happened. And this man was just sitting next to her and just looking kind of blank. He was deaf. He couldn't hear so the oxygen mask was there, but the conditions, meaning the interpretation for him to know that he needed to do that, was missing.Nkem Ndefo:So we need collective care to put the conditions for the self care, which makes the space to do... What did I say? You're looking for a commitment readiness when you haven't built capacity readiness. Build capacity readiness first. Are we at... We're at time. I'm sorry, I wish I could take more questions. Thank you so much for your attention and your sharp questions and all your efforts. I know doing the frontline work that you're doing was hard enough pre COVID. With COVID, it's ridiculous. You're doing it. Keep up the good work and I'm happy to be here and hopefully offer some perspectives of ways to support you in feeling better in doing your work too, not just doing work better. All right. Thank you so much.NCTCFP:Thank you so much, Nkem. I think that left us all with a lot to think about, a lot of places to go from here. So just as a followup to everyone, you will receive a link to the survey. You must fill that out if you want CE for this. And we will have this recorded and available for people on our website within two weeks. So thank you so much everyone for joining us and especially thank you, Nkem for your expertise and your time today. It was really wonderful. Thanks so much and take care of everyone. ................
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