Good afternoon, everyone, and welcome to today's webinar, What Clinicians Need to Know About Trauma, hosted by the Providers Clinical Support System in partnership with the National Council for Mental Well-Being, formerly the National Council for Behavioral Health. Thank you so much for joining us. On the next slide, I'm just going to cover a few housekeeping notes. So today's webinar is being recorded and all participants will be kept in listen-only mode. The recording and slides will be made available on the PCSS website within two weeks. We'll have time to ask questions at the end of the webinar, so we encourage you to submit any questions you have using the Q&A box located at the bottom of your screen. On the next slide, I'm just going to introduce our presenter today. So our original presenter, Dr. Linda Henderson-Smith, was unfortunately unable to join today due to some unforeseen circumstances, but our colleague, Dr. Amy Rushline, has graciously agreed to step in today. Amy is a consultant for trauma-informed services with over 20 years of experience as a licensed clinician leading behavioral health care teams and developing and implementing programs in health care settings. She has published research and presented at national and international conferences on the subjects of interpersonal violence, trauma-informed care, compassion cultivation, and leadership and team-based health care. She completed her doctorate with a focus on innovating and creating large-scale social change through transdisciplinary training of mental health practitioners. On the next slide, Dr. Rushline has no disclosures, and the overarching goal of PCSS is to train a diverse range of health care professionals in the safe and effective prescribing of opioid medications for the treatment of pain as well as the treatment of substance use disorders, particularly opioid use disorders, with medication-assisted treatments. So at this time, I'd like to turn it over to Amy, who will review the educational objectives and begin the presentation. Amy? Thank you so much, Casey, and thank you all for having me today. I'm really excited to dive in with all of you. As we're going, if you have any questions, please don't hesitate to go ahead and put them in the chat or to put them in Q&A so we can make sure that we grab them and are able to answer them for you. Today, we're really hoping that everyone will walk away with a really good sense of the impact of trauma, certainly the connection or link between trauma and substance use, and two really practical strategies or more about how to engage folks that are struggling with substance use issues. Our game plan is to talk about trauma, not only its prevalence, but how it impacts the body and the brain. And we're going to discuss that linkage or connection to addiction and how each one of us can become more trauma-informed in our daily work, as well as being able to create a culture of compassion, both for ourselves and those that we serve and those that we serve with. So prior to 2020, when we would do this training, a lot of the times, I would have to really advocate for why it's important for us to talk about trauma. I have to be honest with you all that that isn't something that I really have to do anymore. The reality is, is recognizing the trauma, the crisis, and stress that we are all holding is just a click away, right? As soon as we kind of wake up in the morning, if we check our newsfeed on our smartphones with the pandemic, certainly the social unrest that we've experienced, the racial violence and gun violence, I actually live out in California, so the climate crisis is very real. These are all things that we are impacted with every day that really carry weight in our minds. Now, when it comes to the opioid epidemic, this is one of the certainly pieces that is key to understanding trauma, right? So in the late 90s, these pharmaceutical companies really reassured medical community that patients would not become addicted to opioid pain relievers, right? And so what we found is healthcare providers started to prescribe them at greater rates. And this increased prescription of these medications led to widespread misuse of both prescription and non-prescription opioids before it became clear that these medications could indeed become highly addicted, right? And as you can see by looking at these numbers, this is really a public health emergency, right? And so recognizing these devastating consequences of this epidemic, it has really been something that I think we recognize and see as providers, as humans within our communities, and certainly those that we serve. Now, what's interesting is that although a lot of us might be aware of the opioid epidemic, we don't, and we might also be aware of what it means to be, you know, or what trauma-informed might be. Historically, this has been something that we might see that is a type of treatment, maybe an intervention that we use for clients, right? But the reality is, is being trauma-informed is not an intervention, right? What it actually is, is being trauma-informed is a stance that we want to take with all humans, right? It's not just for clinicians. It's just about being one human engaging within a system with other humans, right? And so it's important when we're working with folks, particularly those who have struggled with opioid use, that we are treating and recognizing the immense amount of stress and harm that they might be suffering from. And we're going to talk about what that potentially can look like. Now, when I say the word trauma, I'm not talking about a diagnosis, right? According to SAMHSA, or the Substance Abuse and Mental Health Services Administration, trauma really has three key components. So it is a circumstance or an event that is experienced by someone, and it can either be directly experienced or indirectly, that can have effects on individuals, both on their well-being, their psychological, social, spiritual kind of impact that they feel, right? And so what one individual might experience as traumatic, another individual could have the same exact thing happen to them and experience it as not traumatic. So it's incredibly subjective. It's not something that I can decide that you have, just like how you can't decide if I've had it. Now when I talk about different types of traumas, these are just a few of them. So really it spans everything from child maltreatment and complex trauma, in other words, traumas that happen repeatedly, or a one-time acute event of trauma. If you're willing to, I'd love you to go ahead and throw in the chat other types of trauma that you're aware of, or perhaps that you've seen in those that all of you serve. So I'm seeing everything from medical trauma to accidents or illnesses, health care issues, domestic violence. Great. Thank you so much. Racial trauma, good. I'm seeing a lot of stigma, immigration, forced relocation, significant losses in grief. This is something that a lot of us, isolation. Great. Oh, you're brilliant. Perfect. So these are just a few of the categories of trauma, well, more than a few from what all of you are putting down. But again, remember trauma, much like crisis, is subjective. So if someone experiences something as traumatic, it's traumatic. Now one thing that a lot of you wrote about is this idea of intergenerational or historical trauma. Right? This is one that sometimes historically has been overlooked, right? So this is intergenerational or historical trauma is something that's been experienced by a specific culture, a specific collective community. And this quote, which I just love, comes to us from Yellow Horse Braveheart, who is a professor who really studies and talks a lot about this emotional wounding that kind of continues to extend across generations. And so with these types of events, trauma is held on personally and then passed across generations, so much so that even those who didn't personally experience the trauma, right, are affected generations later. Can any of you, much like you did before, think of some examples of intergenerational or historical trauma that you might have experienced? Or perhaps those that you've worked with have experienced, right? Who might, what groups or cultural collections of individuals have been impacted by intergenerational or historical trauma? All right, great. Oh, thank you so much for all of this. So we've got a list here of, goodness, slavery, pandemics, right? Like what we've just been through. Any kind of destruction of cultural practices, discrimination where we see genocide and slavery, right? Unfortunately, you know, these all have to do with incorporating the presence of trauma symptoms in groups, so much so that even if they weren't presently or physically present for the trauma, it carries this collective wounding. And oftentimes we find individuals or groups of people who actually identify with one another through these circumstances. And so this is something that, again, we want to have in the back of our minds as providers when we're thinking about attuning to the needs, right? And I'm seeing in here everything from natural disasters and ethnic cleansing, some of the things that we did around Japanese internment camps, even just verbal abuse, right? Substance use, right? Some of these, all of these can apply. Now what's interesting, I think, is when we actually focus on how might these types of intergenerational traumas be perpetuated today, right? And so one of these or one of the ways this can happen is with microaggressions, right? So microaggressions are these kind of like brief or very common verbal behavior or environmental indignities, right? And they can be intentional, but oftentimes they're unintentional, but they absolutely communicate hostile, derogatory, or negative slights or insults, particularly to those that have been marginalized in the past. And so the micro in microaggression refers to person-to-person interactions, whereas if we can also see this as macroaggression. And this refers more to like systemic racism where we really see institutional racism and things like this. You know, these are kind of those stings or barbs that really negatively impact our connection to others. It can impact our own self-compassion and certainly can lead to mental health issues, right? We also know that they can impact physical health. So some of these, and I threw a few terms in here, right, that you may or may not be familiar with. One of these is using endearments. So calling someone sweetheart or honey, right? I work a lot with some folks in Texas, right? And it's not uncommon for them to call me honey as we're talking, right? The problem is, is that it diminishes professionalism for certain individuals. And again, it probably is meant as an endearment, but unfortunately, you know, it certainly can make you feel less than, right? The idea of same behavior, different description. So this would be seeing someone maybe who is my gender. So someone who identifies as being a woman, being described as needy or too emotional or high strong, maybe someone being bossy, right? At times we might see this with people of color being labeled as being too aggressive, right? Whereas if we saw it in someone who was Caucasian or someone who had a different gender, you know, we might see them as being assertive instead. This idea of benevolent sexism. So if we've got maybe a woman who's a new mother, assuming that she doesn't want to travel anymore, but not doing the same for a new father. Or underestimating, you know, assuming that because of the way somebody looks, that they have a certain type of education or experience, right? Attribution bias. You know, this is something we all fall into, where we really attribute our successes to ourselves, right? And I've certainly fallen in this too, with the group of people that I work with. You know, if things go well, yeah, we pat ourselves on the back and say, go team. If things don't go well, then we blame others, right? We'll blame the failure on other folks. Well, it couldn't have been us, right? It had to be somebody else. These are just ways that our mind buckets things that accidentally might exclude individuals or make them feel pushed away. And it's important for us to really think about how this might impact those that we work with, in particular, you know, the clients or the patients that we serve, right? And so thinking about, you know, from the moment that someone schedules an appointment, whether that's being done online or they actually called and picked up and spoke to somebody, to when they show up for their appointment, meeting with their new provider, and that provider then makes a treatment decision. All along the way, our brains are constantly searching for cues about if an experience is positive or negative. And because our brains are constantly scanning for threat, any kind of significant slight oftentimes might make us feel pushed away. And when that happens, our brain can start to become flooded. Now, it's important in the context of historical trauma that we also recognize, you know, the disproportionate history of people of color, in particular, Black children with conduct disorder diagnoses, right? Black kiddos that even are in preschool tend to get kicked out and even expelled at much higher rates than their Caucasian counterparts, right? We tend to diagnose individuals, particularly Black men with schizophrenia or antisocial personality disorder, which correlates directly with higher rates of incarceration. We even look, if we were to take a step back and look at providers, you know, advocacy of Black psychiatrists like Charles Pinderhughes, who, you know, oh, goodness, 50, 60 years ago identified that, you know, Black or African-American applicants were less likely to receive grants for their research. And still, as recent as, you know, 15 years ago, 10 years ago, we still are finding that Black or African-American applicants are less likely to receive NIH funding compared to Whites, even after we control for differences in applicants' educational backgrounds, country of origin, training, prior research awards, publication records, and employer characteristics. This can date all the way back to some of our psychiatric diagnoses, specific to slaves, frankly, who misbehaved or fought for freedom. And later on, of course, mental hospitals and psychiatric diagnoses like schizophrenia that we've used. And so with this, I think it's important, you know, we've got these histories of trauma. You know, how do they impact ourselves and those that we serve? Well, the first part of this is remembering that memory and experience is never based on fact. And all I have to do is challenge you all to think about, have you had an experience growing up? Okay? Think about maybe in your family, if you had siblings or with a partner or a close friend where an event happened and you swear it happened a certain way, and your sibling or friend or partner just really believes it happened a different way, right? This happens to us all the time. And that's because perception is based on individual, right? The way we encode information goes through this lens of who we are. And so because of this, trauma absolutely impacts the way that we see things. Trauma shapes our beliefs, right? It impacts the way that we view our world, our connection to things outside of ourselves. And internally, you know, it can create a feeling of being unworthy or being unsafe, feeling intense fear or maybe having a need for power and control. So important to recognize that it really impacts the lens through which we interpret the world and how we encode things. We also now know that there's a physical impact of trauma, right? Both, you know, on how we might feel in any given moment because, you know, when the brain floods with stress or cortisol and adrenaline, what happens is that fight, flight or freeze response kicks in. And when that happens consistently, right, when I'm experiencing constant stress or constant trauma, what ends up happening is that we now have a nervous system that tends to get stuck in being on or being off, right? Now, it's brilliant. You know, our bodies are wired for stress. It's a normal part of life. And so is our response to it. The problem is, is that, you know, this beautiful physiological response that's hardwired into us is evolution's way of keeping us alive, right? So if a saber-toothed tiger comes after us, you know, we have this natural instinct to either, you know, fight, flight or freeze. But the problem is, is that when it gets stuck in on, so when I'm living in a constant state of stress or fear, what happens is, is that we really struggle with turning it off. And this really leads us to talk more about some of the adverse childhood experience study and things like that. The other part of this is recognizing loneliness. You know, right now we're living in an era where communication might seem more simple than in times of the past. You know, in essence, we're all an email or a text away. And even though communication can be easier and faster, its connection is still super complicated. And so because of this, and this, some of this research comes directly from the current U.S. Surgeon General, Vivek Murthy, recognizing that rates of loneliness have doubled in the United States. And this was pre-pandemic numbers, right? And so, unfortunately, the body actually experiences loneliness. This is that kind of subjective experience where you feel solitary, where even if you're surrounded by others, you don't feel like you can lean into them and share your suffering and lean into them for support. And so, I think that loneliness itself is a stressor on the mind and the body, and can be associated not only with cardiovascular problems, but with premature death. And so, I think that people who have experienced loneliness are less likely to achieve quality sleep. Matter of fact, I even read something that said that it's almost like smoking over half a pack of cigarettes a day, physiologically, on your body. So, I tried to really write some of the seen and unseen burdens that people bring into the room with them when they've experienced trauma. And that goes for not only just the patients that we serve, but those of us who serve as well, right? And so, I contend that even the worst behaved person in the room is trying really hard not to show what's just underneath the surface. And sometimes we can do that, and sometimes we can't, no matter how hard we try. And I remember before I was saying that for traumatic events, you know, our brain kind of goes into the alarm system, and the alarm system then releases adrenaline and cortisol. And so, I think that this can get stuck in the on position. And what I mean by that is that people appear hypervigilant, on edge, right? They can't really sleep very well. They might come across as being aggressive or anxious. And so, those are folks who kind of have a lack of affect, meaning they, you know, don't show a lot of emotion. Typically, they will sleep and have chronic fatigue, right? Kind of always be down, never having a lot of energy, right? Having a really hard time concentrating. So, this is what is very normal. This is what our brains and bodies are wired to do when we're encountering chronic and long-term stress or trauma. Again, when that traumatic event happens, we innately either go into that fight, flight, or freeze response. Now, this to me is one of my favorite slides, because it really helps us understand in some ways what's been happening to us during COVID. So, what you'll see on the side is the kind of on the left-hand side, that inverted pyramid. This is kind of the typical brain development. It's also where the energy to the brain tends to lie. So, you'll notice that a lot of the energy and blood flow goes to the cognitive part of the brain. This is the thinking part of the brain, right? Where we can, like, produce and do good work and be curious and all those things. It also goes to socio-emotional reasoning. This is in our limbic system. So, this means that, you know, when we're feeling good, we're able to kind of have a curious stance with what's going on inside of ourselves and also be able to be curious about what might be happening in somebody else, right? Like, hmm, I wonder why they look that way, or, you know, why do their tones sound that way, right? We try to kind of maybe come up with a little narrative about why people are doing certain things. And then to a lesser extent, our body system is focusing on regulating our physiological conditions, like our heart rate, you know, breathing, all of those things, and then finally our survival system. Now, when we're experiencing trauma, right, when we're experiencing stress, or if we have been exposed to developmental trauma or chronic stress, our brain, in essence, again, does exactly what it's wired to do. It flips. And that means that we get very little energy flow to the frontal cortex. So, it's really hard for us to be curious and unknowing, right? It's hard for us to work. We might have difficulty focus. Sometimes it can feel a bit like brain fog, okay? And then, as far as our socio-emotional reasoning, that curiosity I was talking about before, well, we kind of stink at it. In other words, we tend to not have a lot of curiosity about what's going on inside of ourselves. I'm thinking about my own mom voice that comes out at times where I say, like, you need to relax. And if, you know, my partner or someone says, like, well, you need to relax, too, and I'll be like, I am relaxed, right? That kind of, like, instant response that really doesn't match at all how we might be feeling inside. We also tend to really stink at being able to read what's going on within other people. So, when we're stressed, what ends up happening, or if we're in crisis, we tend to read other people, even if they're completely neutral, as aggressive. So, we tend to be a bit more judgmental when we're stressed, right? Or when we've experienced developmental trauma. And the majority of our blood flow and our development is focusing on regulating the body and ensuring those survival mechanisms that, you know, so that we can kind of make sure that we seek safety, whether that's fighting for it or fleeing from it or freezing. And all I have to do is think about what, you know, at times over the past year or so with the pandemic and social unrest, what it's been like for me. I don't know if any of you, but maybe you're writing an email, and then all of a sudden, you think, like, wait, what was I trying to say? Because you kind of are in that brain fog. Or maybe you go into the kitchen to get yourself a glass of water, and you walk in there and you think, like, wait, why did I come in here again? Or maybe you've had an argument with someone, and later on, you think that perfect thing you could have said or should have said, right? That perfect quip. The reason why you couldn't think of it in the moment isn't because of your IQ. It's because the energy flow of your brain isn't focused on cognition at that time. It doesn't go into longer term memory. It's completely focused on survival in those moments. So under stress, as I said before, the brain goes into this fight, flight, or freeze mode where everything else shuts down except for these primal response mechanisms. So one of the most important take home messages is, is that, you know, both we or those that we serve can't solve issues when we're in this stress response pattern. So what do we do when we're in this stress response pattern? Well, first of all, we need to do something about it. Because when somebody's brain is stressed, they really can't respond, learn, or process. What they really need to do is walk away, maybe do some grounding, anything to allow these chemicals to drain so that we can come back and talk when we're out of the red zone. And remember, particularly for those of us that we serve with clients that have experienced trauma, they're likely not going to be in the cognitive space to be able to process information or share information in a meaningful way until they feel safe and understood by us. And again, it's that developmental way of the way the brain is put together. We have to feel safety first, then we have to feel understood and connected to people, and then we can get into the thinking space where we can really make sense of the world. So I'm not going to watch this clip today because we don't have time, but this is something that we'll make sure that we get to you. This is Dr. Vince Folletti really talking about the Adverse Childhood Experience Study and how it came about in his bariatric clinic in San Diego in the mid-90s and what led to the Adverse Childhood Experience Study that he did with the CDC in the mid-90s. And so during this time, with the first Adverse Childhood Experience Study and certainly follow-up studies that have been done, is they screened an immense amount of people. These were, for the original study, over 17,000 adults. Most of them were middle-class, college-educated, employed, and Caucasian. These were people who had Kaiser insurance in the mid-90s. And they were looking to see if there was a correlation between these adverse childhood experiences, which, again, are relatively normal experiences, everything from trauma, such as verbal, emotional, or physical abuse, to having parents that were divorced or having a parent who passed away or had left the home or was incarcerated. A parent who might have, or substance use that might have happened within the home or mental health issues. And what they found was almost 70% of those that were screened had experienced at least one of those adverse childhood experiences. And over 20% had experienced three or more of these by the age of 18. Again, these weren't necessarily huge things. Now, part of this is they found, and certainly studies that have replicated this, have found that not only is it based off of environment, but also epigenetics. Epigenetics is that study of how our genes are turned on or off without altering the gene code itself. And so what we have found is that trauma, we actually know what gene to look for. Trauma is passed from one generation through the next in our genes. And so that means that a traumatic event, say, for example, like the Holocaust, then modifies genes that then is passed on to future generations. And numerous studies have cited that we see this genetic expression in at least six generations. And so some of this have said, with the stressors around COVID that we've experienced in the past year, we expect to see that in the next five to six generations of those of us who have lived through it today. Pretty profound. What the Adverse Childhood Experience Study also found, and what follow-ups have confirmed, is that there's a dose-response relationship between adverse childhood experience score and many health outcomes across the lifespan, including smoking, obesity, and heart disease. And this dose-response relationship is really important for public health because it ultimately tells us, hey, disease is not randomly distributed. It tells us that a particular group of people are at risk, and so learning to understand who's at risk and under what circumstances holds a lot of promise for helping us to reduce costs and, of course, suffering in the future. And it really helps us to get an understanding of the level of risk, right? So this dose-response relationship means that when you have a bigger dose of adverse childhood experiences, then there tends to be more disease. And what the population has a bigger dose of disease, what we end up finding is earlier death. And so those with three or more of these adverse childhood experiences are said to die 25 to 35 years earlier than the general population. And this is really profound for us to think about both, you know, for primary care clinicians, for, you know, those of us in social services, it's recognized, particularly with addiction, right? As a young clinician, I remember wondering, you know, working with people who are struggling with substance use and wondering, well, why is it that some people can go cold turkey, right? Whether it's quitting smoking or drinking or using substances, whatever it is, how come some can do it and it almost seems easy in a way, right? That the first time they try to stop, they're able to. And others, it takes 8, 12, 15, 25 times. Now, part of this is us starting to understand these adverse childhood experiences. And the more trauma that individuals have experienced, oftentimes the greater dose of disease and the harder it is or can be to adapt and to treat and find recovery. And so these are some of the lifelong outcomes that are linked to these, particularly focusing on inflammation pathway for major chronic diseases. Remember earlier I said that our nervous system can kind of get shut in that on or off position. That means that we constantly are having cortisol released in our systems. When that is happening consistently over a period of time, this actually creates inflammation within our brains, within our bodies, right? And inflammation really appears to be a common denominator in the pathway to many chronic illnesses. And so we want to see that, you know, kind of the keys and the steps that this can really play out, of course, so that we can intervene. There's also this very connected relationship between trauma and substance use, right? So those who are using substances might be less able to cope with a traumatic event. And thus, they might actually, you know, use substances to cope with that event, which then can lead to another traumatic event and so on and so forth. This is where we can really spiral out of control. Gamor Maté, who this quote is from, just released a new documentary that you probably will be able to find online. I know he was offering it free online if you're looking to watch something good about the wisdom of trauma. But really recognizing the ongoing research and studies in neuroscience that show that both trauma and addiction are connected, right? And that unfortunately, a lot of people who use substances are using it as a way to take care of themselves, right? It's a way for them to feel relief or to change the way that they're feeling. And all of that desires or fuels addiction, right? And so I love this slide. I love this slide. So thinking about, you know, some people might use substances. And this is a question I usually ask when I'm treating someone, you know, what is good about it? You know, what have you found helpful or what do substances do for you, right? So recognizing, you know, why people might use and also recognizing, you know, what they're trying to avoid. You know, some people actually often feel worse when they're not using substances, right? This can also lead particularly for those of us who've experienced chronic trauma that might feel like a danger zone within ourselves. It kind of can make feeling out of it feel safer than being in it, right? We also often find that when you use substances, it can kind of release adrenaline. Same with some self-destructive behaviors that we might find out there releases these endorphins or other mood enhancers so that we don't feel as much pain, right? Or that sense of being in control. Also, maybe, you know, oftentimes with trauma, it can make you feel remember we were talking about that lens with which we view the world. Trauma can make you feel less than or worthless or damaged. And using substances can kind of somewhat create an alignment for us. You know, the more self-destruction we might be, it, you know, it can feel like we're living in alignment with who we truly are. And while it's completely false, it can reduce feelings of otherness or disconnection. Shame is certainly a huge piece for those of us that are struggling with addiction, right? And it's certainly something that unfortunately, historically, we have not been very good at managing, right? So instead of shaming someone, what if we embrace them in a new way, a more compassionate way? You know, again, it's about creating connection versus assuming fault. And all of this is connected to that idea of adverse childhood experiences. So let's talk about some of the practical takeaways that we really can take. One of them is we really want to have a parallel process. We want to model desired relationships between ourselves and others, right? We want to create, you don't have to be a therapist to be therapeutic, right? We want to create healing relationships because we know the number one protective factor for crisis, for stress, or for trauma is having another individual that can help you make sense of the world, someone else you can lean into. So that's really our task at hand is how can we create and embody safe and healing relationships where we can try to understand each other and meet each other where we're at. Also the idea of cultural humility. Back when I was in training, we talked a lot about cultural competency, right? Now we view it as like that's not really realistic, right? How could I ever be competent in every single person's individual experience of life and culture? And so the idea of cultural humility is really recognizing and being committed to lifelong reflective learning, be able to kind of look outside of ourselves with the critical eye for seeing, and in a humble way for saying, you know, how can I learn more about this? What is your experience like? Making sure that we're trying to partner in ways with folks that recognizes and challenges power imbalances when there shouldn't be any, and how we can have accountability, right? You know, the whole idea or goal of cultural humility is to have a sense of equity and equality and respect that drives us forward. We want to have universal expectation, right? So coming from a place where we're just going to assume everybody has been traumatized, everybody is having the worst day ever, right? And so if we take that approach, we really can program for those of us that are hurting the most, right? What if we were to create systems, engage with people, assuming, you know, that they're experiencing the most amount of trauma? Therefore, we have to be the most healing, supportive, and empathetic selves that we possibly can be. And we do this by trying to listen to each other, right? Attend to distress that we might be seeing, be open and involved with others, particularly around, you know, what people's wishes are. I can't tell you how often it is that I've, you know, worked with people that might be given medication by their treating providers when, you know, they're not, they don't have any interest in taking medication, right? Or vice versa, you know, maybe they're seeking something and their provider might not, you know, really realize what stage of change that they might be in, right? So recognizing that motivation levels ebb and flow, and it's our job as providers to really attune to what those are. And that part of that process is honoring voice and choice, right? Asking for feedback, seeing how things are going, even ending a few minutes early to get feedback from folks, like, how did that go today? Any concerns? Any moments where you might have felt pushed away? Anything I can do to make it better? A lot of this has to do with empathy. Again, here's another short that I included from Brene Brown's work around, you know, what it means to be empathetic versus kind of silver lining situation. You know, as not just an individual practice, but as an organizational practice, you know, us really standing back and looking if we might be accidentally excluding anyone, you know, is there a way that we can simplify any of our client-facing forms or documentation or what's on the internet, you know, online? You know, how much are we orienting people ahead of time before they even show up for their appointments? And do we ever practice, you know, looking at our waiting rooms and seeing if we're fostering safety? Are we fostering psychological safety for those of us who work together? Looking to see if there's moral safety and cultural humility and constantly doing a continuous quality improvement on these. So it's not just a one and done, but we're constantly relooking for these and asking for feedback. Being really aware of the words that we use, right? We want to stop using some of the words that are on the screen to describe people or clients or staff and recognize that people are doing the best they can with what they have. You know, when we use language like this, it separates us and dehumanizes those that we treat. And because we really want to approach everyone through mutual respect and compassion, we want to challenge this. And a lot of us might not have had a lot of training in substance use disorders, right? And so constantly seeking out ongoing training, you know, heuristics, words change over time, right? And so the idea of being an addict, right? Those words really no longer should be used. You know, we might want to think about how we conceptualize and what terminology we're using, because what it might implicitly reflect and influence how we think about and approach substance use disorders. Oftentimes looking at, you know, what is the most stigmatized, right? And oftentimes it's addiction, it's schizophrenia, it's personality disorders, right? And how are we, you know, really challenging any bias that we might have around those areas and making sure that we're getting clinically and research informed training. You know, there's something, well, there's a lot to be said about getting continuing ongoing training and working with those that are in recovery. You know, this really gives us good ideas that it absolutely is possible to recover and to have immense quality of life for those of us who've struggled with some of these issues. Also, you know, a lot of the training, unfortunately, that we get are focused on, you know, how we can impact the brain as far as like thinking about problems and thinking through problems. Well, that goes against our understanding of trauma, right? CBT is wonderful if you're in an action stage of change, but unfortunately, if you're not, right, if maybe you're in more of a pre-consumplative state of change, where you don't really think you have a problem, it's not going to be very helpful. So making sure that we're using interventions that impact the lower brain, interventions that are repetitive and rhythmic, you know, that really are resonant with neural patterns that we're focusing on rewarding the brain and on relationships. All of this important for us to recognize, you know, this idea of screening for trauma. You know, if we do, if we decide that everyone has experienced trauma from a universal perspective or universal expectation place, that's great. If we do decide we want to screen further for trauma, we want to think through what those clinical pathways are, right? A great way to do this as well is making sure that we're doing, you know, SBIRT, right? Public health systems of care is that routinely screen for medical problems. You know, making sure that we're actually not just doing the screening, which I think a lot of places do, but this isn't like screening to see for blood pressure issues, right? This is really what's some of the more important pieces of this are, is the brief intervention and the referral to treatment. So making sure if you are doing SBIRT, that you are having staff who are trained in how to do the intervention and the referral to treatment that's focused and based off of where the individual might be in the change process, right? Looking at some of these screening tools, everything from the audit to the assist, which is one of my favorite. If we're using a PHQ-2 or a PHQ-9 that, you know, we're actually making sure that if we pop a positive screen, that we have a clear clinical pathway versus kind of feeling, oh my goodness, what are we going to do with it? Normalizing the impact of trauma. So do we have posters up and now we're in this virtual world, you know, what does it show on our websites? Are we normalizing the fact that people are experiencing trauma? And of course, the impact on ourselves, all of this stuff about adverse childhood experiences, it doesn't just relate to me, it also relates, or I'm sorry, to clients. It also relates to me and you, right? The adverse childhood experience study definitely did not discriminate between, you know, you know, clients versus providers. So how are we taking care of ourselves? This is oftentimes the first step towards creating a culture of compassion, is to prioritize wellness at the individual level, so personally, and not having it be something that we, you know, feel like we're treating ourselves, right? But something that is related to survival. And then professionally, you know, what are we doing as far as prevention in the workplace and during the work day? This is on individuals as well as organizations. And thinking about how every day we can have this daily translation of trauma-informed, resilience-oriented, and equity-focused care, right? Remembering that, you know, we're all just trying to survive. Oftentimes, we, you know, might observe things that can make us feel pushed away, that are likely misplaced coping strategies, and recognizing that, you know, leaning into each other, being able to create connection, is probably one of the most healing activities and interventions and techniques that we can use. Before I open up, if we're able to do any questions and pass it over to others, I also wanted to note some of the resources that I have on here. So we've got a bunch of principles, not only resources that we've put together here at National Council, but also some really compassion-resilience toolkits, the SAMHSA free trauma-informed tip book, which you can download for free today, if you want to. With that, I want to pass it back over to you, Casey, and you can let me know if we've got time for questions or anything else that we can do. Yeah, it looks like we do have some time for questions. Thank you so much for your presentation. It was so interesting and engaging, and it's really great to see everyone, you know, agreeing with you in the chat and like learning so many new things. We have a few questions here. One of them is, how would you suggest breaking the cycle of perpetuating and reliving trauma, being professional care providers and not bringing it into our personal lives? I'm sorry, you cut out for a second. Could you say it one more time for me? How can we? Yeah, no, no. I think it was on my end. Go ahead. How would you suggest breaking the cycle of perpetuating and reliving trauma as professional care providers and not bringing it into your personal life? Right. I think doing, you know, some of those ingredients or the recipe for creating a culture of compassion, right? You know, when I first started in the field, I always kind of had this really silly thought that like, oh, wow, these therapists or these psychiatrists, like they were like gods, like they just seem like nothing would ever impact them. They always were cool, calm and collect. I have to tell you, after being in the field for over 20 years, like that's baloney. Like we're people, too. Right. So I think us normalizing, talking about it, that that burnout absolutely can happen and really normalizing how to take care of ourselves, whether that's building habits together for, you know, instead of kind of like eating at our keyboards during lunch while we're trying to write notes, you know, actually, you know, closing the computer and getting outside, going for a walk. You know, these things are seem silly and small. And honestly, for me, too, they're the first things to go when time gets tough. But it's engaging in these activities that actually make us more resilient and are immense barriers to trauma. So if we can make sure that we're able to stay in that kind of like green zone and not be in fight or flight ourselves, that's the number one way that we can make sure that we're able to do it for those that we serve. Great, thanks so much. Going back to a little bit more client facing, would you recommend using motivational interviewing with clients with trauma and SUD or any other tools? Yeah, I think that there's a lot of them. I think motivational interviewing is fantastic. It's also something that like I don't think you can ever have enough training in because we all get caught up in stuff at times. But I think that there's some other really great methods out there, especially thinking about the way that trauma works. So somatic experiencing type of treatments, I think, are really helpful. I also just love the idea of mentalization based training. I'll put it in the chat so you know what it is. This is something that's really big in Europe and the UK. And there's little pockets across the country, usually academic centers that are doing it. But it's a wonderful way of trying to create that curious and unknowing stance and then try to stimulate that within the client. And that's a wonderful technique because it really is helping them to kind of do those building blocks of brain development so that they're able to get out of those places of threat and into understanding. So eventually, they're able to create more tools for themselves. Great question. Great, thanks so much. I think we have time for maybe one more. With COVID-19 stabilizing in the US, are there any local, state, or federal policies that may take into consideration mandatory or recommended trauma-informed work for consumers and employees in the workplace? Yeah, and I don't know if I know that I might have some colleagues on here. So Casey, if you or Erin have any thoughts in addition to what I'm going to say. But I think that there are enormous innovation in this that we're seeing in states and cities across the country. Agencies like PACE's connection, I don't know if any of you, I'm going to put that in the chat as well. If you just Google PACE's connection, they're nationwide and they're doing amazing efforts. Even before the latest administration took office, they were sending them a bunch of resources and an open letter to require trauma-informed training for all individuals in school systems and citywide communication. I, myself, and some members of my team are working across the country with different cities and states on how to be trauma-informed, how to be recovery-oriented, whether it's for people who are driving trains and buses to environmental services to care providers. Erin, did you have something that you wanted to add on to that? Yes, I would just plug that we are at the National Council for Mental Well-Being, also are conducting a lot of work around our trauma in terms of our health equity and social justice project, ECHO, learning communities that we're running under our Center of Excellence for Integrated Care. So we're doing some work in this regard there, working with providers to help them as they think about some of these issues as well. So I would just kind of plug that we're kind of doing that work in some learning communities already, too. And we plan to continue that work going forward. And I would say that both Erin and I, don't hesitate. I always used to be scared when I go to trainings, like, oh, I don't email the person who does the training. Don't hesitate. If this is something that is making your mind sing and you want to learn more about it, please feel free to reach out to us. We're always happy to link you to resources and other great stuff that's going on in the field around this. Great. Thanks so much for always being willing to help and share your experience and knowledge. Unfortunately, that is all the time that we have for questions today. So thank you again, Amy, for stepping in and presenting today. As a reminder, the recording and slides will be posted on the PCSS website within two weeks from today. And there's also a couple of resources offered through PCSS that may be of interest to you. First is the PCSS Mentor Program, which offers mentoring assistance to anyone in need of more one-on-one interactions with a colleague to address clinical questions. And you can either request a mentor from the directory or PCSS will pair you with one. Next is a discussion forum comprised of mentors and other experts in the field who can help provide prompt responses to clinical cases and questions. A mentor on call each month can answer and address any submitted questions through the discussion forum. Next is just a list of the consortium of lead partner organizations that are part of PCSS. And finally, the PCSS website contact info and social media handles are on the next slide if you want to find out a little bit more about the resources and trainings offered today. So thank you all again for joining, and we hope that you have a great rest of your day and week. Thank you, everybody. Take good care.

What Clinicians Need to Know About Trauma

Providers Clinical Support System

PCSS

National Council for Mental Well-Being

Dr. Amy Rushline

trauma-informed services

trauma and substance use disorders

engaging individuals with substance use issues

Adverse Childhood Experiences study

trauma-informed care