Giving Trauma It’s Due in Education, Diagnostic, and Treatment Processes: The THEN Effort

Giving Trauma It’s Due in Education, Diagnostic, and Treatment Processes: The THEN Effort

Many years ago, an integrative colleague and adviser – my spouse! – explained something to me about an important part of her lengthy integrative intake process. The time is needed to build trust to have the patient divulge what is going on at the time a chronic condition set its hooks so that the freeing might commence. The past half-century was witnessed a slow, cultural recognition of the power of trauma in micro and macro ways. The “shell-shocked” of WWI became, post Vietnam, a potentially actionable PTSD. The women’s movement opened the lid on pervasive sexual abuse, emotional abuse, and rape. Adverse Childhood Experiences (ACES) emerged as powerful determinants of life chances and choices. George Floyd’s murder ripped open reckoning on police battery, slavery, Jim Crow, red-lining, and mass incarceration.

The reductive predilections of organized medicine quickly answer why U.S. health care has not appropriately granted these forces the power they warrant. In Chicago, a multi-disciplinary set of professionals has created The Center for Collaborative Study of Trauma, Health Equity and Neurobiology (THEN Center) to connect the pulses of how what was THEN is here today – haunting, harming and debilitating – and ways we may go forward.

The home-page of the project, an educational program of the Hektoen Institute, advertises its mission of providing “Free Science Education” – scientific references, books, and videos. (See an intro video here.) The goal is to enter the fortress of the academy through the portal that it recognizes: “We invite you to learn this profound science and embed it into your theory, teaching, clinical practice and research.”

Rush, Stillerman, Cohen and Weber

I was introduced to two of THEN’s co-founders via a good friend, Linnea Larson, LCSW, RYT, a Chicago-based member of the 1999-2002 White House Commission on Complementary Medicine Policy. Audrey Stillerman, MD is a board-certified integrative family physician that Crain’s Chicago has honored as a “Notable Woman in Health Care.” Stillerman presently serves as associate director of medical affairs for the University of Illinois Office of Community Engagement and Neighborhood Health Partnerships. She is also a Clinical Assistant Professor there. For 40 years, Patricia Rush, MD, MBA has focused on underserved populations and “complex, chronic conditions.” A fellow of the American Academy of Medical Acupuncture, her approach led Rush to develop, 20 years ago, a trauma-focused clinical approach she dubbed “Primary Care Plus.”

Their co-founders are Mardge Cohen, MD, whose background includes co-founding the Women’s Equity in Access to Care and Treatment to facilitate HIV primary care for women infected after rape during the 1994 Rwandan genocide, and Kathleen Weber, RN, MS, a co-investigator and project director of the NIH Women’s HIV Study in Chicago. The 4 are supported by an Advisory Panel that includes a clinical neurobiologist, an medical school assistant provost, an MPH, a psychiatrist, a community engagement expert, yoga therapist, a pediatrician, social worker, and experts in interdisciplinary and team collaboration from diverse racial and ethnic backgrounds. The combination of academic position and social action activism is a running theme in the short bios. The importance of the appetite for activism is in the transformational goal embedded in this portion of THEN’s statement of mission:

Inspire the creation of an expanded medical model focused around neurophysiology and Brain-Body regulation.  We feel this is especially important for the many people with both complex physical disease and a history of complex emotional trauma. Treatment plans based on the new medical model would go beyond “controlling” disease to build patient-clinician partnerships including foundational Brain-Body regulatory processes (sleep, emotional peace, supportive relationships, exercise, and more) with an emphasis on prevention.

Stillerman and Rush speak to the increasing attention these linkages are receiving around the world: “We’ve met a lot of people, including people not in our field, who are thinking along these lines.” They are connected with involved parties in Australia, New Zealand, Japan, Germany, the Netherlands and elsewhere. Then they add: “Not so much here.” Why? Their speculation quickly flowed, touching on classic elements of shortcomings of the still mainly fee-for-service incentive structure and trend toward extreme sub-specialization of the U.S. medical industry:

The U.S. is so devoted to the reductionist paradigm. There is the tremendous impact of the pharmaceutical interests, especially of psycho-pharmaceutical medicine –  the pressure to follow an algorithm, quickly assign a diagnosis, and treat.

Rush encapsulated her response to twenty years of trying to fit her increasing awareness of complexity into the model in medicine’s dominant practice model: “This is why I took a leap in starting over.” She began her Primary Care Plus approach. Her co-founder Stillerman’s move toward integrative medicine may be framed similarly: “The [US] healthcare debacle is one piece of the Neo-Liberal disaster. It’s all about making more, and faster.”

Yet at the same time they are finding “all kinds of pockets of people” in the U.S. who are involved with similar clusters of ideas yet are not yet connected. They note centers looking at how racism changes the brain. Harvard has a center for systems biology examining links between trauma and diabetes and depression. Many are looking at the mind body disconnect that leads to suicide and damaging morbidity.  Others are exploring how multiple mind-body approaches care making a difference that pharmaceuticals can hospitals are not. Said Rush:

Part of our work is to create networks – common conversations across a core of topics and then build a set of principles across these fields. Our job is to translate the science so people can see the commonalities so we can begin to have a different conversation.

THEN’s group of educator-clinicians has thus far reached an estimated 6000 professionals through their various grand rounds, seminars and educational programs. While most have been in the upper Midwest, they have traveled to present at Penn State, Emory and for the American Osteopathic Association’s annual meeting. In 2017, Rush presented on their work at the Integrative Medicine for the Underserved conference and Stillerman presented at the Academy of Integrative Health and Medicine.

The team has made efforts to directly storm the citadel armed with commonsense, logic, and science to insert learning about trauma, neuroscience and a need for new practice models directly into curriculum. At least two medical schools have rebuffed their overtures. Rush captures the essential learning: “Most medical schools don’t have anything about this in their curricula. This is still considered an outlier. The content is an elective, at best. This needs to be a very long-term strategy.”

These frustrated efforts birthed a radical strategy that takes them directly the the demographic that is most aware and open:

We’re going straight to the youth.  That’s why we’re developing a social media strategy.  We are also offering mentoring.  We give them science articles and case studies which demonstrate the Brain-Body connection.  We talk about regulation and dis-regulation, about signaling, and how signaling gets disrupted by trauma.  We share the simple kinds of things that can make a difference and enhance physiologic regulation – restorative sleep, knitting, a regular routine including communal meals, singing, sitting in nature, belonging to a church choir and other positive, relational activities. A key component of our teaching is Reflective Practice – asking them to consider how this new science compares to what they are being taught in school. They begin to see it. A light bulb goes off once they see it.

Embracing the central role of trauma as core concern is deeply challenging, even for the young medical students they are targeting. Says Rush: “This learning without including the Brain-Body connection can make their education seem fraudulent. This thinking can give them vertigo. I ask those I am mentoring ‘how much vertigo are you having and how can I support you in weathering it?’”

“Life experience is the supreme influencer”

While Rush and Stillerman are each respectful and appreciative of functional and integrative approaches, they note that these are often heavy on nutrition, and even on the green pharmacy of supplements, to the exclusion of other things. They acknowledge that topics such as the gut-brain interaction gets into parallel terrain. Yet they add: “They can go deep into nutrition, for instance. But what I haven’t seen is an acknowledgement that life experience is the supreme influencer.”

If the young are one demographic where they find low-hanging fruit for this approach, the integrative community may be another, especially in this moment. Multiple complementary and integrative health organizations have indicated commitment to make changes to address racism in their own fields, as I explored here and then here. A sign of action from the Institute for Functional Medicine (IFM) this week on such commitments suggests that THEN’s message may find openness in these communities. The all white board of directors of IFM followed up on its declaration of an intention to make substantive changes by announcing the addition of two new members of color, award winning social change agent Gail Christopher, DN and wellness lifestyle executive David Harris.

Might developing continuing education and webinar programs on THEN’s themes, targeting the tens of thousands in these multiple organizations, be a pleasantly fruitful early portion of their long-term change strategy to give trauma the place it unfortunately merits in clinical approaches?

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