August 18, 2024 • 33 mins
08/18/24
The Healthy Matters Podcast
S03_E20 - From Hurt to Healing: The Power of Being Trauma-Informed
Today, we're diving into a topic that's crucial but often overlooked: adverse childhood events (ACEs), and trauma-informed care (TIC). According to the CDC, nearly two-thirds of all U.S. adults have experienced one or more ACEs. That’s how common they are, and the effects of these adverse events can add up over time. Many of us may not realize how deeply early experiences of stress, neglect, or trauma can shape not only our mental health but also our physical well-being. These early events leave a lasting imprint, whether through relationships, behaviors, or even how our bodies respond to stress. The good news? There's a growing movement toward trauma-informed care, which shifts the focus from asking 'What's wrong with you?' to 'What happened to you?' It's about creating a supportive environment that fosters healing and resilience.
On Episode 20, we’re talking about different types of traumas, and how trauma-informed care is a unique and very effective approach to help people get through the toughest times. Joining us is Dr. Mitch Radin, he’s a Clinical Psychologist and an expert on trauma-informed care at Hennepin Healthcare. We’ll cover the elements of TIC, how they work, and how this approach is making a difference not only with patients but also with healthcare professionals. Did you know you can control your heart through your lungs? Or have you ever heard the analogy that your brain is like a rider and a horse? We cover both of these things too!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to the Healthy Matters podcast with
Dr. David Hilden , primary carephysician and acute care
hospitalist at HennepinHealthcare in downtown
Minneapolis, where we cover thelatest in health healthcare and
what matters to you. And nowhere's our host, Dr. David
Hilden.
Speaker 2 (00:19):
Hey, everybody, it's Dr. David Hilden, your host of
the Healthy Matters podcast.
And this is episode 20, andwe're gonna talk about
trauma-informed care withclinical psychologist Dr. Mitch
Radden . Mitch, thanks forbeing on the show.
Speaker 3 (00:31):
Thanks for having me. It's
Speaker 2 (00:32):
Great to have you here. And we're gonna talk
about trauma-informed care, andso I'm gonna ask you to help us
out with what that is. Myunderstanding is that it's a ,
it's an approach that recognizeand responds to the effect of
trauma in people's lives, andthen how we respond to that in,
in their healthcare . I've beenwell aware of your interaction
with our patients and ouremployees as we care for our
(00:56):
communities . Could you startus off and just give us, in the
most basic level, what istrauma-informed care?
Speaker 3 (01:04):
That is a great question, and it sort of
depends on who you ask. So whenyou think about trauma-informed
care, what you're reallytalking about when you break it
down to its most basic elementsis this kind of framework to
engage in a state ofmindfulness as you're moving
through your day. So what we'redoing is slowing people down a
(01:25):
little bit when we organizearound trauma-informed thinking
to move from a place ofreactivity to a place of
responsiveness and intention.
And that's mostly just slowingpeople down to consider
context. So we're not justlooking at a behavior, we're
looking at what might bedriving that behavior.
Speaker 2 (01:43):
So what do you mean by trauma?
Speaker 3 (01:44):
So trauma is a very complicated word these days
because it's thrown out in alot of different contexts ,
isn't it , though ?
Speaker 2 (01:51):
It really is. You know, I don't know. I haven't
had , I haven't been in a caraccident that that sounds like
trauma. Is it psychologicaltrauma? Is it your life
experiences? What
Speaker 3 (02:00):
Is it? Right? There are three different kinds of
trauma. There's the acutetrauma, which is typically what
you see following a car crashor an assault or a gunshot. So
what that is, is an event thatoverwhelms somebody's already
developed ability to cope, andsort of throws them into a
space of helplessness wherethey're unable to respond in a
(02:20):
way that gives them any senseof control. Often that's
associated with a sense of fearfor one's own bodily integrity
or life. Um, so it's a reallykind of life shattering moment.
The easiest definition fortrauma, when you think about
it, when you break it down andkind of understand how it
impacts people, is it's anyevent or series of events that
(02:42):
overwhelm somebody's nervoussystems ability to make a
distinction between past andpresent real threat and
perceived threat. So whensomebody is activated into a
state where they fear for theirlife, the system gets stuck
there, unable to make adistinction between past and
present. So everything nowfeels like a threat,
Speaker 2 (03:03):
But isn't it, if you, if you're experiencing
some, some pretty traumaticthing in your life at this
moment Mm-Hmm. ,physical, emotional,
psychological, whatever that isin your life, isn't it normal
or isn't it common that youmight feel very at a
fundamental like cellularlevel? I feel unsafe,
Speaker 3 (03:20):
Yes. Because you are unsafe in that moment, and yes,
it is . That's the thing Ithink that gets really
complicated is that it is acompletely normal response.
It's an appropriate responsefor the way the brain and body
is impacted in a context likethat. Where people get stuck is
that they feel crazy becausethey feel out of control. They
feel like they're unable tomanage the world in ways that
(03:43):
they used to be able to. Andthat's where this turns into a
more complicated bag . You havesome people who experience
something really overwhelming.
They may have a period wherethey feel overwhelmed, but
return to a state of baselinewhere everything sort of goes
back. For some people, thenervous system is just hit in a
different way. That's when thetrauma sort of lives devoid of
(04:05):
space and time. The eventcontinues to recur in that
person's mind and their body asthough it's happening all over
again. So instead of it being amemory, it's a relived
experience.
Speaker 2 (04:16):
Oh, that, that is, that is helpful. So is that
what we mean by chronic trauma?
Speaker 3 (04:21):
Right. So when we're talking about the three
different kinds of trauma,there's, there's the acute
trauma, which is the singularevent. There's the chronic
trauma, and then there'scomplex trauma. Chronic trauma
and complex trauma are prettyhard to parse out when you've
got the chronic trauma. Whatyou're really looking at are
experiences where people are inan environment or in a
relationship where there's anongoing threat. So it could be
(04:45):
a child living in anenvironment where there's child
abuse, could be physical, itcould be sexual, could be a
domestic violence situation. Itcould be a situation where you
are working in a hospitalsetting and chronically exposed
to people who are , uh,engaging in really threatening
behavior, or for people who'vebeen assaulted , uh, multiple
(05:06):
times.
Speaker 2 (05:07):
I think of that a lot, that part in our own
workplace, not only for ourpatients, but the people who,
who work with our nurses. Yep .
Um , paramedics things, thingslike that. People who are
experiencing trauma as they'retrying to help others who are
living with these complextraumas. We're gonna get a
little bit later, I hope, Yep . Into the basic
(05:28):
tenets of trauma informed care.
But before we leave this kindof foundational discussion,
what do we know about thecumulative effects of trauma
throughout someone's life? Andnow, a lot of people have heard
the term adverse childhoodevents . Adverse childhood
experiences. Yep . Can you talkabout that?
Speaker 3 (05:44):
So that's where you start to get into the more
complex trauma piece of it. Soyou've got the chronic trauma
where it's like a singular kindof trauma from a one singular
individual typically, or asingular environment. With the
complex trauma, what you'relooking at is a really
complicated set of experienceswhere people are living in an
environment where threat isalways present in some way. It
(06:05):
could be neglect, it could beviolence , uh, it might be
within the home. It might alsobe in an environment where
somebody steps out the door andis feeling unsafe. So the
adverse childhood experiencesstudy started to look at
trauma. This was back in theearly nineties, and it was done
at Kaiser Permanente Hospital,and I think outta San Diego at
the time. And they did aquestionnaire of about 17,000
(06:27):
people, most of whom werewhite, most of whom were middle
class , and people who all hadinsurance. So this is like a,
Speaker 2 (06:35):
That's a subset of the world.
Speaker 3 (06:37):
Yep . . What
they found, however, is that of
those 17,000 people, a hugenumber of them had at least one
adverse childhood experience. Asurprisingly large number had
two or more. And there was asignificant number of people
who had four, six or moreadverse childhood experiences,
which I'll explain what thoseare in a moment. What they
(06:58):
found is that people with moreadverse childhood experiences
had significantly more complexhealth issues and significantly
worse outcomes when trying tomanage their health issues,
Speaker 2 (07:12):
Physical health issues,
Speaker 3 (07:13):
Physical health issues. Yeah. So what adverse
childhood experiences are they?
So they did this questionnaire,I think it was 10 questions,
and they looked at things like,did you grow up in a home where
there was physical abuse? Wasanybody in your home ever sent
to prison? Uh, did you witnessphysical abuse in the home?
Were you exposed to neglect?
That kind of thing. So all thethings that you might think
(07:33):
about as far as like childhooddifficult experiences in a
family. So when people thinkabout trauma often, and they
think about that more complextrauma, they don't typically
think about it in terms of theeveryday individual that they
run into. They might thinkabout it more in like a, you
know, either you are working ina job like as a first responder
(07:53):
where you're exposed to allthat stuff, or you are growing
up in an inner city environmentwhere there's a lot of violence
and that kind of thing.
Speaker 2 (08:01):
I think of my, my wife Julie is a high or high
school. She's an elementaryschool social worker. And every
day of her life, she had tolocate some of the children
because they're living inunstable housing. Um, she had
to send taxi cabs to abandonedbuildings to locate children
who were experiencinghomelessness. Uh, and, and a
(08:22):
lot of these kids were facingexactly what you've just said.
Um , all of those things thatyou might imagine aren't
healthy for a , a developingchild. So my question to you
is, how does that affectpeople's mental health, their
physical health, theiremotional health, not only in
childhood, but even all the wayinto adulthood?
Speaker 3 (08:40):
That's a really complicated question in that
it's not only adverseexperiences that happen in
childhood that change the waythat our bodies and our brains
operate, it's also adverseexperiences that happen as
adults. So as children, youknow, our brains are
developing, our nervous systemsare developing. All of our
(09:01):
hormones are starting to kindof do what they need to do to
make us grow trauma, or livingin those kinds of environments
where you're chronicallyexposed to stress is an
inflammatory experience. Thewhole body is trying to respond
to a chronic state of threat. Iwon't go too much into the
nervous system stuff, but youknow, we like to think that our
(09:21):
brain is the primary source ofour ability to manage stress.
In fact, it's not of the nervefibers that go from brain to
body and body backup to brainthat dictate how stressed we
are, how calm we are. Give usinformation about the world.
Only about 20% of those nervefibers go from brain to body.
80% go from body to brain. Soif you think about it, your
(09:43):
brain's just in this littledark box getting information
from all these sensory nerves.
And our brain is then trying tomake sense out of that
information. So what happensis, under the right conditions,
that body and that brain arecommunicating in all the ways
they need to communicate toassess the world in all of its
goodness, all of its badness,and learn from it. But under
(10:05):
conditions where there'schronic threat or somebody's
physical wellbeing ischronically under threat, that
body is constantly activatedinto that stress response where
the body is sending a signal tothe brain in a really
consistent way that something'swrong, something's not okay. So
instead of that prefrontalcortex being online, that part
(10:27):
of us that is super intentionaland tells us where we're gonna
go, how we're gonna do it, bereally thoughtful about things,
our limbic system gets lit up,that fight or flight part of
our brain, that part thatattunes us to threat and
promotes a kind of reactivityto the world, because it's not
appropriate for me to bethinking about how beautiful
the leaves are in the treeswhen I'm being chased by a
(10:49):
bear. So if the bear is aroundevery corner, it becomes harder
and harder for my brain to justslow down and think about
everything around me. I'mconstantly scanning the
environment for threat. Andthat doesn't always happen
along, you know , unconsciouslevels. It happens very much on
an unconscious level becausethe body is hyper attuned to
(11:10):
scan the environment forthreat. And so the way the body
and brain start to developstarts to shift, if you show
images, brain images of a childwho's been significantly
neglected as compared to achild who is growing up in a
healthy, loving, safeenvironment, what you see is
(11:30):
almost no activity in theprefrontal cortex. It's almost
all dark of the, of thechildren, of the children who
are neglected neglect . Andwhat you see is that that
limbic system is pretty lit up.
That midbrain part of it,that's that part that's always
like , lit up to be , how doesthat child learn? Then they
don't in school. They don'tlearn at the same rates . What
you have is a child who has alot of difficulty focusing, a
(11:51):
lot of difficulty sitting,still, a lot of difficulty
taking feedback in a way thatis measured and is able to
integrate into the way somebodymight learn. What you get is
somebody who is reactive and ,uh, fearful and doing anything
they can to just try to survivein an environment because they
can't make a distinctionbetween real threat and
(12:13):
perceived threat.
Speaker 2 (12:13):
That's really, really helpful, Mitch. So we're
gonna take a short break, andwhen we come back, we're gonna
talk about the components oftrauma-informed care. Stay with
us. We'll be right back
Speaker 4 (12:25):
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like acupuncture andchiropractic care available at
(12:47):
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Hennepin Healthcare is here foryou and here for life.
Speaker 2 (13:02):
And we're back talking with Dr. Mitch Radden ,
a psychologist at HennepinHealthcare. We're talking about
trauma-informed care. Mitch,could you talk us through the ,
the components oftrauma-informed care? What is
it?
Speaker 3 (13:14):
It , it depends on who you talk to. There are
basic kind of elements of it.
Everybody calls it something alittle bit different. But the
framework that I was teachinghere, and the way that I make
most sense out of it, where Itypically start with it, the
first step in engaging in atrauma-informed learning or
approach to something isunderstanding interpersonal
(13:35):
neurobiology. So when I teachit here, and this is
particularly effective inworking with medical
professionals, other firstresponders, because it, it can
feel complicated for peoplewhen they think about
trauma-informed care, whichagain, when I introduce this,
it's this exercise essentiallyin mindfulness where you're
just slowing down to notice themoment so that you can respond
(13:57):
versus then versus react .
Speaker 2 (13:58):
Because neurobiology does sound complicated, but
being mindful and slowing down,it does. Is that what it is?
Speaker 3 (14:03):
Yes. So when I talk about the neurobiology, what
I'm doing is just helpingorganize around the fact that
when people are practicing thisstuff, when they're slowing
down and kind of changing theirintention to engage with
something, they're not justdoing something for the sake of
doing it. When they slow down,they're literally regulating
their nervous system. They'reslowing their brain down,
(14:24):
moving from that limbic systemspace to that more prefrontal
cortex space, which allows themto assess an experience or
situation or environment with alot more complexity.
Speaker 2 (14:36):
We could all learn to do that. Totally.
Speaker 3 (14:38):
And this is the thing. So one of the most
important things, like if youtell somebody to take a breath,
it's kind of the equivalent oftelling somebody to like, calm
down, and then they just kindof wanna slap you because
nobody wants you to tell 'em tocalm down.
Speaker 2 (14:50):
So I bet you you don't do that when you're
seeing people . I do not . Youdon't go take a deep breath,
calm down.
Speaker 3 (14:54):
I don't. I will . I say, well, let me explain
something to you, and then wemight do an exercise. So what I
do is explain to people reallybasic stuff around the nervous
system, but what I do reallyhighlight is the , the control
mechanism. That control centerof our entire stress response
is actually our heart. And youcan't control your heart by
thinking about it that much.
(15:14):
You can to some degree, but youcan control your heart through
your lungs. When you breathein, your heart rate goes up a
little bit. When you breatheout, your heart rate goes down
a little bit, and it's thedownbeat on that heart rate
that literally changes thesignal from body to brain. That
puts what we talk about as therider in the horse. But I can
explain that later.
Speaker 2 (15:32):
Would you explain the rider in the horse? Yeah .
Because most listeners, I wouldbet the vast majority don't
know what the Yes . Heck youjust said, but I do. Okay . And
I, I would love you to explainthe rider in the horse. Yep .
Speaker 3 (15:41):
So the rider in the horse analogy is thinking about
the brain, like the rider inthe horse. So the, the rider in
the brain is like thatprefrontal cortex. It's the
thinking part of us that is thejockey who sort of tells the
horse where to go. The horse isthat limbic system or that
emotional beast that carries usfrom place to place when
(16:02):
everything's operating the wayit's supposed to or the way we
want it to. And under calmcircumstances, the rider is
planted firmly on the horse,and our thoughts and our
emotions are meaningfullyintact. And we're going about
our business, thinking aboutall of the dynamic things we
need to think about. But when athreat moves in front of that
rider and that horse, the horsebucks the rider, because in
(16:23):
that moment, a horse does notneed a rider to tell it what to
do. The horse's job is toattune specifically to that
threat, so it knows how tofight it or get away from it.
The problem with that is werarely know whether our rider
is on our horse or off ourhorse, because we're so
impressed with our ability tothink about how we managed a
(16:43):
threat after the fact thatwe're not aware, that we were
completely tuned out to a lotof the things
Speaker 2 (16:48):
That , yeah , I got through . Look at the way I, my
, I thought my way through thatone. And you were bucked off
the horse.
Speaker 3 (16:54):
Yep . Which is the way it's supposed to be. That's
super adaptive. But now, whenthe threat is around every
corner, what happens is. Therider is more and more bucked
from the horse. And what youfind is that somebody's walking
through the world with just ahand on the main of that horse
rather than firmly planted onthat horse. So you have
somebody who's a lot morereactive to the world, not
(17:16):
looking at context, not lookingat threat, and misinterpreting
cues from the environment.
Again, that's where you get thekid in school who gets really
reactive to a teacher who justasks them to sit down when
they're not hearing it assitting down. They're hearing
somebody demanding. They dosomething that is like
extremely difficult orinsulting or whatever.
Speaker 2 (17:37):
So that's the neurobiology.
Speaker 3 (17:39):
That's the neurobiology. So when, when you
go to that stuff, what we'resaying is how do you figure out
whether you're on your rider oryour horse? Are you thinking as
a rider or a horse or when youare engaging with another human
being, are you talking to arider or a horse? The reason
that's important is because ifI'm aware of whether I'm a
rider or my horse, how do youfigure that out? You check your
(18:00):
body. If you're holding tensionin your body and you're
breathing is tight and shallow,you're being chased by a
predator. If you're holdingyour breath, you're caught by a
predator under either one ofthose conditions, you're not
thinking clearly, you're gonnabe reactive. So you slow that
down. You take one slow deepbreath, you reregulate your
neurobiology enough to get thatprefrontal cortex or that rider
on that horse a little bit.
(18:20):
You've already moved from aplace of reactivity to a place
of intention because youthought through the fact that
something's going on. So if I'maware, whether I'm a rider or a
horse in that moment, what Ican do is tune into the
individual that I'm talking to.
Horses do not understandlanguage. So if I know that I'm
talking to somebody who's superactivated or super shut down, I
(18:42):
cannot use a lot of words toengage with them. And you don't
run up to a horse waving
Speaker 2 (18:47):
Hands and start trying to reason
Speaker 3 (18:48):
And yelling at it.
Right . You use the tone andposity of your own voice to
sort of calm them, to get theminto alignment and establish a
sense of safety. And then youcan start to use those words
because you, you get a sense ofwhen that rider is back on
there. And so that's the firststep. Once you have that
neurobiology in place and youunderstand how you react and
how you respond, we move tothis notion of cultural
(19:11):
humility. So cultural humilityis really different than
cultural competence. When wethink about cultural humility,
what we're really, I mean, asfar as cultural competence
goes, I'm not culturalcompetent in my, in my own
culture. It's like I know partsof it, I know all sorts of
things, but you're not anexpert on it . No. But what I
can be is humble about kind ofbeing curious and knowing what
(19:34):
I don't know, and askingquestions and understanding
context, and being curiousabout that context. So if I
understand my own nervoussystem reactions and my
neurobiology, that slows medown enough to be able to be
curious about things that I'mengaging with in unfamiliar
environments, or for peoplewith people who might be
different than me. So I'm notconfusing how I think things
(19:56):
should be from my perspectivewith how things might be from
their perspective. Once I'veestablished that within myself,
I can move to this idea ofsafety, which is one of the
most important components oftrauma-informed care. It is
only when we feel safe thatwe're able to meaningfully
engage with another humanbeing, that we're able to take
in information, that we're ableto make sense out of anything.
(20:20):
How many times as a doctor haveyou spoken with a patient,
given them very clearinstruction, they come back the
next time and are like, wait,you didn't tell me to do any of
that.
Speaker 2 (20:30):
You didn't tell me any of that. Yeah . Oh, that is
listeners so common. Yep .
,
Speaker 3 (20:35):
Right? They're anxious. They're, they're
thinking, what the heck isgoing on?
Speaker 2 (20:38):
And I thought I explained it
Speaker 3 (20:39):
Clearly, and you did probably, you weren't aware
about whether or not theirrider was on their horse or
not. Right ? And so you werespeaking to the horse who
wasn't understanding. Yeah .
And so, but people feel a lotof shame around that. But when
we can understand that stuff,we can really normalize it and
let people know, oh, there'snothing wrong with there. That
was my bad Mm-Hmm.
, you know ?
Mm-Hmm . , Iwasn't paying attention. And so
let's slow down again andfigure out what went wrong and
(21:00):
how we can help you, becausenow the person feels safe. They
trust us enough that we canmove into a space where we're
really cultivating acollaborative relationship with
the patient, rather than thatmore typical hierarchical
relationship. We think about inmedicine, I'm the doctor, I'm
gonna tell you what to do. Wewanna partner with people to
get them to fully understandwhat we're trying to do with
(21:21):
them, how we're trying to helpthem and understand from their
perspective what they need. Arethe interventions that I'm
offering you actually useful toyou? Do they make sense in the
context of your life? Or do weneed to adapt some of this so
that it actually makes sensefor you and your life so you
can actually use it? Once wemove from, from that kind of
safety and co-regulation pieceof it, where we're kind of
(21:43):
creating a space that'smeaningful for both of us, we
really then move into a placewhere we're, we're focused on
empowering the patient to likereally take agency and
ownership of what they'redoing. And from there, once you
have all that stuff puttogether, you're already
cultivating a kind ofresilience and effort at
self-care because you'reregulated, you're understanding
and making meaning out ofwhat's going on with you and
(22:04):
your patients, your coworkers ,and you're moving through the
world in a way that isconnecting you to a sense of
meaning and what you're doing,rather than the slog of patient
after patient after patient.
And the frustration ofsometimes not feeling like you
can be fully helpful to somepeople.
Speaker 2 (22:20):
So you moved from neurobiology riders and horses,
cultural humility all the waythrough collaboration and
empowerment. What a powerfulmodel. How often do we do this
in healthcare?
Speaker 3 (22:34):
We don't, we
try. Yeah . I mean , and I
think everybody who's out thereengaging with patients is
amazingly well-intentioned hasextraordinary skills and
abilities to do this stuff, butI was down in the ed , uh, the
emergency department severalmonths ago, and I was talking
about this with somebody, andthey just said, I would be the
(22:54):
most empathic, amazing doctoron the planet, but I've seen 15
people and it's only 10o'clock. And how am I supposed
to like, stay attuned? You can,if you are aware of this stuff,
and taking moment by moment as, uh, like assessment of what
you're doing and whether youare staying aligned with that,
(23:18):
meaning making process andstaying connected to the
moment.
Speaker 2 (23:20):
Makes sense. So Mitch, you care for patients in
our communities, and you alsocare for the people of this
large downtown Minneapolislevel one trauma center. And,
and where the nurses and theparamedics and the medical
assistants and the respiratorytherapists, you name it, the
patient care coordinators atthe front desks. And yes, even
(23:41):
the doctors are caring forpeople who have experienced
trauma, who are probablyexperiencing some their own.
Could you give us some examplesabout how you approach your
work here in this big
Speaker 3 (23:56):
Hospital? Yeah. So I do a number of things. So I , I
have a team , um, ofpsychologists on a , what we
call a critical incidentsupport team. So we're
available to respond to peopleimmediately following , um, a
difficult event that happened.
Sometimes it's for anindividual who is experiencing
something and having a hardtime getting back into the fray
of work. Sometimes it's for awhole group who is exposed to,
(24:19):
to something really difficultwith a bad outcome. And what I
tell people is that I'm notsuggesting that anybody is
traumatized. I don't know ifthey're traumatized, I'm not
doing that assessment. But whatI can pretty well guess is that
it's very much like when Ithink about a baseball pitcher
throwing a ball for nineinnings, what that pitcher
(24:39):
knows is that they're gonnaexperience some pain and
inflammation between innings.
They're gonna ice, they'regonna keep it loose. They're
gonna do everything they can toperform at optimal efficiency
throughout that game betweengames. They're gonna do
everything they can to stay inshape, to continue to do that
with minimal pain and performat professional levels for
people in healthcare. I talkabout how it's a really, a very
(25:01):
similar thing. We're talkingabout these repetitive strain
injuries. It's not oneexperience, but it's typically
experience after experienceafter experience over time.
It's kind of a complex traumafor medical professionals or
people who work as firstresponders. The nervous system
becomes more and more adaptedto be lit up to be expecting
(25:22):
threat because threat is partof the job. But we operate as
though we're just going towork, which is not effective.
And in medicine, we're trainedto be objective. We're trained
not to have big emotionalreactions to things. What that
does is position most people tobe looking around, seeing
everybody else around themlooking very composed, very
(25:44):
regulated. But the person who'slooking around is looking
inside, feeling completelydysregulated and outta control,
feeling like, there must besomething wrong with me,
Speaker 2 (25:55):
With me. W but but you , and you're in this like
emergency department wherepeople's bodies are insulted in
injuries and emotions and painand you know , the emergency
department, and it's not justthe emergency department. It's
all over. It's all over . Itcould be on the hospital unit ,
it could be in clinics, youknow ? Yep .
Speaker 3 (26:12):
So when I give that framework, I am basically
telling people, this is not afailure to cope. It's not a
weakness. You're havingappropriate emotional
responses. It's just not partof medical cultural to really
acknowledge that stuff.
Speaker 2 (26:26):
And plus there's another patient over there in
that unit, right. That yougotta go see.
Speaker 3 (26:30):
So when I give that framework and I kind of
organize people around, this isnormal. You can, you can manage
this, check your body. If I godown to the ED after a really
intense event, and I work witha group who is just kind of
dealing with something reallycatastrophic, I will say, not
gonna use a lot of words. Iknow you can't hear this right
now. You're still like up. WhatI want everybody to do is just
(26:52):
kind of notice your body, checkit head to toe where you're
noticing tension, release it.
And I will say, when I talk tomost assault survivors or most
car crash victims or otherpeople who've been through a
trauma, if they describe to mewhat happens, their bodies
always move into the positionthey were in at the moment of
impact, at the moment ofassault
Speaker 2 (27:12):
Everybody . And you're making that. Yep .
You're making it . You're like,yep . You're tensing up your
body, your arms are goingcloser to your chest. Yep .
Speaker 3 (27:18):
I'm protecting myself. Yeah . From the threat.
And so almost
Speaker 2 (27:21):
Fetal position.
Speaker 3 (27:22):
Yeah. . And
so what I tell people is their
body just went throughsomething. We don't wanna store
that as a reference point. Wewanna do the opposite of what
your body wants to do rightnow. Don't hold the tension
because that threat is over. Iknow there's another threat,
but you want to move to that inthe most responsive way
possible. Release this, noticeyour breathing. I will say, if
(27:42):
you're breathing tight andshallow, you're being chased by
the predator. If you're holdingyour breath, you're caught by
the predator, even that out.
And I will say, I talk withfirst responders about this all
the time. You can go codethree, which means lights and
sirens to a call and breathe atthe same time. You can do
compressions and breathe at thesame time. You wanna stay
(28:03):
responsive because you do notwanna show up to a scene
reactive, or you don't want togo to that next patient in a
reactive manner and reactivatea trauma that
Speaker 2 (28:12):
Somebody , I've never thought of it that way.
You've got a paramedic racingdown the street code three
lights and sirens, blast intothis horrible situation.
Breathe. Yep .
Speaker 3 (28:20):
And they can, they can do
Speaker 2 (28:21):
It , and it can be done.
Speaker 3 (28:22):
And you see people, their eyes light up, they're
nodding their heads, they ,it's remarkable how you can
give somebody just such simpleinstruction if you put it in a
framework that makes sense tothem. And you see people start
to change. And so before Istarted the critical incident
support team, nobody reallyknew how to get support or what
(28:43):
kind of support to get. I thinkthere were like six requests
for emotional support in thehospital from staff before I
started in the six monthsbefore I started. And the six
months to a year afterwards, wehad somewhere upwards of like
200 requests. And that was notonly , um, individuals, but for
groups doing debriefs and otherthings. So, you know, that's
hundreds of, of staff in thehospital who were supported.
Speaker 2 (29:05):
I can attest to that before, before I've been here
25 years , um, before Dr.
Radden came and did ourcritical incident support team.
It was like that I didn't, wedidn't talk about, well ,
frankly, we just didn't talkabout any of this stuff, right
? , we didn't. Right.
And now we do, and we haveresources and professionals to
help. Yep . Uh , um, largelythanks to this program that you
(29:26):
lead. And so , uh, I reallythank you for that. Mitch,
before I let you go talk aboutif you would, the outcomes of
trauma-informed Care. What isthe result of practicing in
this manner ? Yeah,
Speaker 3 (29:39):
I always go with this, and it sounds weird
because we're talking abouttrauma, but this is
trauma-informed Care is one ofthe most optimistic approaches
that you can take when thinkingabout any environment that
you're operating in. Itcontextualizes things so that
we are not having reactions andresponses that are just out of
nowhere that are confusing.
(30:00):
We're actually understandingthere's a source to this, the
main tenet of trauma-informedCare is not what's wrong with
you, but what happened to you.
So when we don't think about,oh my gosh, there's something
wrong with me here. What we doget to do is slow down and
think, oh my gosh, somethinghappened. I'm actually
responding appropriately. Nowthat I know that something
(30:20):
happened, I can actually dealwith that, address it, or at
least not feel like I'mspiraling out into the
atmosphere. So what we'rereally doing is organizing
people around, again, affordingpeople context, understanding
there's a source to theirdistress, which makes it a more
manageable thing. What I'mseeing throughout the hospital
is staff starting to thinkabout themselves differently,
(30:43):
think about how they're showingup to work differently and
making meaning out of the workthat they're doing, rather than
just focusing on where the nextthreat is gonna be . And really
engaging patients differentlyto think about, okay , this
guy's yelling at me. Maybe theproblem of yelling is not
really the problem. That's anattempt to solve some entirely
(31:04):
other problem. I activatedsomething. Maybe he's
vulnerable. Maybe he's afraidI'm fearful, but I'm regulated.
So if I'm regulated and myrider's on my horse, I can
actually not look at that as animmediate threat, but as a
need. And so now I'm looking atthis person as somebody who is
asking for something ratherthan trying to push me away.
(31:24):
And so I can think through itmore dynamically and support
them. Sorry, I didn't mean toupset you. What's going on?
This doesn't seem like it'sreally about what I said, or
something along those lines
Speaker 2 (31:35):
That's transformational. That isn't
how I learned medicine. Yeah .
Know , frankly, nobody saidanything like that 25 years
ago. And that is, thatresonates so deeply with me,
and I know it does across thisorganization. 'cause I talk to
a lot of people who have beenthe benefit of a new way of
thinking about , uh, uh,trauma-Informed Care. Mitch,
thanks for being on the show.
Pleasure. We've been talkingwith Dr. Mitch Radden ,
(31:57):
clinical psychologist atHennepin Healthcare about
trauma-informed Care listeners.
On our next episode, we'regonna be talking about long
covid , what is it? What do weknow about it, and what to do
about it. I hope you'll join us'cause it's gonna be a great
show. And in the meantime, behealthy and be well.
Speaker 1 (32:13):
Thanks for listening to the Healthy Matters podcast
with Dr. David Hilden . To findout more about the Healthy
Matters podcast or browse thearchive, visit healthy
matters.org. Got a question ora comment for the show, email
us at Healthy matters@hcme.orgor call 6 1 2 8 7 3 talk.
There's also a link in the shownotes. The Healthy Matters
(32:35):
Podcast is made possible byHennepin Healthcare in
Minneapolis, Minnesota, andengineered and produced by John
Lucas At Highball ExecutiveProducers are Jonathan, CTO and
Christine Hill . Pleaseremember, we can only give
general medical advice duringthis program, and every case is
unique. We urge you to consultwith your physician if you have
a more serious or pressinghealth concern. Until next
(32:57):
time, be healthy and be well.
Welcome to the Healthy Matters podcast with
Dr. David Hilden , primary carephysician and acute care
hospitalist at HennepinHealthcare in downtown
Minneapolis, where we cover thelatest in health healthcare and
what matters to you. And nowhere's our host, Dr. David
Hilden.
Speaker 2 (00:19):
Hey, everybody, it's Dr. David Hilden, your host of
the Healthy Matters podcast.
And this is episode 20, andwe're gonna talk about
trauma-informed care withclinical psychologist Dr. Mitch
Radden . Mitch, thanks forbeing on the show.
Speaker 3 (00:31):
Thanks for having me. It's
Speaker 2 (00:32):
Great to have you here. And we're gonna talk
about trauma-informed care, andso I'm gonna ask you to help us
out with what that is. Myunderstanding is that it's a ,
it's an approach that recognizeand responds to the effect of
trauma in people's lives, andthen how we respond to that in,
in their healthcare . I've beenwell aware of your interaction
with our patients and ouremployees as we care for our
(00:56):
communities . Could you startus off and just give us, in the
most basic level, what istrauma-informed care?
Speaker 3 (01:04):
That is a great question, and it sort of
depends on who you ask. So whenyou think about trauma-informed
care, what you're reallytalking about when you break it
down to its most basic elementsis this kind of framework to
engage in a state ofmindfulness as you're moving
through your day. So what we'redoing is slowing people down a
(01:25):
little bit when we organizearound trauma-informed thinking
to move from a place ofreactivity to a place of
responsiveness and intention.
And that's mostly just slowingpeople down to consider
context. So we're not justlooking at a behavior, we're
looking at what might bedriving that behavior.
Speaker 2 (01:43):
So what do you mean by trauma?
Speaker 3 (01:44):
So trauma is a very complicated word these days
because it's thrown out in alot of different contexts ,
isn't it , though ?
Speaker 2 (01:51):
It really is. You know, I don't know. I haven't
had , I haven't been in a caraccident that that sounds like
trauma. Is it psychologicaltrauma? Is it your life
experiences? What
Speaker 3 (02:00):
Is it? Right? There are three different kinds of
trauma. There's the acutetrauma, which is typically what
you see following a car crashor an assault or a gunshot. So
what that is, is an event thatoverwhelms somebody's already
developed ability to cope, andsort of throws them into a
space of helplessness wherethey're unable to respond in a
(02:20):
way that gives them any senseof control. Often that's
associated with a sense of fearfor one's own bodily integrity
or life. Um, so it's a reallykind of life shattering moment.
The easiest definition fortrauma, when you think about
it, when you break it down andkind of understand how it
impacts people, is it's anyevent or series of events that
(02:42):
overwhelm somebody's nervoussystems ability to make a
distinction between past andpresent real threat and
perceived threat. So whensomebody is activated into a
state where they fear for theirlife, the system gets stuck
there, unable to make adistinction between past and
present. So everything nowfeels like a threat,
Speaker 2 (03:03):
But isn't it, if you, if you're experiencing
some, some pretty traumaticthing in your life at this
moment Mm-Hmm.
psychological, whatever that isin your life, isn't it normal
or isn't it common that youmight feel very at a
fundamental like cellularlevel? I feel unsafe,
Speaker 3 (03:20):
Yes. Because you are unsafe in that moment, and yes,
it is . That's the thing Ithink that gets really
complicated is that it is acompletely normal response.
It's an appropriate responsefor the way the brain and body
is impacted in a context likethat. Where people get stuck is
that they feel crazy becausethey feel out of control. They
feel like they're unable tomanage the world in ways that
(03:43):
they used to be able to. Andthat's where this turns into a
more complicated bag . You havesome people who experience
something really overwhelming.
They may have a period wherethey feel overwhelmed, but
return to a state of baselinewhere everything sort of goes
back. For some people, thenervous system is just hit in a
different way. That's when thetrauma sort of lives devoid of
(04:05):
space and time. The eventcontinues to recur in that
person's mind and their body asthough it's happening all over
again. So instead of it being amemory, it's a relived
experience.
Speaker 2 (04:16):
Oh, that, that is, that is helpful. So is that
what we mean by chronic trauma?
Speaker 3 (04:21):
Right. So when we're talking about the three
different kinds of trauma,there's, there's the acute
trauma, which is the singularevent. There's the chronic
trauma, and then there'scomplex trauma. Chronic trauma
and complex trauma are prettyhard to parse out when you've
got the chronic trauma. Whatyou're really looking at are
experiences where people are inan environment or in a
relationship where there's anongoing threat. So it could be
(04:45):
a child living in anenvironment where there's child
abuse, could be physical, itcould be sexual, could be a
domestic violence situation. Itcould be a situation where you
are working in a hospitalsetting and chronically exposed
to people who are , uh,engaging in really threatening
behavior, or for people who'vebeen assaulted , uh, multiple
(05:06):
times.
Speaker 2 (05:07):
I think of that a lot, that part in our own
workplace, not only for ourpatients, but the people who,
who work with our nurses. Yep .
Um , paramedics things, thingslike that. People who are
experiencing trauma as they'retrying to help others who are
living with these complextraumas. We're gonna get a
little bit later, I hope,
(05:28):
tenets of trauma informed care.
But before we leave this kindof foundational discussion,
what do we know about thecumulative effects of trauma
throughout someone's life? Andnow, a lot of people have heard
the term adverse childhoodevents . Adverse childhood
experiences. Yep . Can you talkabout that?
Speaker 3 (05:44):
So that's where you start to get into the more
complex trauma piece of it. Soyou've got the chronic trauma
where it's like a singular kindof trauma from a one singular
individual typically, or asingular environment. With the
complex trauma, what you'relooking at is a really
complicated set of experienceswhere people are living in an
environment where threat isalways present in some way. It
(06:05):
could be neglect, it could beviolence , uh, it might be
within the home. It might alsobe in an environment where
somebody steps out the door andis feeling unsafe. So the
adverse childhood experiencesstudy started to look at
trauma. This was back in theearly nineties, and it was done
at Kaiser Permanente Hospital,and I think outta San Diego at
the time. And they did aquestionnaire of about 17,000
(06:27):
people, most of whom werewhite, most of whom were middle
class , and people who all hadinsurance. So this is like a,
Speaker 2 (06:35):
That's a subset of the world.
Speaker 3 (06:37):
Yep .
those 17,000 people, a hugenumber of them had at least one
adverse childhood experience. Asurprisingly large number had
two or more. And there was asignificant number of people
who had four, six or moreadverse childhood experiences,
which I'll explain what thoseare in a moment. What they
(06:58):
found is that people with moreadverse childhood experiences
had significantly more complexhealth issues and significantly
worse outcomes when trying tomanage their health issues,
Speaker 2 (07:12):
Physical health issues,
Speaker 3 (07:13):
Physical health issues. Yeah. So what adverse
childhood experiences are they?
So they did this questionnaire,I think it was 10 questions,
and they looked at things like,did you grow up in a home where
there was physical abuse? Wasanybody in your home ever sent
to prison? Uh, did you witnessphysical abuse in the home?
Were you exposed to neglect?
That kind of thing. So all thethings that you might think
(07:33):
about as far as like childhooddifficult experiences in a
family. So when people thinkabout trauma often, and they
think about that more complextrauma, they don't typically
think about it in terms of theeveryday individual that they
run into. They might thinkabout it more in like a, you
know, either you are working ina job like as a first responder
(07:53):
where you're exposed to allthat stuff, or you are growing
up in an inner city environmentwhere there's a lot of violence
and that kind of thing.
Speaker 2 (08:01):
I think of my, my wife Julie is a high or high
school. She's an elementaryschool social worker. And every
day of her life, she had tolocate some of the children
because they're living inunstable housing. Um, she had
to send taxi cabs to abandonedbuildings to locate children
who were experiencinghomelessness. Uh, and, and a
(08:22):
lot of these kids were facingexactly what you've just said.
Um , all of those things thatyou might imagine aren't
healthy for a , a developingchild. So my question to you
is, how does that affectpeople's mental health, their
physical health, theiremotional health, not only in
childhood, but even all the wayinto adulthood?
Speaker 3 (08:40):
That's a really complicated question in that
it's not only adverseexperiences that happen in
childhood that change the waythat our bodies and our brains
operate, it's also adverseexperiences that happen as
adults. So as children, youknow, our brains are
developing, our nervous systemsare developing. All of our
(09:01):
hormones are starting to kindof do what they need to do to
make us grow trauma, or livingin those kinds of environments
where you're chronicallyexposed to stress is an
inflammatory experience. Thewhole body is trying to respond
to a chronic state of threat. Iwon't go too much into the
nervous system stuff, but youknow, we like to think that our
(09:21):
brain is the primary source ofour ability to manage stress.
In fact, it's not of the nervefibers that go from brain to
body and body backup to brainthat dictate how stressed we
are, how calm we are. Give usinformation about the world.
Only about 20% of those nervefibers go from brain to body.
80% go from body to brain. Soif you think about it, your
(09:43):
brain's just in this littledark box getting information
from all these sensory nerves.
And our brain is then trying tomake sense out of that
information. So what happensis, under the right conditions,
that body and that brain arecommunicating in all the ways
they need to communicate toassess the world in all of its
goodness, all of its badness,and learn from it. But under
(10:05):
conditions where there'schronic threat or somebody's
physical wellbeing ischronically under threat, that
body is constantly activatedinto that stress response where
the body is sending a signal tothe brain in a really
consistent way that something'swrong, something's not okay. So
instead of that prefrontalcortex being online, that part
(10:27):
of us that is super intentionaland tells us where we're gonna
go, how we're gonna do it, bereally thoughtful about things,
our limbic system gets lit up,that fight or flight part of
our brain, that part thatattunes us to threat and
promotes a kind of reactivityto the world, because it's not
appropriate for me to bethinking about how beautiful
the leaves are in the treeswhen I'm being chased by a
(10:49):
bear. So if the bear is aroundevery corner, it becomes harder
and harder for my brain to justslow down and think about
everything around me. I'mconstantly scanning the
environment for threat. Andthat doesn't always happen
along, you know , unconsciouslevels. It happens very much on
an unconscious level becausethe body is hyper attuned to
(11:10):
scan the environment forthreat. And so the way the body
and brain start to developstarts to shift, if you show
images, brain images of a childwho's been significantly
neglected as compared to achild who is growing up in a
healthy, loving, safeenvironment, what you see is
(11:30):
almost no activity in theprefrontal cortex. It's almost
all dark of the, of thechildren, of the children who
are neglected neglect . Andwhat you see is that that
limbic system is pretty lit up.
That midbrain part of it,that's that part that's always
like , lit up to be , how doesthat child learn? Then they
don't in school. They don'tlearn at the same rates . What
you have is a child who has alot of difficulty focusing, a
(11:51):
lot of difficulty sitting,still, a lot of difficulty
taking feedback in a way thatis measured and is able to
integrate into the way somebodymight learn. What you get is
somebody who is reactive and ,uh, fearful and doing anything
they can to just try to survivein an environment because they
can't make a distinctionbetween real threat and
(12:13):
perceived threat.
Speaker 2 (12:13):
That's really, really helpful, Mitch. So we're
gonna take a short break, andwhen we come back, we're gonna
talk about the components oftrauma-informed care. Stay with
us. We'll be right back
Speaker 4 (12:25):
When he up in healthcare says, we are here
for life. They mean here foryou, your life, and all that it
brings. Hennepin Healthcare hasa hospital, HCMC, and a network
of clinics both downtown andacross the West Metro. They
provide all the primary careand specialty care you would
expect to find, but did youknow they also have services
like acupuncture andchiropractic care available at
(12:47):
many of their primary careclinics and at their
integrative health clinic indowntown Minneapolis? Learn
more@hennepinhealthcare.org.
Hennepin Healthcare is here foryou and here for life.
Speaker 2 (13:02):
And we're back talking with Dr. Mitch Radden ,
a psychologist at HennepinHealthcare. We're talking about
trauma-informed care. Mitch,could you talk us through the ,
the components oftrauma-informed care? What is
it?
Speaker 3 (13:14):
It , it depends on who you talk to. There are
basic kind of elements of it.
Everybody calls it something alittle bit different. But the
framework that I was teachinghere, and the way that I make
most sense out of it, where Itypically start with it, the
first step in engaging in atrauma-informed learning or
approach to something isunderstanding interpersonal
(13:35):
neurobiology. So when I teachit here, and this is
particularly effective inworking with medical
professionals, other firstresponders, because it, it can
feel complicated for peoplewhen they think about
trauma-informed care, whichagain, when I introduce this,
it's this exercise essentiallyin mindfulness where you're
just slowing down to notice themoment so that you can respond
(13:57):
versus then versus react .
Speaker 2 (13:58):
Because neurobiology does sound complicated, but
being mindful and slowing down,it does. Is that what it is?
Speaker 3 (14:03):
Yes. So when I talk about the neurobiology, what
I'm doing is just helpingorganize around the fact that
when people are practicing thisstuff, when they're slowing
down and kind of changing theirintention to engage with
something, they're not justdoing something for the sake of
doing it. When they slow down,they're literally regulating
their nervous system. They'reslowing their brain down,
(14:24):
moving from that limbic systemspace to that more prefrontal
cortex space, which allows themto assess an experience or
situation or environment with alot more complexity.
Speaker 2 (14:36):
We could all learn to do that. Totally.
Speaker 3 (14:38):
And this is the thing. So one of the most
important things, like if youtell somebody to take a breath,
it's kind of the equivalent oftelling somebody to like, calm
down, and then they just kindof wanna slap you because
nobody wants you to tell 'em tocalm down.
Speaker 2 (14:50):
So I bet you you don't do that when you're
seeing people . I do not . Youdon't go take a deep breath,
calm down.
Speaker 3 (14:54):
I don't. I will . I say, well, let me explain
something to you, and then wemight do an exercise. So what I
do is explain to people reallybasic stuff around the nervous
system, but what I do reallyhighlight is the , the control
mechanism. That control centerof our entire stress response
is actually our heart. And youcan't control your heart by
thinking about it that much.
(15:14):
You can to some degree, but youcan control your heart through
your lungs. When you breathein, your heart rate goes up a
little bit. When you breatheout, your heart rate goes down
a little bit, and it's thedownbeat on that heart rate
that literally changes thesignal from body to brain. That
puts what we talk about as therider in the horse. But I can
explain that later.
Speaker 2 (15:32):
Would you explain the rider in the horse? Yeah .
Because most listeners, I wouldbet the vast majority don't
know what the Yes . Heck youjust said, but I do. Okay . And
I, I would love you to explainthe rider in the horse. Yep .
Speaker 3 (15:41):
So the rider in the horse analogy is thinking about
the brain, like the rider inthe horse. So the, the rider in
the brain is like thatprefrontal cortex. It's the
thinking part of us that is thejockey who sort of tells the
horse where to go. The horse isthat limbic system or that
emotional beast that carries usfrom place to place when
(16:02):
everything's operating the wayit's supposed to or the way we
want it to. And under calmcircumstances, the rider is
planted firmly on the horse,and our thoughts and our
emotions are meaningfullyintact. And we're going about
our business, thinking aboutall of the dynamic things we
need to think about. But when athreat moves in front of that
rider and that horse, the horsebucks the rider, because in
(16:23):
that moment, a horse does notneed a rider to tell it what to
do. The horse's job is toattune specifically to that
threat, so it knows how tofight it or get away from it.
The problem with that is werarely know whether our rider
is on our horse or off ourhorse, because we're so
impressed with our ability tothink about how we managed a
(16:43):
threat after the fact thatwe're not aware, that we were
completely tuned out to a lotof the things
Speaker 2 (16:48):
That , yeah , I got through . Look at the way I, my
, I thought my way through thatone. And you were bucked off
the horse.
Speaker 3 (16:54):
Yep . Which is the way it's supposed to be. That's
super adaptive. But now, whenthe threat is around every
corner, what happens is. Therider is more and more bucked
from the horse. And what youfind is that somebody's walking
through the world with just ahand on the main of that horse
rather than firmly planted onthat horse. So you have
somebody who's a lot morereactive to the world, not
(17:16):
looking at context, not lookingat threat, and misinterpreting
cues from the environment.
Again, that's where you get thekid in school who gets really
reactive to a teacher who justasks them to sit down when
they're not hearing it assitting down. They're hearing
somebody demanding. They dosomething that is like
extremely difficult orinsulting or whatever.
Speaker 2 (17:37):
So that's the neurobiology.
Speaker 3 (17:39):
That's the neurobiology. So when, when you
go to that stuff, what we'resaying is how do you figure out
whether you're on your rider oryour horse? Are you thinking as
a rider or a horse or when youare engaging with another human
being, are you talking to arider or a horse? The reason
that's important is because ifI'm aware of whether I'm a
rider or my horse, how do youfigure that out? You check your
(18:00):
body. If you're holding tensionin your body and you're
breathing is tight and shallow,you're being chased by a
predator. If you're holdingyour breath, you're caught by a
predator under either one ofthose conditions, you're not
thinking clearly, you're gonnabe reactive. So you slow that
down. You take one slow deepbreath, you reregulate your
neurobiology enough to get thatprefrontal cortex or that rider
on that horse a little bit.
(18:20):
You've already moved from aplace of reactivity to a place
of intention because youthought through the fact that
something's going on. So if I'maware, whether I'm a rider or a
horse in that moment, what Ican do is tune into the
individual that I'm talking to.
Horses do not understandlanguage. So if I know that I'm
talking to somebody who's superactivated or super shut down, I
(18:42):
cannot use a lot of words toengage with them. And you don't
run up to a horse waving
Speaker 2 (18:47):
Hands and start trying to reason
Speaker 3 (18:48):
And yelling at it.
Right . You use the tone andposity of your own voice to
sort of calm them, to get theminto alignment and establish a
sense of safety. And then youcan start to use those words
because you, you get a sense ofwhen that rider is back on
there. And so that's the firststep. Once you have that
neurobiology in place and youunderstand how you react and
how you respond, we move tothis notion of cultural
(19:11):
humility. So cultural humilityis really different than
cultural competence. When wethink about cultural humility,
what we're really, I mean, asfar as cultural competence
goes, I'm not culturalcompetent in my, in my own
culture. It's like I know partsof it, I know all sorts of
things, but you're not anexpert on it . No. But what I
can be is humble about kind ofbeing curious and knowing what
(19:34):
I don't know, and askingquestions and understanding
context, and being curiousabout that context. So if I
understand my own nervoussystem reactions and my
neurobiology, that slows medown enough to be able to be
curious about things that I'mengaging with in unfamiliar
environments, or for peoplewith people who might be
different than me. So I'm notconfusing how I think things
(19:56):
should be from my perspectivewith how things might be from
their perspective. Once I'veestablished that within myself,
I can move to this idea ofsafety, which is one of the
most important components oftrauma-informed care. It is
only when we feel safe thatwe're able to meaningfully
engage with another humanbeing, that we're able to take
in information, that we're ableto make sense out of anything.
(20:20):
How many times as a doctor haveyou spoken with a patient,
given them very clearinstruction, they come back the
next time and are like, wait,you didn't tell me to do any of
that.
Speaker 2 (20:30):
You didn't tell me any of that. Yeah . Oh, that is
listeners so common. Yep .
Speaker 3 (20:35):
Right? They're anxious. They're, they're
thinking, what the heck isgoing on?
Speaker 2 (20:38):
And I thought I explained it
Speaker 3 (20:39):
Clearly, and you did probably, you weren't aware
about whether or not theirrider was on their horse or
not. Right ? And so you werespeaking to the horse who
wasn't understanding. Yeah .
And so, but people feel a lotof shame around that. But when
we can understand that stuff,we can really normalize it and
let people know, oh, there'snothing wrong with there. That
was my bad Mm-Hmm.
Mm-Hmm .
let's slow down again andfigure out what went wrong and
(21:00):
how we can help you, becausenow the person feels safe. They
trust us enough that we canmove into a space where we're
really cultivating acollaborative relationship with
the patient, rather than thatmore typical hierarchical
relationship. We think about inmedicine, I'm the doctor, I'm
gonna tell you what to do. Wewanna partner with people to
get them to fully understandwhat we're trying to do with
(21:21):
them, how we're trying to helpthem and understand from their
perspective what they need. Arethe interventions that I'm
offering you actually useful toyou? Do they make sense in the
context of your life? Or do weneed to adapt some of this so
that it actually makes sensefor you and your life so you
can actually use it? Once wemove from, from that kind of
safety and co-regulation pieceof it, where we're kind of
(21:43):
creating a space that'smeaningful for both of us, we
really then move into a placewhere we're, we're focused on
empowering the patient to likereally take agency and
ownership of what they'redoing. And from there, once you
have all that stuff puttogether, you're already
cultivating a kind ofresilience and effort at
self-care because you'reregulated, you're understanding
and making meaning out ofwhat's going on with you and
(22:04):
your patients, your coworkers ,and you're moving through the
world in a way that isconnecting you to a sense of
meaning and what you're doing,rather than the slog of patient
after patient after patient.
And the frustration ofsometimes not feeling like you
can be fully helpful to somepeople.
Speaker 2 (22:20):
So you moved from neurobiology riders and horses,
cultural humility all the waythrough collaboration and
empowerment. What a powerfulmodel. How often do we do this
in healthcare?
Speaker 3 (22:34):
We don't
think everybody who's out thereengaging with patients is
amazingly well-intentioned hasextraordinary skills and
abilities to do this stuff, butI was down in the ed , uh, the
emergency department severalmonths ago, and I was talking
about this with somebody, andthey just said, I would be the
(22:54):
most empathic, amazing doctoron the planet, but I've seen 15
people and it's only 10o'clock. And how am I supposed
to like, stay attuned? You can,if you are aware of this stuff,
and taking moment by moment as, uh, like assessment of what
you're doing and whether youare staying aligned with that,
(23:18):
meaning making process andstaying connected to the
moment.
Speaker 2 (23:20):
Makes sense. So Mitch, you care for patients in
our communities, and you alsocare for the people of this
large downtown Minneapolislevel one trauma center. And,
and where the nurses and theparamedics and the medical
assistants and the respiratorytherapists, you name it, the
patient care coordinators atthe front desks. And yes, even
(23:41):
the doctors are caring forpeople who have experienced
trauma, who are probablyexperiencing some their own.
Could you give us some examplesabout how you approach your
work here in this big
Speaker 3 (23:56):
Hospital? Yeah. So I do a number of things. So I , I
have a team , um, ofpsychologists on a , what we
call a critical incidentsupport team. So we're
available to respond to peopleimmediately following , um, a
difficult event that happened.
Sometimes it's for anindividual who is experiencing
something and having a hardtime getting back into the fray
of work. Sometimes it's for awhole group who is exposed to,
(24:19):
to something really difficultwith a bad outcome. And what I
tell people is that I'm notsuggesting that anybody is
traumatized. I don't know ifthey're traumatized, I'm not
doing that assessment. But whatI can pretty well guess is that
it's very much like when Ithink about a baseball pitcher
throwing a ball for nineinnings, what that pitcher
(24:39):
knows is that they're gonnaexperience some pain and
inflammation between innings.
They're gonna ice, they'regonna keep it loose. They're
gonna do everything they can toperform at optimal efficiency
throughout that game betweengames. They're gonna do
everything they can to stay inshape, to continue to do that
with minimal pain and performat professional levels for
people in healthcare. I talkabout how it's a really, a very
(25:01):
similar thing. We're talkingabout these repetitive strain
injuries. It's not oneexperience, but it's typically
experience after experienceafter experience over time.
It's kind of a complex traumafor medical professionals or
people who work as firstresponders. The nervous system
becomes more and more adaptedto be lit up to be expecting
(25:22):
threat because threat is partof the job. But we operate as
though we're just going towork, which is not effective.
And in medicine, we're trainedto be objective. We're trained
not to have big emotionalreactions to things. What that
does is position most people tobe looking around, seeing
everybody else around themlooking very composed, very
(25:44):
regulated. But the person who'slooking around is looking
inside, feeling completelydysregulated and outta control,
feeling like, there must besomething wrong with me,
Speaker 2 (25:55):
With me. W but but you , and you're in this like
emergency department wherepeople's bodies are insulted in
injuries and emotions and painand you know , the emergency
department, and it's not justthe emergency department. It's
all over. It's all over . Itcould be on the hospital unit ,
it could be in clinics, youknow ? Yep .
Speaker 3 (26:12):
So when I give that framework, I am basically
telling people, this is not afailure to cope. It's not a
weakness. You're havingappropriate emotional
responses. It's just not partof medical cultural to really
acknowledge that stuff.
Speaker 2 (26:26):
And plus there's another patient over there in
that unit, right. That yougotta go see.
Speaker 3 (26:30):
So when I give that framework and I kind of
organize people around, this isnormal. You can, you can manage
this, check your body. If I godown to the ED after a really
intense event, and I work witha group who is just kind of
dealing with something reallycatastrophic, I will say, not
gonna use a lot of words. Iknow you can't hear this right
now. You're still like up. WhatI want everybody to do is just
(26:52):
kind of notice your body, checkit head to toe where you're
noticing tension, release it.
And I will say, when I talk tomost assault survivors or most
car crash victims or otherpeople who've been through a
trauma, if they describe to mewhat happens, their bodies
always move into the positionthey were in at the moment of
impact, at the moment ofassault
Speaker 2 (27:12):
Everybody . And you're making that. Yep .
You're making it . You're like,yep . You're tensing up your
body, your arms are goingcloser to your chest. Yep .
Speaker 3 (27:18):
I'm protecting myself. Yeah . From the threat.
And so almost
Speaker 2 (27:21):
Fetal position.
Speaker 3 (27:22):
Yeah.
body just went throughsomething. We don't wanna store
that as a reference point. Wewanna do the opposite of what
your body wants to do rightnow. Don't hold the tension
because that threat is over. Iknow there's another threat,
but you want to move to that inthe most responsive way
possible. Release this, noticeyour breathing. I will say, if
(27:42):
you're breathing tight andshallow, you're being chased by
the predator. If you're holdingyour breath, you're caught by
the predator, even that out.
And I will say, I talk withfirst responders about this all
the time. You can go codethree, which means lights and
sirens to a call and breathe atthe same time. You can do
compressions and breathe at thesame time. You wanna stay
(28:03):
responsive because you do notwanna show up to a scene
reactive, or you don't want togo to that next patient in a
reactive manner and reactivatea trauma that
Speaker 2 (28:12):
Somebody , I've never thought of it that way.
You've got a paramedic racingdown the street code three
lights and sirens, blast intothis horrible situation.
Breathe. Yep .
Speaker 3 (28:20):
And they can, they can do
Speaker 2 (28:21):
It , and it can be done.
Speaker 3 (28:22):
And you see people, their eyes light up, they're
nodding their heads, they ,it's remarkable how you can
give somebody just such simpleinstruction if you put it in a
framework that makes sense tothem. And you see people start
to change. And so before Istarted the critical incident
support team, nobody reallyknew how to get support or what
(28:43):
kind of support to get. I thinkthere were like six requests
for emotional support in thehospital from staff before I
started in the six monthsbefore I started. And the six
months to a year afterwards, wehad somewhere upwards of like
200 requests. And that was notonly , um, individuals, but for
groups doing debriefs and otherthings. So, you know, that's
hundreds of, of staff in thehospital who were supported.
Speaker 2 (29:05):
I can attest to that before, before I've been here
25 years , um, before Dr.
Radden came and did ourcritical incident support team.
It was like that I didn't, wedidn't talk about, well ,
frankly, we just didn't talkabout any of this stuff, right
?
And now we do, and we haveresources and professionals to
help. Yep . Uh , um, largelythanks to this program that you
(29:26):
lead. And so , uh, I reallythank you for that. Mitch,
before I let you go talk aboutif you would, the outcomes of
trauma-informed Care. What isthe result of practicing in
this manner ? Yeah,
Speaker 3 (29:39):
I always go with this, and it sounds weird
because we're talking abouttrauma, but this is
trauma-informed Care is one ofthe most optimistic approaches
that you can take when thinkingabout any environment that
you're operating in. Itcontextualizes things so that
we are not having reactions andresponses that are just out of
nowhere that are confusing.
(30:00):
We're actually understandingthere's a source to this, the
main tenet of trauma-informedCare is not what's wrong with
you, but what happened to you.
So when we don't think about,oh my gosh, there's something
wrong with me here. What we doget to do is slow down and
think, oh my gosh, somethinghappened. I'm actually
responding appropriately. Nowthat I know that something
(30:20):
happened, I can actually dealwith that, address it, or at
least not feel like I'mspiraling out into the
atmosphere. So what we'rereally doing is organizing
people around, again, affordingpeople context, understanding
there's a source to theirdistress, which makes it a more
manageable thing. What I'mseeing throughout the hospital
is staff starting to thinkabout themselves differently,
(30:43):
think about how they're showingup to work differently and
making meaning out of the workthat they're doing, rather than
just focusing on where the nextthreat is gonna be . And really
engaging patients differentlyto think about, okay , this
guy's yelling at me. Maybe theproblem of yelling is not
really the problem. That's anattempt to solve some entirely
(31:04):
other problem. I activatedsomething. Maybe he's
vulnerable. Maybe he's afraidI'm fearful, but I'm regulated.
So if I'm regulated and myrider's on my horse, I can
actually not look at that as animmediate threat, but as a
need. And so now I'm looking atthis person as somebody who is
asking for something ratherthan trying to push me away.
(31:24):
And so I can think through itmore dynamically and support
them. Sorry, I didn't mean toupset you. What's going on?
This doesn't seem like it'sreally about what I said, or
something along those lines
Speaker 2 (31:35):
That's transformational. That isn't
how I learned medicine. Yeah .
Know , frankly, nobody saidanything like that 25 years
ago. And that is, thatresonates so deeply with me,
and I know it does across thisorganization. 'cause I talk to
a lot of people who have beenthe benefit of a new way of
thinking about , uh, uh,trauma-Informed Care. Mitch,
thanks for being on the show.
Pleasure. We've been talkingwith Dr. Mitch Radden ,
(31:57):
clinical psychologist atHennepin Healthcare about
trauma-informed Care listeners.
On our next episode, we'regonna be talking about long
covid , what is it? What do weknow about it, and what to do
about it. I hope you'll join us'cause it's gonna be a great
show. And in the meantime, behealthy and be well.
Speaker 1 (32:13):
Thanks for listening to the Healthy Matters podcast
with Dr. David Hilden . To findout more about the Healthy
Matters podcast or browse thearchive, visit healthy
matters.org. Got a question ora comment for the show, email
us at Healthy matters@hcme.orgor call 6 1 2 8 7 3 talk.
There's also a link in the shownotes. The Healthy Matters
(32:35):
Podcast is made possible byHennepin Healthcare in
Minneapolis, Minnesota, andengineered and produced by John
Lucas At Highball ExecutiveProducers are Jonathan, CTO and
Christine Hill . Pleaseremember, we can only give
general medical advice duringthis program, and every case is
unique. We urge you to consultwith your physician if you have
a more serious or pressinghealth concern. Until next
(32:57):
time, be healthy and be well.
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