A recent patient at a clinic in Texarkana, Texas, bowed her head and cried as she talked to Kim Burden. “She was feeling bad about herself. She started crying and telling me things about her past, so I just sat and listened to her. She was appreciative that someone took time to listen and show that they care.”
Burden isn’t a therapist; she’s a dental hygienist who was helping a patient at a dental appointment. Had the patient needed a therapist, though, she could have talked to one on the spot. That’s because, in 2019, a sea-change occurred at Genesis PrimeCare, a safety-net clinic that also provides medical, dental and mental health care for families.
That’s when Genesis decided to train all of its 350 staff members in trauma-informed care. This includes understanding what constitutes adverse childhood experiences (ACEs) and how widespread they are, how toxic stress from ACEs affects the brain and behavior, and the practices that can help promote healing. Genesis PrimeCare is part of the Texas Association of Community Health Centers (TACHC). TACHC is training teams in trauma-informed care from health centers all across the State of Texas. To date, teams from 20 of the 73 TACHC clinics are now training staff at their clinics. By 2023, TACHC expects that all of its 73 clinics will be spreading the word to an employee base of more than 11,850. (See the attached document for more details.)
The term adverse childhood experiences comes from the landmark Centers for Disease Control and Prevention/ Kaiser Permanente Adverse Childhood Experiences Study of more than 17,000 adults, which linked 10 types of childhood trauma to the adult onset of chronic diseases, mental illness, violence and being a victim of violence. The study found that ACEs are remarkably common — most people have at least one. People who have four or more different types of ACEs — about 12 percent of the general population, but more in communities with people of color who are poor — have a 1,200 percent higher risk of attempting suicide and a 700 percent higher risk of becoming an alcoholic, compared with people who have no ACEs. Many other types of ACEs—including racism, bullying, a father being abused, and community violence—have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)
The epidemiology of childhood adversity is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, how toxic stress is passed on from generation to generation, and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.
If you think that a collaboration between dentists and therapists is not intuitive, you’re not alone. “For some reason, we never connected with the dental department,” says Kelli Cook, the director of behavioral health for Genesis Prime Care and the clinic’s trauma-informed practices trainer until last July. The TACHC training prompted Cook and the other trainers to reach out to a department with which they rarely work. For Cook, once she learned about ACEs, it made total sense to her that dental visits can be triggering for patients who have ACEs, particularly physical or sexual abuse. On top of the general anxiety many people feel around going to the dentist, “there’s somebody in their mouth, standing over them and touching them.”
In April 2020, the dental department closed its doors for eight hours so that staff members could learn about a trauma-informed approach to dental care. That’s when Burden learned about ACEs. “I was shocked to learn that the health issues people have [could] relate back to the trauma they experienced as children,” she says. “I had no idea. It was really eye opening.”
As a result of the training, Burden and 12 other employees from the practice — including its dentists, hygienists, receptionists and a manager — decided they wanted to screen patients for anxiety and depression, and to offer immediate access to a therapist if a patient needed one. (See the attached anxiety screening form.) Within the first 90 days of implementing the program last April, they provided an immediate connection to therapists for two patients who were suicidal, and connected 45 patients to counseling services. The therapists provide ACEs surveys to their patients, educate them about childhood trauma and work with them on any issues that arise from their experiences, according to Cook.
Cook, who now runs her own counseling and consulting firm, Hopeful Insights, has advised Burden’s dental staff on how to work with patients to lessen their anxiety. She tells them that before starting to work on a patient, they should explain what they’re going to do and let them know they can take breaks during the procedure if they want to. They’ve also identified staff members with have a soothing manner to sit with a patient if they become anxious.
“Just being able to be present with them and help them breathe and calm down is really the big thing,” she explains. And if the patient is still feeling overwhelmed, that’s when they can call in a therapist trained in a number of grounding techniques.
Burden, who is among the staff identified as having a calming effect, describes a menu of items she uses to ease patients’ rattled nerves, including squeeze toys, paintings of birds, and a menu of soundscapes, such as ocean waves and rain. “I had one little girl tell me she fell asleep listening to the waves,” she says. Sometimes she even brings in the leaded apron, which is used to protect a patient who is having X-rays, but that now doubles as an anti-stress weighted blanket.
Cook also describes an idea a staff member came up with during the training for how to help a patient overcome the feeling of being trapped in a small procedure room: “The person asked, ‘What if we had a sliding door, and [the patient] could decide whether to leave it open, to close it halfway, or to close it altogether?” As it happened, the clinic was in the middle of a renovation, “so [someone] literally got up, walked out and went to the project manager who was working on the plan and asked for sliding doors.”
In El Paso, 800 miles away, another TACHC member, the Project Vida Health Center, also integrated ACEs science into its dental practice in 2019, along with medical and mental health. Chief Dental Officer Dr. Daniel Sudimack, a dentist, is a true believer, pointing to the clear connection in research between ACE scores and poor dental treatment outcomes. As such, he insists, “trauma-informed care needs to be comprehensively integrated into dental schools.” As an example of how it works in his clinic, he and the others are using a practice known as, “Tell, show, do.”
“It basically means that anytime you put something near the patient's mouth or in their line of sight, you tell them what it is and what you're planning on doing with it,” he explains. “You’re doing everything in your power to relieve the anxiety associated with [dental work].”
That practice is among the suggestions presented in a 2014 article in the Journal of the American Dental Association entitled “Treating Patients with Traumatic Life Experiences,” by Dr. Sheela Raja, Michelle Hoersch and others. Trauma-informed care is recommended, the authors write, because “trauma survivors often report that a lack of control in medical settings increases their anxiety.”
Sudimack says staff members have developed criteria to identify patients who may benefit from working with a therapist. These criteria include any patient who has an emotional outburst from anger or anxiety, or those who are fearful or disclose a feeling of hopelessness.
And trauma-informed practices are not just for the patients; they’re for the staff as well — an idea that couldn’t have come at a better time, Sudimack says. The dental clinic staff has been hard-hit by COVID-19 personally and in their families. As a result, clinic staff made a conscious effort to institute practices to support each other.
“One thing we added to our daily huddles,” he says, “is talking about self-help — what's going on in everybody's personal life, and what they’re doing to make things better for themselves.” Weekly meetings of the leadership team have also incorporated a check-in. “Every single time we start off with staff morale,” he continues. “How’s everybody doing? What are people feeling good about?”
Burden has even found that sharing some of her own feelings with patients can be helpful: “Once they know that you’re not just someone above them, and that you’ve experienced something too, they feel better about themselves and more like opening up.”
Of course, Sudimack is aware that patients with traumatic histories aren’t going to be cured at the dentist’s office. But he sees the services he provides as a great first step in helping people whose childhood trauma is hampering them from having a fulfilling life.
“We’re not necessarily going to be the ones to treat trauma,” he explains. “But if you can get a patient to come in and be comfortable in a dentist’s chair with a provider who shows empathy, eventually that patient may open up to you, and the dental appointment may become an opening for them to heal.”
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