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The trouble with trauma (-informed), the aggravation of ACEs (screening): We're trying to fit both into traditional frameworks and it isn't working BY: Jane Stevens (PACEs Connection Staff)


REPOST of Jane Stevens' blog 12/13/22

What do you call it?

The PACEs movement (PACEs = positive and adverse childhood experiences)?

The NEAR movement (NEAR = neurobiology, epigenetics, ACEs and resilience)?

The resilience movement?

The trauma-informed movement?

No matter what you call it, this movement emerged from two mind-bending, culture-changing developments that grew and evolved over the last 25 to 30 years. One is a groundbreaking epidemiological study, the CDC-Kaiser Permanente Adverse Childhood Experiences Study, first published in 1998 and followed by 70 publications that expanded its significance over the subsequent 20 years. The other, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) work to acknowledge and address trauma that began in a series of meetings in 1994 when substance abuse and mental health were considered two separate entities and systems trauma was a concept that those receiving services understood, but most providing services did not.

An appreciation of the significance and impact of both coalesced between 2012 to 2014. SAMHSA, part of the U.S. Department of Health & Human Services, published the Concept of Trauma and Guidance for a Trauma-Informed Approach, which became the bible for trauma-informed approaches and interventions. Separate trajectories in five areas of scientific inquiry coalesced into one: the science of adverse childhood experiences (ACEs science). It comprises the epidemiology of ACEs (the ACE Study and others), which added other ACEs as time went on, including racism, bullying, homelessness, systems trauma, classism and essentially all the social determinants of health; the neurobiology (brain science) of toxic stress; the epigenetics of toxic stress, including historical trauma, generational trauma and systems trauma; and the long- and short-term health consequences of ACEs and toxic stress. The fifth, resilience science, led to the inclusion of positive adverse experiences with a scale that could be scored from 0 to 7, and referring to PACEs science.

Perhaps the trouble began with the SAMHSA paper not mentioning the ACE Study (even though it had several references to its publications). Or not mentioning or providing an accurate definition of ACEs science. Or the misperception in the ACEs community that ACEs science didn’t include resilience and solutions. It seems as if too many people looked at the ACE Study’s 10 original questions and stopped there, ignoring both the expanded understanding of what comprises ACEs and that people in the community were developing stunning solutions:

Schools stop suspending and expelling students. After one year of involvement with Safe Babies Courts, 99 percent of kids suffer no further abuse. A family physician in Tennessee who treats people addicted to opioids sees 99 percent of his patients able to hold down a job, which is the best indicator of healing. Within 24 to 48 hours after a person recovers from an opioid overdose in Plymouth County, MA, a police officer visits and offers to take them to a rehab facility right then and there. And then says, “How about I treat you to dinner on the way?” Opioid deaths in the county dropped 26 percent, while in the surrounding counties, death rates increase 84%. Over the last eight years, a batterer intervention program in Bakersfield, CA, saw recidivism rates fall from 60 percent to below 5 percent. In Cowlitz County, WA, youth suicide and suicide attempts dropped 98 percent. The list goes on…

Generally speaking, instead of intertwining as they should have, the trauma-informed and ACEs science communities followed their noses down different roads. Organizations focused on learning how to become trauma-informed. Most courses offer a quick and easy path. Some say a three-hour workshop is enough! Quite a few don't include all the parts of the science of positive and adverse childhood experiences, although many address, but gloss over, brain science.

Also generally speaking, the ACEs science community dove into ACEs screening. Although most of the activity has taken place in the healthcare community, there’s screening occurring in education, juvenile justice, and social services. In the healthcare community, this led to controversies ranging from people advocating not screening at all to people embracing it wholeheartedly. The different points of view have played out in journals and on PACEs Connection.

Our approach is that PACEs science is the what, the foundation. Trauma-informed is the how…the practices and policies. They’re supposed to be joined at the hip. The knowledge from one informs the other and continues to do so as the implications of each reveal themselves, every step of the way. In other words, the layers in each are many; you don’t just learn it and move on. As you implement, you realize that there’s another aspect you need. You circle back to find there’s another layer, you learn its implications and figure out the next step. So how can we facilitate this process? As it stands now, this separation doesn’t really serve.

The solution is not what you might expect. It’s something that organizations ignore, not only at their own peril, but in their ultimate success in serving their clients, patients, students, inmates, customers, etc.

The solution: Eliminate the “them-us” dilemma we’ve created. One of the most important conclusions that Dr. Robert Anda, co-principle investigator of the ACE Study, came to was this: “There is no more them and us.” He meant that ACEs affect us all. ACEs science is apolitical. Toxic stress from ACEs is a human condition. No matter who you are or where you live on this planet or who you vote for, if you’re put under enough stress, your brain and your body will suffer. Thus, ultimately, organizations, communities, systems, cities, states, and nations will suffer, because they are, after all, created by and made up of humans.

This means that organizations need to address their own ACEs and PCEs first. The best way to start, after educating people about the basics of PACEs science, is to have staff members complete an anonymous PACEs survey together (in person or live webinar) by using instant polling software such as PollEverywhere. The individual PACE scores are compiled in real time so that everyone can see the organization’s collective burden of ACEs and the collective strength of its PCEs instantly. Make sure to include the range of ACEs and PCEs (1-2, 3, 4+) to get a handle on how much the organization needs shoring up.

Why should organizations do this? If people in an organization have a better understanding of themselves, they’ll have a better understanding on how to work with those they serve as well as fellow staff members. They’ll understand their own triggers. They’ll be more responsive and listen more carefully. Trauma-informed practices and policies will come naturally with a scientific foundation and spur creativity in developing solutions. The transition is likely to go smoother. This also prevents what’s beginning to crop up: a fatigue with PACEs and trauma-informed practices, which comes from trying to fit the new science and practices into existing old boxes. What most people don’t grok is that this new science and trauma-informed practices work best in new boxes. And most important, if an organization is  asking its clients, patients, students, inmates, customers, etc., to address their own ACEs and PCEs, the entire organization staff must do so, too.

By implementing the understanding that “There is no more ‘them and us’”, we can move beyond the current traditional approaches of “I’m healthy; you’re not.” and “I have all the power; you have none.” We move to a place of understanding that we all learn from each other.

This approach isn’t easy, but what exercise in self-examination and reorganization is? And it isn’t a one-day journey. When a family services organization in New York implemented this approach, they thought that their transition might take a few weeks. Twelve years later, they changed the weekly meeting of the committee managing the transition to monthly. The organization still serves families and children, but it’s just not the same organization. It operates in a much different way.

Only when organizations start on this journey with minds and hearts wide open will they be able to see and chart a clear path to use this science, and the trauma-informed policies and practices in a way that works best for them and their clients. Until then, they’ll just be trying to fit this amazing knowledge of PACEs science and trauma-informed care into the same old traditional framework.

This is the first of two parts. Here is Part Two.

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