Action Plan: You’re all about emotional health We’re connecting the dots between behavioral health care and all aspects of family, school and work life.

Deborah Harris worked as clinician and adjunct faculty at the University of New Mexico Department of Psychiatry, where she provided direct service and program development on the adolescent inpatient unit and supervision and teaching for psychiatry residents. Deborah now provides training and reflective supervision and consultation for agencies and individual practitioners on a state and national level, with a specific focus on rural, frontier and indigenous communities.

With an epidemic of trauma, each community faces numerous mental health challenges. Can you share what you have observed through your work?

I have seen some positive changes with regard to the awareness and acknowledgment of the importance of early childhood development (including prenatal, infancy and early childhood periods). There is a greater understanding of trauma’s impact on brain development, physical and mental health, and personality development. Clinicians, judges, attorneys, legislators and policy makers have the hard data and proven evidence that early experiences matter from brain research and the longitudinal ACEs study.

In my 30-plus years of work in the field of infant mental health in New Mexico, I have observed a growing acceptance of these facts and an openness to using the data when decisions are made regarding children’s needs. That said, all this progress is still not nearly enough to meet the needs of preventing childhood deaths, minimizing or eliminating the childhood trauma experienced in every corner of our state, and addressing and treating its impact. The bottom line is that childhood wellbeing in New Mexico is still not yet a high priority issue. And until it is, children will continue to be treated as second class citizens, and their critical needs will be minimized.

Some people have a difficult time connecting the dots between childhood trauma and the impact later in youth and adulthood. Can you talk about the long term impact of ACEs and trauma?

We can look at the long term impact of Adverse Childhood Experiences and traumatic situations from many angles. It is indisputable that babies and young children remember what happens to them and they demonstrate this experience through their psychological development, the emotional quality of their relationships and how they progress cognitively, socially, emotionally and even physically. It’s clear that a child’s developing brain and neurobiology is negatively impacted by trauma at critical periods, and yet, early childhood mental health interventions do not usually include a systematic assessment of child exposure to traumatic events. Dr. Jack Shonkoff and the Developing Child Center at Harvard has published numerous papers on the physiological assault of toxic stress and trauma. To quote from some of his work:

[Childhood trauma] produces serious disruptions of the developing brain and other biological systems that can lead to a wide range of problems in health and development. Persistently elevated stress hormones can disrupt brain circuits that affect memory and the ability to focus attention and regulate behavior. Excessive inflammation and metabolic responses to stress in childhood increase the risk of heart disease, diabetes, depression, and other chronic illnesses in the adult years. Unlike ‘positive’ or ‘tolerable stress, which can build resilience, the extended absence of the nurturing protection provided by a parent or other responsive caregiver produces a toxic stress response that increases the risk of serious impairments that can last a lifetime.

Research has also shown that this kind of hindrance to development is also true when young children experience life-threatening events and chronic, ongoing adverse and traumatic conditions. Generational trauma has now been added to the ACEs pyramid and we know that historical trauma — unresolved, unacknowledged and unrepaired — is passed down to subsequent generations and reveals itself in the chronic repetition of emotional and physical distress. Unfortunately, in New Mexico we have more than our share of historical trauma that has been passed down and we see this re-enacted over and over again. I believe this is a great contributor, along with poverty and lack of resources, to our ranking at the bottom for childhood well-being.

We have yet to invent a countywide system of accessible behavioral health care for all. Instead we have individual providers with pay-for service or limited access with programs like Medicaid. How does a city and county begin to collaborate to address mental health care disparities?

I have been working in the field of infant and early childhood mental health for over 35 years, primarily in rural communities where services are scarce, access is difficult and systems are confusing to navigate. Inadequate funding is a perennial problem, but I feel that lack of collaboration is perhaps an even bigger barrier to successfully overcoming the disparities in access to mental health care. There are good early childhood mental health and family therapy providers in New Mexico (although certainly not enough), and there is a workforce that is well trained in infant and early childhood mental health and a smaller number that is trained in assessing and treating early childhood trauma and the impact of ACEs. However, this professional force is spread across agencies and is not adequately networked. The knowledge, skills and best intentions of a scattered field of providers cannot address the problem at hand. To successfully reach and meet the needs of traumatized young children and their families there must be a well-structured system of oversight that “connects the dots” of service provision. This can only happen if there is true communication, based on trust and a shared understanding of the problem and a shared commitment to addressing it. Such an effort must address entrenched, siloed programs, ego-driven agendas, turf wars and monetary territorialism. Children’s needs are left by the wayside by a lack of communication and collaboration among the very departments that were created to serve children and families.

I would be remiss not to also emphasize that at the state and local level, those working on the front lines in the child protection system have unmanageable caseloads. They need training and support to meet the challenges of working with profoundly distressing situations every day, all day. This results in a high turnover rate in this workforce. And this, along with a lack of training and education regarding trauma and its early and life-long impacts, most often results in inconsistencies in approach and decision-making when dealing with vulnerable and traumatized young children.

We asked a few questions of Heidi H. Rogers, a family nurse practitioner and assistant professor at the University of New Mexico.

What can health care providers do in their practice to address childhood trauma and untreated trauma in adults?

I have worked in settings where almost everyone has a history of being a victim of violence, and in my current patient community, the percentages of patients with a history of violence or other traumas is about 25%. Everything I do in my primary care practice is informed by these numbers and the trauma-informed care model. I think it’s important for health care providers to be able to slow down in their comprehensive and new patient visits, to be able to take time for the patient to get to know us, and to understand our framework for how we approach health care and how we work with patients. Ideally this is with a patient partnership model, where we narrate that we are not caring “for” but rather caring “with” the patient and that ultimately the work we do together is grounded in what they identify they want our help with.

I often screen for mental health with positive questions. Instead of screening for “disorders,” I screen for indications of resilience first. I ask how they would describe their mental health: is it good? Are there things that worry you? These are the screening questions I ask: “for the most part would you say you are happy, with a general sense of well-being? Do you feel like for the most part you respond to stressors appropriately? Are you in relationships that are good/healthy and support you for who you are as an individual? Do you feel like you have a strong sense of yourself and your purpose?

These questions are non-judgmental, and they allow space for patients to share areas they’d like to work on without having to be too specific or venture into tricky territory.

It is also important that health care providers understand the trauma-informed care model and can screen for a history of trauma without triggering the patient. If I am working with a patient, I do this screening by saying something like this: “many of the people I see have a history of violence or similar trauma, and I always want to check in around this to see if there is a history. If yes, you don’t need to share the details, I mostly want to know if there are any residual symptoms you are having that are interfering with your sense of well-being currently.”

What training would be helpful to health care providers to address an epidemic of trauma?

We need training in trauma-informed care. We need to understand the research in resilience in the context of trauma, and we need to be able to hold psychologically and culturally safe health care spaces. It’s important for health care providers to have a good, evidence-informed theoretical framework for working with people who are victims of trauma.

What role do health care providers have in creating trauma-free communities?

As health care providers, we need to be partnering with our communities to inform the understanding of trauma, narrating the research on prevention, early detection, mitigation and recovery. Communities play a key role in reducing trauma, not only through screening and care services, but also through creating community structures that help to reduce stressors on the individuals in the community. We know that there are multiple ways to reduce trauma in families, for example: reducing financial stress, providing access to treatment models for substance abuse that are inclusive and centered in family care models. We need to provide support for violence prevention in young families that includes community connection, as well as a structure for child development and parenting education that is culturally translatable and non-judgmental. Most violence happens when there is isolation, so having more community connection can help. Health care providers should be in community leadership, and should help to inform community interventions to reduce violence and trauma as well as mitigate the impacts. Health care providers can help school systems build structures and training to support resilience in the context of ACEs.

We asked a few questions of Robin Swift, a long-time public health advocate in New Mexico. She works with Project ECHO on projects related to behavioral health care provider mentoring at the University of New Mexico.

What are the biggest behavioral health care challenges facing the community?

It’s a long list that includes: lack of access to care, expensive care, not enough providers and few trauma-informed care providers.

How do community change agents begin to address this long standing challenge?

Think about recruitment of the kinds of professionals you need. Establish a scholarship fund to train promising college graduates in the field. Recognize service providers who go “above and beyond” to help people.

Many behavioral health care providers in the private and public sectors do not see themselves as part of a “system” of care — they are siloed. How does a county create a network of providers to create a virtual community?

Figure out incentives for cooperation. Consider having the hospital “buy” practices and insure them under a central liability policy.

How is technology impacting the capacity of behavioral health care providers to serve families?

Telemedicine can bring a skilled behavioral health provider virtually to patients. Many patients are anxious about using such a service for behavioral health and need to be educated about how the process works and its benefits. Apps and self-help strategies work best if there’s someone to tell about your successes or roadblocks. Also, Project ECHO at the University of New Mexico can train primary medical care providers to integrate behavioral health care into their practices, and it provides them a community of peer support as well.

Speaking of real world perspectives, we are constantly updating our electronic and paper edition of 100% Community. If you would like to share a perspective, please contact us at www.endingtrauma.com.

Progress-at-a-glance for Action Teams

Innovation #1: Designing a county data system to track supply and demand within behavioral health care

The “all-important behavioral care analysis” project
The “behavioral care accessibility analysis” project
The “what’s ailing you” project
The “does our behavioral system exist and if so, where should it be” project
The “can you get cared for from here?” project

Innovation #2: Ensuring currently accessible behavioral health care programs are fully supported

The “who’s working on accessible behavioral health?” project

Innovation #3: Engaging the private sector in supporting behavioral health care innovations

The “cool technology of care in the future” project

Innovation #4: Harnessing technology to create an online directory and resources

The “plain language on existing websites” project

Innovation #5 : Generating public awareness and engagement

The “create the Behavioral Health Care@100% user-friendly website” project
The “be patient and focused” project
The “can we address the stigma of mental health care so it’s as normal as fixing a broken arm?” project
The “can we view substance use disorders as chronic diseases like heart disease?” project
The “email Behavioral Health Care@100% often” project

Innovation #6: Make sure your education system is on board

The “let’s explore the Santa Fe ‘Sky Center’ model” project
The “Can the ‘Madison Public Schools model for care’ work for us” project
The “analyze the ‘rural Kentucky online care’ model” project

Innovation #7: Ensuring that local higher education is engaged in solutions, research and evaluation

The “convene behavioral health provider training programs to talk about addressing provider scarcity” project
The “Learn how Oregon does incentives” project
The “Emotional Care for U” project
The “ECHO and telemedicine for health care provider mentoring” project
The “Evaluate the effectiveness of mental health first aid in the US — especially in areas with few care providers” project
The “integrate ACEs data and the Resilient Community Survey into primary care” project
The “evaluate the ‘mental health & psychosocial support (MHPSS) model’” project
The “What are the cutting edge, groundbreaking approaches to substance misuse?” project

Innovation #8: Supporting city and county governments in behavioral health care innovation

The “learn how other localities in the nation are addressing behavioral health care” project

Innovation #9: Identifying how the federal and state levels can strengthen local services

The “invest wisely in care for all” project
The “we need a state coalition to make great things happen” project

Innovation #10: Institutionalizing the work by developing the City Department of Behavioral Health and funding for innovations

The “County/City partnership that funds the Department of Behavioral Health Care” project
The “convene your fellow behavioral health advocates and enhance your skills in public speaking, committee briefing and how to get to a lawmaker” project
The “know your stuff before you meet the mayor” project
The “create a bold vision and strategic plan” project
The “create a ‘no family goes without care’ tax” project
The “Cause Marketing to allow customers to donate part of their sales to funding behavioral health care” project.

Next Steps

Gather your action team* to:
Prioritize projects
Assign tasks
Schedule timelines

*Ideally, you are part of an action team, which is part of a countywide 100% Community initiative (which could be part of a statewide campaign). If you are reading this as a solo prospective change agent, please contact us to connect with like-minded local folks and get the synergy and support needed to take on projects. www.endingtrauma.com