DP/HH: Journeys Paved By Relationships

1. Ann Bullock, MDDivision of Diabetes Treatment and Prevention Indian Health Service DP/HH: Journeys Paved By Relationships

2. DP/HH staff • Recently joined your local DP/HH project • “What did I get myself into???” • Been doing this a long time • “Getting tired here…” • Either way, we’re in a marathon, not a sprint • What keeps us going? • Maybe relationships are really what make this work • Not just how our relationships with participants affect them, but also how they affect us • Seeing deeper into what is going on for participants, co-workers—and ourselves

3. How do we see our participants and ourselves? • Old Model: Stereotyping, paternal • Participants are a bit lazy and must be reminded, coaxed, and even guilted or threatened into following our good health/clinical advice. • New Model: Relationships, partnering • Given the contexts of their past and current life circumstances, participants (and us too) are doing the best they can—DP/HH staff can be important educators, counselors, cheerleaders, and non-judgmental companions to patients on their life journeys.

4. “Nothing records the effects of a sad life so graphically as the human body.”--Naguib Mahfouz-- So let’s start by talking a bit about where things too often go wrong

5. Stress Basic Stress Pathway Brain Cortisol Adrenaline

6. Stress and Trauma • Stress: anything that requires a response, can be “good” or “bad” • Trauma: anything that overwhelms our ability to respond, especially if we perceive that our life or our connection to things that support us physically or emotionally is threatened

7. Original Trauma Any input which amygdala interprets as like original trauma Amygdala Recreates body state at time of original trauma Cortisol Adrenaline Original emotion re-experienced: fear, rage, sadnessAdapted from LeDoux, The Emotional Brain, 1996

8. Somatic Experiencing website, 10/11

9. Somatic Experiencing website, 10/11

10. “Trauma is the great masquerader and participant in many maladies and “dis-eases” that afflict sufferers. It can perhaps be conjectured that unresolved trauma is responsible for a majority of the illnesses of modern mankind.” Peter Levine, PhD In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness

11. The brain itself is changed by stress • Complex process of “sculpting” the brain, converting experience into neuronal changes • Corticosteroids (including cortisol) • Brain-derived neurotrophic factor (BDNF) • Chronic stress and depression: • shrink the hippocampus and prefrontal cortex • Memory, selective attention, executive function/decision making • potentiate growth of the amygdala • Fear/hypervigilience, anxiety, aggression McEwen, Physiol Rev 2007;87:873-904

12. Stress and the Brain

14. Adverse Childhood Experiences (ACE) • Physical, emotional, sexual abuse; mentally ill, substance abusing, incarcerated family member; seeing mother beaten; parents divorced/separated --Overall Exposure: 86% (among 7 tribes) Non-Native Native Physical Abuse-M 30% 40% Physical Abuse-F 27 42 Sexual Abuse-M 16 24 Sexual Abuse-F 25 31 Emotional Abuse 11 30 Household alcohol 27 65 Four or More ACEs 6 33 Am J Prev Med 2003;25:238-244

15. ACEs and Adult Health • ACE Score ≥4 • 4-12 x risk for alcoholism, drug abuse, depression and suicide attempt • 2-4 x risk for smoking, teen pregnancy, STDs, multiple sexual partners • 1.4-1.6 x risk for severe obesity • Strong graded relationship at all levels of ACEs for almost all outcomes, including heart disease Am J Prev Med 1998;14:245-258 and Circulation 2004;110:1761-6 • Across 10 countries, adults who experienced ≥3 childhood adversities • Hazard ratios 1.59 for diabetes, 2.19 for heart disease • Risk similar to the association between cholesterol and heart disease • Both in magnitude as well as population prevalence Arch Gen Psychiatry 2011;68:838-844

16. What is the average ACE score of: --the participants in your DP/HH program?--your co-workers?What is your ACE score?

17. “Only in the presence of compassion can people allow themselves to see the truth.” Gabor Mate, MD

18. Stress in Children Positive Normal/necessary part of healthy development First day with new caregiver; immunization Brief increases in heart rate and stress hormones Tolerable More severe, longer lasting stressor Loss of a loved one, natural disaster, injury If buffered by relationship with supportive adult(s), brain and body can recover Toxic Strong, frequent, prolonged adversity Abuse, neglect, caregiver mental illness, poverty If no adult support, can disrupt brain and organ development long-term Center on the Developing Child at Harvard Univ.

19. Cook, et al. 2005. Psychiatric Annals 35(5) p. 392

20. “…many adult diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood.” “The Lifelong Effects of Early Childhood Adversity and Toxic Stress” Pediatrics 2012;129:e232-e246

22. LifestyleOvereating as an Adaptive Response • Food Insecurity: • Prevalence of overweight in women ↑’s as food insecurity ↑ Journal of Nutrition. 2001;131:1738-1745 • 42% of households below poverty level are food insecure, 21% of all households with children NEJM 2010;363:6-9 • Independent risk factor for poor glycemic control Diabetes Care 2012;35:233-238 • Carbohydrates affect brain serotonin levels Obes Res 1995 Suppl 4:477S-480S • “Comfort Foods” ↓ HPA axis stress response Proc NatlAcadSci 2003;100:11696-11701

23. “Most people would rather get through the day than get through their lives.” Dean Ornish, MD

24. Behaviors we can see from participants • Different threshold for “normal” behaviors • Anger, rage “out of proportion” to situation • Escalation of emotions/voice if demands aren’t met • Dissociation: can look like disinterest, “spaciness” • Desensitized to loss • Distrust of staff • Difficulty bonding • Overly dependent on staff • Participants say they are doing something (e.g. exercising, eating healthy foods, etc.) that they aren’t • Participants deny doing something that they are (e.g. eating unhealthy foods, smoking, # hrs of TV, etc.)

26. Now for the good news:there’s a lot we can do to support healing in others and in ourselves

27. Trauma-informed DP/HH Programs • How would we set up our programs if we assumed that most patients are dealing with trauma? • Make appointment and visit processes as easy as possible • Peaceful, cheerful program/clinic environment • Posters on walls: triggers or calming/positive? • Staff who are calm, kind and give straight-forward directions and explanations • Caring, supportive, nonjudgmental interactions • Encourage questions, ask about and validate patient’s concerns • Give participants the time and “presence” to really listen to and “see” them

28. Trauma-informed Care • Make the relationship with patient the primary goal, not just meeting a particular requirement • Meet pts where they’re at and find something to praise, even that they came in for appt • Think about the staff members who do this work really well—what words would you use to describe them? • Positive interactions with authority figures like DP/HH staff contribute to healing from trauma • Great pamphlet available free on web: • “Trauma Survivors in Medical and Dental Settings: Why Is This Important to Doctors and Dentists” The Western Massachusetts Training Consortium: www.wmtcinfo.org

29. Settle down, it’ll all be clearDon’t pay no mind to the demons they fill you with fearBut the trouble it might drag you downIf you get lost you can always be foundJust know you’re not alone‘Cause I’m going to make this place your home “Home” Holden/Pearson

30. Relationship-centered Care • Beyond “patient-centered” care? • A provider’s individual nature and personal experiences are as important as and interact with the patient’s • Clinicians are encouraged to empathize rather than maintain professional detachment • Clinicians impact a patient’s health, but a patient can also influence the clinician’s well-being (“reciprocal influence”) • Clinicians’ self-awareness improves cultural competence and relationships with patients, other clinicians and the community J Gen Intern Med, Supplement, Jan 2006

31. “Relationship-centered Care” • “…calls on the health care system to recognize that all individuals involved in the process of care bring who they are to the table; that emotions are an important part of illness and health; and that patients can influence physicians as much as physicians influence them. …(It) calls on physicians and patients to have longstanding compassionate relationships with each other. … ‘For many years, the focus has been on disease elimination. We need to focus on the process of healing.’ ” AMA NEWS 1/16/06, p.1&4

32. Rachel Naomi Remen, MD“Finding New Eyes”My Grandfather’s Blessing

33. A few ways to “be present” • Know that we can’t fix all the issues in participants’ lives, but we can meet people where they’re at, listen compassionately, look them in the eye/offer a hug (as appropriate), help what we can and pray/wish silent blessings on the rest. • We may be one of the few people some patients feel they can really talk to in their lives • Don’t pick up the painful energy and carry it into your next visit or take it home • “I am enough” Rachel Naomi Remen, MD Kitchen Table Wisdom

34. Importantly… • Recognize that we have our own trauma responses • Do not take it personally when patients don’t do as we say—e.g. get their A1C/BP/weight down or exercise (it’s not about us!) • Do our own work: healing, find ways to stay present and to clearly separate our own issues from those of our participants (“counter transference”) • What do we do to take care of ourselves?

35. Newer Mental Health Approaches • Working with how trauma is held in the body • EMDR (Eye Movement Desensitization and Reprocessing) • Somatic Experiencing : Peter Levine, PhD • Mindfulness-based: Dialectical Behavior Therapy • “Rewiring” Parenting: • Child-Parent Psychotherapy, Parent-Child Interaction Therapy • “Mindsight”: Daniel Siegel, MD • Strengthens prefrontal cortex’s ability to “watch the mind” and override signals from the amygdala • Trauma narration in presence of empathetic nonjudgmental therapist or lay person • Narrative Exposure Therapy JAMA 2011;306:549-551

36. Things that help to positively rewire the brain • Write down 3 new things you’re grateful for each day • 2 minutes/day for 21 days in a row • Journal about one positive experience each day • Exercise • Meditation • Conscious (“random”) acts of kindness Shawn Achor

37. “May We Be Released”Carrie Newcomer May you bless the place you live, And bless the place you fell, And let go of hidden stories, Too dangerous to tell. May we be released, May we be held dear, May we listen to the wisdom, That we didn’t want to hear. May we be released, May we. May we finally see May we finally hear, All the perfect lies, That kept us here. And the skills we learned, Just to keep us whole, Be thanked for what they were, And finally let go.

38. Guided Imagery ExerciseBelleruthNaparstek

39. Discussion • Anything you’d like to share from the exercise? • What led you to do the work that you do? • What helps you stay present in your work? At home? With yourself? • How many of us have had a serious illness ourselves or have closely supported a loved one with one? • What did you learn from this experience? Does this help you in your work? • What helps you heal? • What is your vision for the world?

40. Celebrate Our Resilience “The medicine is already within the pain and suffering. You just have to look deeply and quietly. Then you realize it has been there the whole time.”—Duran, 2006