By Dr. Tahmeena Ali (biography, no disclosures)
What I did before
I always thought of myself as a dedicated family physician, but underneath was an unconscious judgement towards some of my patients. In my brain injury practice, filled with triple-diagnosis patients (mental illness, substance abuse, and acquired brain injury), I sincerely believed that patients who struggled with addiction simply had a willpower problem.
“If they just stopped using, then their troubles would be resolved. Why do they choose to keep doing this to themselves, time and time again?” I wondered to myself.
Patients who frequently no-showed or didn’t follow-up with referrals or other suggestions to improve their health were deemed non-compliant and difficult. They didn’t really want my help, obviously.
Trauma informed practice (TIP) wasn’t on my radar, let alone something to prioritize for my suburban practice. How could it apply to my patient population? TIP was for patients out there with inner city problems: abuse, addiction, abandonment. That was for social workers to worry about—not medical science for a family physician to concern herself about.
When difficult patients rattled me, the question I often returned to was, “What is wrong with that patient?”
What changed my practice
On September 29, 2017, I attended a talk about ACEs (Adverse Childhood Experiences) and the neuroscience behind it. Despite having an unused copy of the questionnaire in my EMR for years, on this day, I felt compelled to actually calculate my own ACE score and quantified my own childhood adversity. Suddenly, I realized that you don’t have to be grow up in the inner city or live in poverty to have suffered difficult experiences in childhood. I realized childhood toxic stress is so much broader than I previously recognized. Me and my patients have vulnerabilities that are crucial to acknowledge.
Hungry for more information, I utilized The Brain Story, a series of free, online, self-paced educational modules that immersed me in the robust research about ACEs. I was dumbfounded by all I learned. An ACEs score of 4 (out of 10) increases one’s risk of substance abuse, depression and suicide attempt by 4-to 12-fold, the risk of ischemic vascular disease rises by 2-fold, and a score of 6 or more decreases one’s life expectancy by 20 years. The neurobiology is astounding. The environment encompassing a growing human being—from the moment of conception onwards, impacts the brain. Elevated stress hormones shapes neuroanatomy and these structural changes will affect its responses to external events for years to come. This was not social work fluff; this was hard core science.
Learning about the neurobiology of ACEs and the long-term health ramifications helped me understand the cycle of intergenerational trauma that often accompanies ACEs. Reflecting on my brain injury practice, I made the connection between my triple-diagnosis patients and their childhood traumas. They weren’t lazy or willpower deficient; they had a biologic propensity born from childhood challenges. Framed in this manner, one starts to recognize that many marginalized populations, including our Indigenous peoples, have rampant ACEs. Knowing this, Indigenous health leaders are cognizant to ensure that any tools to screen for trauma are used in a culturally safe manner. For this and other reasons, widespread use of the ACEs questionnaire in many vulnerable populations as a screening tool is an active area of research.
An ACEs score is akin to a Framingham risk assessment. Having a high Framingham isn’t a guarantee that you are destined to have a cardiovascular event. However, if your Framingham score is high, we work diligently to mitigate all risk factors. Even for patients with low scores, we continue to screen for high blood pressure or diabetes because ongoing surveillance is important for all and the consequences of an event so significant.
With my new insight, I acknowledged the shame and confusion I feel when reflecting on my own training and the hidden curriculum I witnessed as a medical trainee. I wish I had viewed some of my patients from my early years in practice through a trauma informed lens. It would have given me so much more compassion for their struggles, enhanced my care of them, and decreased my own frustration. I now recognize my blinders when it comes to my “difficult” patients or those struggling with addiction.
Dr. Nadine Burke-Harris’ work at the Centre for Youth and Wellness (CYW) in San Francisco helped me gain further confidence in using the questionnaire with parents and children. The CYW has a de-identified version of the questionnaire that also includes seven additional validated questions that address other childhood stressors such as bullying, time in foster care and the death of a parent. There is also a self-report version for teens. The toolkit includes background information to educate staff and scripts to increase their comfort level when administrating this tool with patients and their families.
What I do now
The critical pivot point for trauma-informed providers is shifting from: “what is wrong with you?” to “what happened to you?” That was a game changer for me. ACEs was my entry point to trauma-informed practice. Starting small, I implemented the ACEs questionnaire in my fee-for-service suburban family practice. I use laminated sheets and have patients use a dry erase marker to mark their score and I add the score to their charts. See below for sample questionnaires and intro letters. Much to my surprise, I encountered no resistance from patients and uncovered many patients with high ACE scores; patients I never imagined to have suffered significant childhood adversity. Most did not feel re-triggered by completing the questionnaire. The majority felt they had processed their trauma over the years and did not currently require any further supports. All of them were extremely appreciative of my asking and desire to know them better. Some admitted that they would have never shared their past trauma if asked directly instead of via the questionnaire.
Now, I ask all patients: young and old; new to my practice and established for years; male, female or trans, to complete an ACEs questionnaire in my clinic. I compliment all my patients with any ACE score on their resilience and ask how I can support them. I acknowledge the pain they endured and educate them on how that early trauma can affect their biology and how it might be effecting their health now. I did not encounter any Pandora’s boxes and did not end up grossly behind schedule. Instead, I opened up many boxes of resilience—patients with various childhood challenges living successful lives. For some, it helped them recognize specific challenges such as parenting and made them very deliberant in how they were going to parent their own children to avoid repeating some of the mis-steps made by their own family of origin.
In my use of the ACE questionnaire at a child and youth mental health clinic, I have been astounded by how common childhood adversity is—even amongst a demographic where you wouldn’t expect it. My adolescent patients often report a differing score from their parents which reminds me to keep a patient centric lens because youth often experience their environment differently from their care-giving adults. I make finding supports for these young vulnerable patients one of my top priorities—as important as a referral to a specialist or for diagnostic imaging.
I teach patients about the mind-body connection and how past events from their childhood can effect their adult health and physiology. I check-in with parents frequently to ensure they are seeking self-care strategies and suggesting parenting classes and/or peer support groups, if needed. I normalize the challenges of being a parent and the fact that not caring for ourselves is akin to not caring for our children and that the two concepts are not mutually exclusive but intertwined and essential.
My relationships with my patients have been enhanced with the use of this tool. My admiration for their resilience has sky-rocketed. My ability to support patients where they are at instead of where I want them to be has improved substantially. I pause before I see a patient with frequent no-shows and wonder, “what is going on for this patient in his or her life right now?” versus, “why are they being so inconsiderate to no-show routinely?” I ask patients if they are lonely and we brainstorm ways to help counter their loneliness. I ask them about their passions and hobbies. I suggest volunteering: in schools, in daycares, in residential care facilities, in mental health clubhouses or seniors’ come share societies.
The science of ACEs opened a door to trauma informed care for me. It has helped me grow as a mom, wife, friend, and physician. Adverse childhood experiences are common and silent. Spreading this knowledge amongst professionals and the public alike will enrich our society for generations to come.
References, Handouts and Additional Reading:
- Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. (Read with CPSBC or UBC)
- Siegel DJ, Hartzell M. Parenting from the Inside Out. How a Deeper Self-Understanding Can Help You Raise Children Who Thrive: 10th Anniversary Edition. New York NY: Penguin Group; 2014. (Find in library, request from UBC, request from CPSBC Library)
- Van der Kolk, Bessel A. The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. London: Allen Lane; 2014. (Find in library, request from UBC, request from CPSBC Library)
- Maté G. In the Realm of Hungry Ghosts: Close Encounters with Addiction. Toronto: Vintage Canada; 2009. (Find in library, request from UBC, request from CPSBC Library)
- ACEs Infographic by Harvard https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/(Acessed Aug 2019)
- Centre for Youth and Wellness. ACEs user guide and questionnaires for download for children and teens: https://centerforyouthwellness.org/aceq-pdf/ (Accessed Aug 2019)
- Sample Patient Letters and Questionnaires https://med-fom-tcmp.sites.olt.ubc.ca/files/2019/01/Office-ACEq.pdf. Note from the author: I use laminated sheets and have one for parents and one for adult patients. The letter for parents is combined with the CYW questionnaire: https://centerforyouthwellness.org/aceq-pdf/. (Accessed Aug 2019)
- Harvard Centre of Developing Child https://developingchild.harvard.edu (Accessed Aug 2019)
- The Brain Story. Alberta Family Wellness Initiative. http://www.brainstory.org/ (Accessed Aug 2019)
- The Beginning of Life, Netflix Series. https://www.netflix.com/ca/title/80107990 (Accessed Aug 2019)
- Robert Wood Foundation https://www.rwjf.org/en/library/collections/aces.html (Accessed Aug 2019)
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Though I work from this perspective I was delighted to read her article and how she transformed her approach and practice and began to screen every client. If this were the standard we’d be much further ahead in patient care excellence. I want all my students to read this article!
Thank you, Dr. Ali, for your insights and for sharing some of your own personal journey. So much of this remains missing in medical practice (and medical training, and medical culture). I am grateful for the resources you’ve shared here and tips on how you’ve implemented this. I hope these practices can become more widespread.
All physicians should have to learn about social services, social structure, cultural & social conceptualizations on normal, healthy, abnormal, and unhealthy. More than that, they should be taught to be much more critical evaluators rather than a cut-and-copy version of their predecessor. Courses in Anthropology and Sociology ought to help with that. The truth is: biology, medicine, and health care have all been so convoluted with the social world that understanding how each is “intertwined” is “essential”.
I am so excited to read this!
I am an Occupational Therapist working on a mental health outreach team. I am so happy to hear about your thoughtful self reflections that have lead to the change in your practice.
I am proud to say, trauma informed practice is the becoming the norm in OT mental health practice.
I can provide too many examples of clients dismissed by medical professionals simply because they are utilizing the only tools (substance use, self harm, frequent ER presentations, etc etc) they have to cope with extraordinary feelings surrounding trauma. Learning how to self soothe and regulate emotions in a positive manner is part of a healthy childhood. It is no wonder people with disrupted childhoods have learned maladaptive coping mechanisms… often simply to survive.
I have had experience working at a federal halfway house, a place where unfortunately Indigenous people were extremely overrepresented. Reading many of the “offender’s history, while many of their crimes were truly awful, every single time their childhood history was more difficult to read.
Finally, as a survivor of childhood abuse, I have experienced the first hand dismissal of my mental and physical suffering. It was only until I connected with doctors who understand TIP was I able to heal. I was lucky. Because of two fantastic doctors who are well versed in TIP and knowledge of ACEs, I was able to become healthy. I was able to finish my masters in occupational therapy, instead of being a “drain” on the system. Instead, I am actively contributing as a health professional dedicated to propagate the message you have so elegantly discussed.
Working in a wealthy part of Vancouver I’m always struck by how prevalent childhood trauma and parenting dysfunction is. I was delighted to read how the author came across this body of research and the direct impact it had on her daily practice from her chair. I particularly like the way she screens all her patients with a questionnaire. If we all read this and changed our practice we would be light years ahead in clinical excellence. Thank you
Mental health, family dysfunction, substance abuse etc are the visible tip of the iceberg. ACE’s are often the hidden, underlying part. Knowledge and understanding of ACE’s seems crucial to effective treatment and solving of these problems.
Hi Dr. Ali,
Thank you so much for writing this post! I am not usually one to comment in this way, but I really felt compelled to do so after reading this pearl. I am new to practice as of July, and had been directed to Nadine Burke-Harris’s book a few months prior. I also implemented ACE questionnaires at new patient visits and have had a very similar experience – no one is surprised when I explain the rationale, people are very supportive, and often grateful. (Coincidentally I have the exact same set up as you – laminated sheets with a wax pen, and I log the number in the “risks” portion of my CPP).
Again, thanks for sharing!
Thank you for highlighting this valuable aspect to integrated care Dr. Ali. I appreciate that you point out how trauma may impact anyone, and is not reserved for marginalized populations.
It truly takes a team approach to provide holistic care for patients. Counsellors and social workers play a vital role in helping patients work through trauma, as well as a number of other difficult mental health concerns that directly impact physical and overall health. It is often social workers or counsellors who do the bulk of trauma care, as many physicians are not trained, nor do they have the time to provide patients with the depth of care needed to support patients with the impact from ACE’s. Trauma is complex and the effects are far reaching – and this is exactly what counsellors and social workers are trained to help with. We are all working to improve the quality of life for the patients we work with.
Wonderful post! I have been aware of ACE for years, working in the downtown eastside and in mental health where the ACE scores are routinely elevated – especially in the 1st nations population, and this knowledge has informed my practice, but I do not have scores on my charts. I admire your systematizing it – with the laminated sheets – and I can’t agree more that the score should be on all patients charts.
Such important work you have done – your patients are very lucky to have you.
I now plan to get the score on all my charts too.
Thanks so much
Dr. Ali
Really appreciated your insights and application to practice. Bringing awareness to traumatic experiences in this way can further help other clinicians to step outside the comfort zone. I’m also learning about TIP and exploring how to integrate this approach in LTC homes. PTSD is more commonly referred to as it relates to the older population, however, there are so many other causes of trauma that are not disclosed or asked about. Less is known about people living with neurocognitive impairment who experienced ACE and how this presents in later life. Thank you for being an inspiration.