When O’Nesha Cochran teaches medical residents about adverse childhood experiences in patients, she doesn’t use a textbook.
Instead, the Oregon Health & Science University peer mentor walks in the room, dressed in what she describes as the “nerdiest-looking outfit” she can find.
And then she tells them her story.
“My mom sold me to her tricks and her pimps from the age of three to the age of six,” she begins. “I could remember these grown men molesting me and my sisters. I have three sisters and we all went through this,” she says.
When she was 13, some adults enticed her to start smoking crack cocaine. “They knew if they got me strung out on drugs, they could sell me easily from person to person and that is what they did,” she says matter-of-factly. For the next 20 years, she tells them, she stole things, beat up a lot of people, and was homeless and in and out of the penitentiary.
“I tell this story very plainly and you can see their mouths drop open,” Cochran says. It’s exactly the effect she’s aiming for – that her story doesn’t match the wonky-looking teacher standing in front of them. It’s partly a lesson, she says, about making snap judgments based on appearances.
And that lets Cochran offer a deeper lesson: “Nobody is born thinking ‘I want to be a dope fiend. I want to be a criminal.’”
Cochran asks the medical residents to consider that under the circumstances she was thrust into as a 13-year-old, using crack actually helped her survive her trauma. “It made me feel beautiful. It made me feel invincible, like nothing can hurt me!”
At that point she says, she can see a light bulb go on in the students. “They think, ‘Wow, this is a little girl at 13 making a bad decision, but with the best information she had available to her at that time.”
This is how Cochran opens the door to the CDC-Kaiser Permanente Adverse Childhood Experiences Study, the groundbreaking research by the CDC and Kaiser Permanente that looked at 10 types of childhood trauma. This includes: physical, emotional and sexual abuse, physical and emotional neglect, living with a family member who’s addicted to alcohol or other substances, or who has mental illness. It also includes experiencing parental divorce or separation, having a family member who’s incarcerated, and witnessing neighborhood or family violence, such as a mother being abused.
Subsequent ACE surveys have demonstrated the obvious: ACEs aren’t limited to the 10 in the ACE Study. They also include racism, witnessing violence outside the home, bullying, spanking, losing a parent to deportation, living in an unsafe neighborhood, and involvement with the foster care system. Other types of childhood adversity can also include being homeless, living in a war zone, being an immigrant, moving many times, witnessing a sibling being abused, witnessing a father or other caregiver or extended family member being abused, involvement with the criminal justice system, attending a school that enforces a zero-tolerance discipline policy, etc.
The ACE Study found that the higher someone’s ACE score – the more types of childhood adversity a person experienced – the higher their risk of chronic disease, mental illness, violence, being a victim of violence and several other consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700 percent and the risk of attempted suicide by 1200 percent. (For more information, go to ACEs Science 101. To calculate your ACE and resilience scores, go to: Got Your ACE Score?).
Dr. Andrew Seaman, an assistant professor at Oregon Health & Science University who assembled the curriculum for the medical residents, has already introduced them to other aspects of ACEs science, including how a history of childhood trauma affects a child’s developing brain. Seaman first integrated ACEs science into the curriculum in 2014.
But Seaman understood that medical residents were perplexed in how to care for severely traumatized patients. “As a medical educator for the past five years, I’ve seen residents struggle to wrap their heads around the care of traumatized patients, especially those coping with addiction,” he says. “And I’ve come to see this struggle as a reaction to a vacuum of tools to care for the traumatized patient.”
That’s why he asked Cochran to teach the students about what it means to have experienced trauma. And Cochran’s personal story paves the way for what she and Seaman both think is of greatest value to their students — role playing.
Besides her personal story, Cochran incorporates into her role playing a mix of the traumatized patients she’s encountered as a peer counselor and certified recovery mentor for the Mental Health Association of Oregon at Oregon Health and Science University.
The medical residents take turns trying to interact with Cochran, with a typical interchange going something like this:
Medical resident: “Hi Miss Cochran, how are you doing today?”
Cochran: “How the fuck do you think I’m doing?”
Medical resident:”What will make you feel better?”
Cochran: “If you get the fuck out of here and leave me the fuck alone. That’s what will make me feel better. They be coming in here every fucking 5 minutes taking my fucking vitals.”
Several medical residents attempt to make inroads and fail. “They continue to ask their doctor questions. And I continue to be belligerent and angry,” says Cochran.
Then she models potential ways of responding. It could be, “I see you’re mad. Someone’s pissed in your Cheerios (a little humor, says Cochran, never hurts). “I really don’t know what to do. I have never been through a situation like yours. All I know is doctor stuff. But I also know that you’re an experienced person and your experiences have value too. What if we put my doctor experience and your experience together and come up with a plan that works for you. And if you’re not up to it today, I can come back tomorrow.”
Cochran says the biggest problem for medical residents is making peace with how they feel about the experiences of patients who have suffered trauma.
“Because the patient can feel the judgment. They can feel the fear. They can feel the pity and that’s the worst. It’s so disserving, because it doesn’t feel good.”
Seaman agrees, saying that he hopes that the medical residents – and eventually faculty — “become more attuned to their own visceral reactions to behaviors and diseases linked to early childhood trauma.”
But both he and Cochran understand how hard it is to field rage and swearing from patients. Seaman provides a number of techniques for residents to stay calm and take care of themselves. These include: Pay attention to how they’re feeling stress in their bodies. If necessary, step out of the room for a minute. Use grounding or centering exercises, such as deep breathing and remind oneself of the commitment as a healer to treat every patient the same.
Cochran has helped Seaman incorporate tips to help medical residents better navigate their interactions with patients who have or are currently experiencing trauma. These include ways to make patients feel safe and empowered:
- Ask permission to talk to them
- Acknowledge the patient’s strengths and don’t talk to them in “clinical child-speak.”
- Don’t block the exit.
- Be aware of body language. Don’t stand over patients.
- Don’t go into the room with a large team
- Don’t ask too many questions during one visit.
Of those points, she says, listening to patients is top of the list. “These people have never been heard. They hold the white coat up really high, no matter how street they are.”
The bottom line, says Cochran, is finding common ground with patients, no matter how different their lives have been, a point she repeatedly makes to medical residents.
“The [residents] have to find a time in their lives where they have felt so desperate that they would do anything to get what they wanted,” Cochran suggests. “And if they have felt that desperate, then multiply that by a thousand and imagine that’s how you lived every day of your life.”
I work with students at an alternative school and these techniques will help me. I have learned so much from. The students and they have learned from me the training she is offering is priceless. The student can feel when you are scared and show them pity all of which they don’t want. I want them to feel the love and concern that I have for them, because they deserve it. Thank you for this article.
Thanks Stephanie. I’m curious if you’ve been able to use some of the techniques at your school?
Thank you. Ive worked out I have a score of 8. Despite that ive been a high achiever until now. I have failed and feel like a complete failure and my back is so bad now. I physically and mentally cant work or cope. I have become a poor hermit in chronic pain. Now my biggest wish is to be pain free physically and mentally.
It’s great that all this information is finally coming out, but the focus is too narrow. What about those of us who are not in therapy, who are just average middle-aged adults and trying to heal ourselves?
Join ACEs Connection, our companion social network. There’s a community on there called Practicing Resilience that might be helpful.
I am really glad to see other residency programs looking at this type of work. A number of years back I helped our hospital system develop protocols for identification and intervention for human trafficking victims using our family medicine residents as a platform for education and training. Our residents now routinely identify victims within the hospital settings they work using survivor led victim centered trauma informed techniques. We subsequently developed a medical safe haven for human trafficking victims and survivors within our residency clinic where we collaborate with community agencies, social work, law enforcement/FBI, and provide longitudinal care using approaches we developed for those who have suffered severe trauma. Last year we were able to provide survivor led victim centered trauma informed care to over 125 new victims/survivors from Sacramento, CA averaging 5+ visits/each (500+ visits) in this safe haven medical clinic. We are providing continuity of care for these patients in the clinic, caring for them in the inpatient hospital setting, delivering their babies on labor and delivery, identifying them in the ER, and caring for them in the ICU. It has been incredibly successful, and the consistent feedback from organizations is that it has changed the game for them, allowing the trafficking victims to move from victim to survivor. It is also a truly viable low utilization construct for providing widespread medical care to victims while concurrently training our future physician workforce to recognize and appropriately treat this vulnerable patient population. By putting this education and patient care into residency clinics we could open over 530 centers for care across the country.
You can see our website with links to our protocols, testimonials, and a video made by a survivor who received care at our clinic at:
We are currently working to replicate the model at 10 locations/residency clinics throughout California over the next 2 years. Early study data is showing us a significant improvement in resident skills, knowledge and attitudes on concepts that translate to various vulnerable patient populations they care for.
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This is wonderful, Dr. Chambers. Are you expanding this approach to other types of childhood adversity, i.e., the 10 types measured in the CDC-Kaiser Permanente ACE Study as well as other ACEs that are being measured in other ACE studies?
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I am looking to find or develop training for my fellow Primary Care physicians and health care teams. I am hoping to find some evidence that shows better patient health outcomes and better provider satisfaction when we screen with ACE or other Trauma Informed screener. So far I’ve only found Risking Connection curriculum adapted through NIH R34, and the pediatric START program, but hoping to find something more validated – help?
Hi, Darrell: Here’s an article about a clinic in Pueblo, CO, that has integrated practices based on ACEs. It describes how they made the transition.
Here’s an article about a family physician who’s integrated ACEs into his practice in helping people addicted to opioids.
The National Council for Behavioral Health, in partnership with Kaiser Permanente, has worked with about 10 FQHCs, and is continuing to do so. Contact me at jstevens at acesconnection dot com if you want a contact there.
And consider joining ACEsConnection.com, our accompanying community-of-practice social network for people who are integrating practices based on ACEs science.
Hi Darrell, Stay tuned: Dr. Seaman and O’Nesha Cochran will likely be offering a webinar on the curriculum on our sister website acesconnection.com towards the end of March.
Is it possible for someone at your outfit to include a link to Facebook? We have needed this information for the last 50 years and I for one would like more people to know about it. Thanks.
On Tue, Jan 23, 2018 at 12:37 AM, ACEs Too High wrote:
> laurieudesky posted: ” When O’Nesha Cochran teaches medical residents > about adverse childhood experiences in patients, she doesn’t use a > textbook. Instead, the Oregon Health & Science University peer mentor walks > in the room, dressed in what she describes as the “ner” >
We posted this article on the ACEsTooHigh FB page; most of our other articles are there, too.
The good news is that this kind of horrific treatment of children is coming into the open. Places like this site exist for the abused to find their voice and rehumanize themselves. But, a lot of work to do.
Of course, these stories rip our hearts open.
I say these horrors are still unreported though, in incidence and to the wider community!