Carl Maronich (Host): Welcome to the Kirby Connections Health Podcast, where we help to nourish your wellness journey with Kirby Medical Center. I'm Carl Maronich, your host. And on this episode we'll be talking about trauma and the impact on a person's health and wellbeing. And to guide us in this conversation, we have Anna Crawford, Wellness Coordinator with Kirby Medical Center.

Anna, welcome.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Thanks for having me.

Host: Delighted to have you here. And, and maybe we should start by talking a little bit about your background. You know, exactly what a wellness coordinator does and, and your background, what got you to this point and kind of all that you bring on this topic.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah, well, I'm definitely a lifelong learner, so my initial education was in dietetics. From there, that followed credentials in exercise. So I did group exercise, I did a yoga training. I became a personal trainer, and I got a master's degree in exercise. That led into just wanting to keep learning nutrition.

So I went back and got a second master's degree in nutrition. That really opened up the opportunity to step into this role here at Kirby and figure out what does it actually take to help somebody change their health? What does that actually look like to inspire somebody to figure out one, what does optimal health and wellbeing look like for them?

And what are the steps that they want and need to take in order to see success with that? And through that work, listening to real patient experiences, I started to realize that everything I knew in nutrition and exercise wasn't the whole story. My first step then was to be curious about wellness coaching, which seemed to broaden the conversation just a little bit.

We can think about the wellness wheel that takes into account your occupational health or your environmental health, your social connections. So I really loved the structure of a wellness coaching session, but that still wasn't quite the whole picture. And so I started to get really curious about the potential underlying traumas that some clients, not every client, but some client would present with.

And so started to dig into some of the research of trauma, did mentoring with other dieticians and healthcare providers, to try to understand what are we talking about when we're talking about trauma and how does that show up when somebody's trying to make life and health changes? And so just an example within the field of nutrition, that really drew me in, one of the initial studies that started to quantify the experience of childhood trauma, so the Adverse Childhood Experiences Study actually was published in 1998, and that study came out of an obesity treatment program. And it was from listening to clients talk about their life experiences that they started to realize, hey, there are some underlying factors here that impact, for certain individuals, their eating behaviors that may impact their chronic health indicators.

And so that study was really a foundational study that showed this correlation between prior trauma and not just mental health concerns, but physical health concerns as well. And so that just further spurred on my interest in this topic to try to learn everything that I could. So I went ahead and did a three-year program in somatic experiencing, and I'm actually, I don't know if I'll stick with it, just started a social work master's degree. So I have a learning problem.

Host: And it sounds like all that learning has brought you to the point where you're, you're really helping people, that's what it's about, helping people and particularly those that have, have, have suffered trauma. And then let's talk a little bit about the definition of that. When you talk about trauma, what all does that incorporate?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah, there's a lot of definitions for trauma. So you can find slightly different definitions out there. But one that I particularly like is this idea that trauma is an overwhelming experience or a series of experiences without sufficient support because that points to our intervention. So almost every human at some point in their life is just a part of being human is we're going to have something hard happen.

If there's enough support at the time of that experience around that experience, the likelihood that there's going to be ongoing lasting impacts of trauma are mitigated to an extent, particularly those kinds of situations where something overwhelming happens and there is not support are the times where we're more likely to see ongoing challenges that can show up for that individual.

Host: Is it fair to ask them the kinds of trauma we would be talking about? Specific examples of what they might be.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah, so I really wanted to be sensitive to this during this conversation, because there's so many different types of trauma that someone could experience. So some of the early research was done around before PTSD was even actually a diagnosis, was done coming out of military service and some of the studies that were done trying to understand what kind of support was needed after that experience, which could be overwhelming.

This ACES, Adverse Childhood Experiences study really highlighted the potential role of childhood trauma. But we could expand to a variety of other traumas as well. So more recently we've had some really interesting evidence coming out about discrimination and racial trauma and how that correlates with chronic health concerns.

We could look at even socioeconomic factors. So financial stressors, building up over time could be a form of, of trauma. It is hard to define different types, but one category that's used are kind of big T, very acute traumas. Something that's one incident that happens that may be very even life threatening.

It could be a car accident, it could be a natural disaster. It could be an assault or an abuse versus, and there's limitations in any definition, but versus small T trauma, which might be something that's more chronic and ongoing, such as bullying or lack of food access, or, just any variety of the different kinds of challenges we experience that we often minimize, we often minimize those little T trauma experiences.

So hopefully that helps as a starting definition.

Host: Yeah, and I would guess that trauma doesn't impact everybody the same. So what in fact impacts one person isn't going to necessarily to the same degree impact another. So I'm sure the work you do kind of gets to that and roots that out a bit.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah, and I just want to be clear that I'm not currently a mental health provider, so more this awareness and understanding of trauma I think is important for every healthcare provider to have. Because any patient you know, clientele that we're working with, some segment of that, usually a fairly large segment, is showing up with prior experiences that may impact their interaction with us and may impact their health behaviors in their life.

So I'm not necessarily assessing or treating trauma per se, but it informs my full picture of that person to understand how that might impact the health changes that they're looking to make. And in terms of how different individuals might impact how trauma would impact different individuals differently, that's such an important piece. So two people that go through a car accident could have very, very different ongoing impacts from that. So it's why that sensitivity of how we talk about trauma, how we, what assumptions come along with someone disclosing a trauma within us, understanding, oh, what's my bias? That showing up when I hear that that was their experience, is so important. Just because we don't know for sure how that life experience impacted that individual.

Host: Sure. You talked about PTSD and you know, that's, I think an example of things that don't affect everyone the same. Two soldiers may come back, one affected, one not, and, and you just don't know. So I guess part of the thought there is not to, to minimize if one isn't suffering, one is, buck up, be like your brother. It doesn't bother him. Why does it bother you? That kind of thing I, I see can potentially happen.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah, and just to highlight another interesting set of research is if we have layers of trauma, we can see greater risk. So if we are starting with that childhood trauma and we compare military personnel who have underlying childhood trauma versus those who don't, the risk for PTSD and ongoing impacts actually increases based on that underlying level of childhood trauma.

And we can see that in a lot of these different potential adult experiences we might be in, that those can be, build on top of any prior childhood trauma, and we can see greater risk coming outta that.

Host: Another term that may be talked about that maybe we should get a definition for is trauma informed care and what exactly that is.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah. Trauma-informed care is a model that's been designed to really be used more at the organizational or like systems level of change. It applies to the individual patient, person, employee as well. But it's more of a, a model. And one way to think about trauma-informed care is it's a shift from what's wrong with you to what happened to you, to what's strong about you, and it feels really different

if someone's viewing us in those different lenses. If someone's viewing us with a lens of what's wrong with you, that feels yucky. If someone's viewing us with a lens of what's strong about you, that's like, oh my gosh, that's really cool. They want to see the good in me. So that's one way to think about trauma-informed care.

There's another model that's called the Four Rs that's used to describe trauma-informed care. First is realizing, realizing that trauma is widespread and impacts many individuals. Being able to recognize, recognize is the second R, the signs and symptoms of trauma when it does show up and interact.

 And that could be within like a coworker, employee relationship, but it also is in a healthcare provider patient relationship. Responding. So actively making changes either in the environment, in the way an appointment is structured, in the registration process, any way that we can respond to help decrease potentially contributing to lack of awareness of someone's experience of trauma and how that's impacting them.

And then finally, is resisting retraumatization. So trying to anticipate what those potential challenging environments might be for someone, if that's maybe lack of control. If there's a medical procedure where you don't, you can't move, that could potentially be a challenging environment. Or really trying to anticipate what those needs are and resist retraumatization when we can.

Host: Kind of to build on that, what are the strengths and challenges that survivors of trauma often have?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: So I've gotta pull out my list for this one because there's a lot of strengths and there's a lot of potential challenges. And we can talk about some of these that I listed or more. But one is a high level of empathy and compassion, and so very often, when someone has experienced something challenging, they have an awareness of the pain that they experienced and they want to prevent that for somebody else.

So we could see that even just in like when someone forms a, you know, a not-for-profit organization to help others that have maybe had a similar life experience to them. We see some interesting research for helping professionals. So, helping professionals like teachers or healthcare providers, are found to sometimes have higher levels actually of childhood adversity that may be a contributing factor for going into that field.

So we tend to see really that high level of empathy and compassion there. Trauma survivors, they tend to be, especially childhood trauma survivors. So some of these, and again, I want to bring sensitivity that these strengths or challenges are not necessarily going to be the same for everybody.

 Just that there is a uniqueness there. But we could potentially see that, especially for those childhood trauma survivors, they had to be very attuned to their environment and the people around them. So they may be very, very good at reading facial expressions, tone of voice, picking up on kind of the unspoken emotion in the room. We can see that after somebody goes through something challenging, they may lean on maybe a spirituality or a faith, or even for a kid it might present as like magic, that there's this comfort sometimes in having that response to something really challenging. We can see that a lot of times, trauma survivors are very hypervigilant, so they're wonderful in a crisis.

They're really good at responding very quickly to what needs to happen. We often see some shame and self-hatred and often very high levels that go along with all different types of trauma, but especially again, that childhood trauma category where a lot of times when we're in a more challenging situation, especially if we don't have control over it and it's overwhelming; we may feel like it's our fault that that happens.

And so that can get internalized as a sense of shame or, or really high self-hatred. As a dietician with food and eating, I often see that show up as shame and hatred around body size and weight. So that's one place that that does show up often in my work.

 We see that traumas often, the impact is underestimated. We tend to minimize that experience is pretty common for someone after a challenging, overwhelming event. And memory is sometimes shifted in weird ways because of the way the body responds in moments of stress. So that can be a confusing layer there potentially in understanding what happened.

Host: Does that speak to the idea that they may not remember it or they delete it from their memory or they remember it differently? Or how, how does that kind of impact the go forward?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah, this is an ongoing area of study and research. I think you'll find differing opinions. My views are informed by some of the training I did in somatic experiencing, where we're working to separate the verbal story of an event from the physiologic body story of an event. And by slowing that down, sometimes we can get new insight that may be verbally, there weren't the words to describe it, but the body knows that experience and so

that, I think ambiguity can be very confusing if someone's coming out of a traumatic experience and trying to understand what actually happened. That can take a long time with support to actually piece together different aspects of that.

Host: I was going to ask about another term and that's stress response, what that means and how does it manifest oftentimes?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah. Okay. So if there was that 1998 Adverse Childhood Experiences Study that showed a correlation, what we've seen since then in the evidence that we have and the research that we have, is a growing awareness of all the underlying mechanisms of chronic disease. And so our stress response in the short term, the acute stress response, is a really normal reaction to being in a scary experience.

So an example that's often used like if a tiger or a lion came in here, we need our body to be able to react. We need to be able to either fight or run, or worst case scenario, we just play dead and that's the freeze. And so that is actually built into our physiology. And a lot of processes start happening in our body in that moment that we aren't consciously controlling.

And so we're going to see that our immune system revs up. We're going to see that our hormonal system, endocrine system is revving up and coming on board. We're going to see that our metabolism changes. So as a dietician, I'm really interested in that when our body goes into stress, it starts to release more fuel so that we're ready to run or we're ready to fight.

And so that stress response in the short term is very important for us and it's very effective. And in a healthy nervous system, we're going to see that come back down to a stable, balanced place. That's the ideal, is that when a nervous system has flexibility, it can expand into that stress response, no problem.

When it needs to, it can come back to a baseline calm state, no problem when it needs to. Now, if we imagine maybe chronic ongoing trauma that doesn't stop. And that could be a lot of different things. It could be domestic violence, it could be other life circumstances, maybe a caregiving role. It could be other life circumstances that go on for a really long time and the body stays in this heightened

chronic stress response; then we can see that that does contribute to some of the other underlying mechanisms that we have more research for now. So it contributes to inflammation in the body, which is one of the driving mechanisms under a lot of our chronic health concerns. It correlates with changes in our microbiome, which is also often correlated with their chronic health concerns.

We see that it can impact, especially at younger ages, it may even change kind of the structure and function of the brain. So we see that that stress response when it stays isn't good for us. And there can be a point where that starts to contribute to, sort of those physiologic changes that line up with chronic disease.

Host: So things like, you know, we talked about being a dietician, nutrition and eating that may, you know, is a way that we deal with some past trauma or addictions. Do those factor into it in some way?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Yeah. So if we're trying to go back to that basic question of how come that ACE Study found such an interesting correlation between childhood trauma and physical health indicators for diabetes, heart disease, cancer, chronic pain, why did they find those correlations? And a correlation means these two things happen together.

So it opens the question of why do those two things happen together? Why are they finding that? And so there can be that underlying stress response, that physiologic mechanism change within our body that we probably don't even necessarily notice that that's happening. And then there's definitely potential impacts on our health behaviors.

And we know that there's also correlations between prior traumatic experiences or even a stressor of any kind and the health changes or choices that we may be making. And so when we have a coping mechanism that's showing up, sometimes that could be a useful coping mechanism, but there's often a time where it could potentially be a harmful coping mechanism as well.

 I think though it can be very affirming to share the actual change in the physiology too. Because I think we're quick to blame the health behaviors without understanding that there's this other component that's present impacting health risk too.

Host: What can someone do if they realize, you know, come to realization that they've gone through a childhood trauma, or they, that's starting to impact them in some way. What, what actions can they take?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Well, I think mental health counseling and support is a wonderful, wonderful resource. And if you are in a stable place and ready to move in that direction, that would be the first step. If you feel like you are in a less stable place, then knowing your emergency resources that are available.

And that could be starting with the 988, lifeline number. And if you need to, that could be reaching out to your emergency services, going to the emergency room. But as long as you're in a stable space, I think finding a mental health provider that you can start to establish that rapport with is a really important first step. When we're looking at all the different kinds of support that are available and we're looking at what is kind of a, a treatment plan to help take care of the physiologic body changes as well; then we do start looking at, are you eating nourishing foods? Are you able to do some gentle movement every day? Are you able to, in any way possible, maximize your ability to sleep and get some, some rest? Do you have a support system and who would be a part of that?

So those lifestyle factors come into play too, and that's what we would focus more on in health and wellness coaching appointments. So doing both mental health counseling, and health and wellness coaching can be a helpful tool, but definitely not going without that mental health provider as a support through that.

Host: Very good. Anna, anything we didn't cover that you want to make sure that we mention?

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Just to again, say, I try to be as sensitive as possible when I'm talking about this, but knowing that I don't know everyone's experience. So just knowing that your experience is valid and seeking support is definitely an important step of healing. So just affirming that.

Host: Absolutely. Anna Crawford, Wellness Coordinator with Kirby Medical Center. We thank you. A lot of great information, you provided today.

Anna Crawford, MS, RDN, LDN, NSCA-CPT, NBC-HWC: Thanks so much for having me.

Host: For more information, you can go to kirbyhealth.org. You can search mental health. You can search Anna, Anna Crawford and find it more from there. She has a great video that talks about the work that she does.

And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest. I'm Carl Maronich, and this is Kirby Connections Health Podcast. Thanks for listening.