Facing Our Past, Finding a Better Future – Adverse Childhood Experiences

This week I had the privilege of listening to Prof Warren Larkin, advisor to the Department of Health on Adverse Childhood Experiences. This is something I’ve written about on this blog before and Warren has made me more determined than ever to keep talking about this profoundly important issue. This blog draws on his wisdom and learning.

I believe that Adverse Childhood Experiences are our most important Public Health issue. So I want to be really clear about what they are, how and why they affect us so deeply, where we can find help if we’ve been affected by them and how together we can change the future, by preventing them.

 

What Are Adverse Childhood Experiences?

 

• Physical abuse
• Sexual Abuse
• Emotional Abuse
• Living with someone who abused drugs
• Living with someone who abused alcohol
• Exposure to domestic violence
• Living with someone who was incarcerated
• Living with someone with serious mental illness
• Parental loss through divorce, death or abandonment

 

How Common Are They?

 

The answer is – far too common. There have been some really wide ranging studies across the UK and USA into the numbers of us who have experienced ACEs, and it’s not just in our “most deprived communities” but in predominantly white, middle class areas where we see the stark statistics. Depending on the study you read, between 50 and 65% have experienced at least one ACE. And shockingly 1 in 10 of us have experienced more than 4.

 

How and Why Do They Effect Us?

 

Firstly, they affect us by quantity. The more ACEs we experience, the worse our physical, mental and social health and wellbeing is. If you have experienced one ACE, you have an 86% chance of being subject to several. If you experience more than 4, your health and wellbeing is significantly affected. If you experience more than 6 then you have a 46 times higher chance of becoming an IV drug abuser, a 35 times higher chance of committing suicide and an overall 20 year decrease in life expectancy.

 

Secondly, the toxic stress levels significantly change the way in which our brains grow and function. This has a profound impact on our day to day functioning. ACEs are a massive cause of absenteeism from work, high cost to the health and social care system and highly predictive of time behind bars. That is why so many of us have complex relationships with things like food. Losing weight, for example, is not as straight forward as eating less, exercising more or ending up with a gastric band. Did you know that suicide rates are massively increased after bariatric surgery? By removing the ability to eat, the very thing that takes away or comforts the pain, we expose the underlying issue, but provide no healing into that void.

 

Thirdly, our bodies literally keep the score of the negative experiences. So, we become more likely to develop chronic pain, inflammatory conditions, heart disease, cancer and mental health issues.

 

Fourthly, the toxic stress actually alters the way our DNA works and therefore changes the genetic information that we pass onto future generations. As an example, domestic violence in pregnancy is predictive of child developmental issues and offspring of the survivors of the holocaust or genocide are far more likely to develop chronic anxiety. This highlights just how important our family history really is.

 

Fifthly, there are proven things we can do a) to help our brains learn how to cope in the midst of really difficult circumstances (resilience) and b) therapeutic interventions that can genuinely heal us.

 

Where Can We Find Help?

 

Here’s the thing – this is where the rubber hits the road.

 

Many of us, who have experienced difficult things in childhood/adolescence never talk about them. Sometimes that’s because we can’t remember the experiences – they happen to us before our memories fully form. But perhaps more frequently we bury them because we don’t want to talk about the deeply painful memories, we don’t know how to or we’re worried about what might happen to us, or the people who caused us the pain if we do. And how do you start a conversation like that anyway? What? Are you going to just blurt it out to someone? And what on earth will you do if you just start crying in the middle of a restaurant when you talk to your girlfriend/boyfriend about what happened to you? And what about all those complicated associated feelings of shame, guilt, fear, thoughts of rejection? So…..we keep the lid on….even though it’s to our own detriment because we don’t know how to bring it into the open.

 

And here in lies the starting place. It’s vital that we learn this in the world of health and social care, but actually we all need to hear this incredible truth. Various studies have shown that it takes 9-16 years for people to be able to talk about trauma/abuse they experienced, but most never do. Fraser and Read found that in their patients struggling with mental health issues, only 8% of them volunteered that they had experienced ACEs. However, when they were actually asked about this, 82% then talked about ACEs they had experienced. So? So, we find it almost impossible to talk about, but when someone asks us about what we have lived through, it takes the lid off the box, peels the sticky plaster off the deep wound and allows us to begin talking about our pain. And here’s something really remarkable……Felitti and Andra found in a study of 140000 people that simply by routinely asking all patients about ACEs, they saw a 35% decrease in visits to the GP and an 11% reduction in use of the Emergency Department!

 

What does that mean? It means that giving someone the chance to talk about their journey, what they have been through, breaking the cycle of shame, fear and rejection is, in and of itself, deeply healing! Knowing that you’re not a freak, knowing that it wasn’t your fault, knowing that it doesn’t mean that you yourself will become an abuser/alcoholic/poor parent and many more realisations can make a significant difference to a person’s wellbeing. Maybe it doesn’t have to wait for a GP’s surgery or a counsellor’s chair. Maybe, just maybe if we all care enough to ask each other deeper and more caring questions we can help to heal each other. I know this is true of my own journey and that of many of my friends.

 

But let’s not be naive. For some of us, the experiences we have had are so horrific that we are stuck in a moment and we can’t get out of it. And this is where good therapy really comes in. I wonder if we invested more in therapy and less in drugs to numb our pain, how much more healed we might be – perhaps more expensive in the short term, but overall the cost is far less, both for the individual and society as a whole. There is help available and it can take many forms. EMDR, Trauma Focussed-CBT, Bereavement Counselling and even things like working through a forgiveness process. Unfortunately, many of the waiting lists are very long, and private options are way too expensive for most people to afford.

 

So, Can We Change The Future?

 

You know that I believe together we can! But it’s not going to be easy, especially not in the context of our floundering social services, restrictive school curriculums, reduction in numbers of health visitors and school nurses, eye watering cuts to public health budgets and significantly stretched CAMHS and Adult Mental Health Teams. And I think we have to very real and honest about that, because if this is such a massive issue in our society (and the data and evidence is astounding) then we need, as Warren Larkin so eloquently argues, genuine commitment from leaders and organisations to shift towards a culture of learning and collaboration to bring about change.

 

Here are some things we need to do together:

 

1) Own up to what a massive issue this is.

2) We need to learn how to ask our friends better questions and care enough to listen to each other’s experiences and journeys because it is really hard to know how to start talking about ACEs, but is more possible when someone bothers to ask!

3) We need to recognise that by bottling things up, we do further harm to ourselves. Perhaps some of our complex addictive patterns of behaviour, our mental health issues, our physical pain and symptoms might well be linked to the ACEs we have experienced. So maybe we don’t need a life on painkillers, cigarettes or with a complex addictive behaviour patterns. Maybe we can find a way to deeper healing.

4) In health and social care, we need to adopt REACh (routine enquiry about adversity in childhood) – we need to change the way we take histories from patients and ask better questions. Remember that even by asking, it doesn’t open up scary and messy consultations that we don’t have time for, actually it opens up a therapeutic space which can massively alter how a person goes on to use the health service in the future.

5) We need to ensure schools are more vigilant to thinking that ‘naughty’ or ‘difficult’ children are actually highly likely to be in a state of hyper vigilance due to stressful things they are experiencing at home. Expecting them to ‘focus, behave and get on with it’, is not only unrealistic, it’s actually unkind. Simply recognising that kids might be having a really hard time, giving them space to talk about it with someone skilled, teaching them some resilience and finding a way to work with their parents/carers via the school nurse/social worker could make a lifetime of difference. It is far more important that our kids leave school knowing they are loved, with a real sense of self-esteem and belonging than with good SATS scores or GCSEs. The academic stuff can come later if necessary and we need to get far better at accepting this.

6) Parenting classes should not just be for the well-motivated or struggling. They should be for all of us – a routine part of antenatal care and alongside our children’s education and include help in dealing with previous ACEs, so they are not repeated for the next generation. Prevention is possible. And that means we need to learn to be a whole lot less judgemental and a great deal more open, honest, vulnerable and restorative with each other. One of my best memories of growing up, was going to a “foster home” for families that my mum used to work with and seeing parents being given the chance to learn how to love their kids, rather than have them taken off them. I know sometimes there is no choice, but helping people learn how to be family and to love and cherish their children is a really beautiful thing. When there has been generational abuse, it is is also of the upmost importance. I’m not saying that a child should never be removed, but we can hardly say that our care system is a rip-roaring success story.

7) We need to find a way of working with men and women in our prisons that enables them to find a way to healing and restoration, not retribution for what are often extremely complex stories.

8) We must learn from best practice around the world. For example, did you know that the vast majority of paediphiles begin offending at the age of 14?! Most of them do not go on to become prolific offenders, but the damage caused to the child they abuse is obviously significant. There is some amazing work now going on in Pennsylvania which has shown that you can actually prevent young men from becoming offenders in the first place. Simply by doing some better sex education, explaining to boys about testosterone, the urges they are having and who it is appropriate to perform sexual acts with; alongside creating a really safe space where they can come and talk about feelings they are having (a bit like AA – with no ridicule or judgement) – data shows that you can decrease the incidence of child sexual abuse. We have to learn from this kind of approach and find a better way of talking about difficult issues. Prevention IS possible!

9) We need to find a way to fund more psychological therapies and become much less reliant on drugs to numb the pain with the associated colossal bill paid to Big Pharma.

 

 

This is an area I am really passionate about. I am committing to keep this conversation alive, to ensure that we make a shift in our organisations towards a REACh approach, to find a deeper and more effective partnership with colleagues in education, social services and the police and to create space for more training and awareness for all our staff teams. I know how painful this conversation is, but I also know how utterly damaging it will be if we don’t change the future and prevent this from being a perpetual story through the generations. It is time for the hearts of the elders to turn to the children. Together we can reimagine the future. Together we can.

 

 

Here is a really helpful film:

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A Collaborative Clinical Community 

*Warning – this blog contains swear words (not that I’m usually a potty mouth!)

This last week we had a gathering of clinical leaders around Morecambe Bay – Nurses, Occupational Therapists, Health Visitors, Midwives, Doctors, Surgeons, Physiotherapists, Pharmacists etc. We were gathered from across primary and secondary care to look together at the financial deficit we are facing as a health community across the Bay where we are seeking to serve our population.

The debt we’re facing (a hole of around 38 million of our English pounds!) is no small thing. Most of it is historic and much of it had nothing to do with us. I spent my first eighteen months as a commissioner feeling furious at the government. I wanted to rail against the machine, the injustice of working in such an oppressive, top down and hierarchical system, which feels like being among the Hebrew Slaves in Egypt when they were told to make the same number of bricks with less resource available to them. I felt so angry with the fact that we invest so little of our GDP into health and social care compared to similar countries and when further unthought through policies were dictated from Whitehall, I felt a total rage. It doesn’t help being politically pretty far to the left and working under a regime to which I feel ideologically opposed.

But one day, I realised two things. The first thing I realised is that the government are not going to change their position or policy. Our systems of government are not set up in a relational, collaborative or solutions focussed way. It doesn’t have to like this, but this is the way it currently is. Our systems have become the very antithesis of their purpose. Rather than serve the needs of the people, the people now serve the systems. The second thing I realised was that my anger didn’t achieve anything except to make me feel tired, disempowered and stressed. I had retreated into the less healthy parts of my personality in which I was keeping false joy alive and feeling burnt out in the process.

Truth has the ability to set you free. When we face truth, no matter how painful, it gives the choice of being more free. Facing up to the truth that the government are not about to change their modus operandi and that I was feeling angry and stressed allowed me to step out of rather childish thought processes and step into something altogether more wholesome. It allowed me to step out of a false sense and rather oppressive noun of responsibility and gave me the space to think more creatively about how I am part of a community of people who can respond to the situation we find ourselves in. We can respond (verb) once we step out of the oppressive yolk of responsibility (noun).

So, those of us in clinical leadership may have not created the financial situation, but there are some stark realities for us to face up to. Whether we like it or not, our current ways of working carry much waste, caused partly by the way the finances of the system operate, but also because we have not thought of ourselves as one. There are ways we behave within the system that create more financial problems and do not serve the community as well as we could. And so it is time for us to do what we can, within our gift by being much braver in our approach. I am suggesting that there are three Cs that are vital to our future.

  1. Collaborative

imagesWe need to reimagine ourselves as all being part of a team who are together tackling the health crises we are facing. We know only too well that, as just one example among many, we are failing kids with asthma because we have not joined up our resources or thinking adequately enough. Yes there are major issues with housing, smoking and pollution, but let’s not point the finger or push the problem somewhere else. Let’s use the phenomenal brains God has given us to pull the right people round the table and work out what we’re going to do about it. Let’s change the way we spend our time so that we’re in schools, we’re listening to our communities and we’re partnering together outside of our normal comfort zones to change the health of the generations to come. We know only too well, that if we don’t shift our focus towards population health and work more intentionally with our communities, doing things with them rather than too them, we will never win this battle. We’re not about playing political games. We are about working with our communities to create optimal health for every person no matter who they are or where they are from. We need to be braver, push the boat away from the shore we know and face the uncertain waters of working altogether differently. In my next blog I will explore some of the possible ways we could work differently.

2) Clinical

In order for the NHS to adapt and become sustainable for the future, we must not be afraid of clinical leadership. Our managers have a phenomenal set of skills, which we must draw on, but there is a trust we have amongst the communities we are embedded in that means they will trust us, if we engage with them properly that will allow us to turn this ship in a new direction. We must partner with our managerial colleagues, but be braver about the direction in which we know deep down we need to head in. We have gained so much expertise and trust and this is not a time to waste it or bury our heads. We must be braver and bolder in our vision of what we can really achieve together.

3) Community

iuAs clinicians we must, as many have stated this week, build bridges not walls. There is far too much division, suspicion and competition amongst us. (Here comes the swearing)…..I was in a conversation with a consultant colleague recently and he was relaying to me that another consultant referred to GPs as a “bunch of Fuck Wits”. In a separate conversation, one of my GP colleagues referred to consultants as a “bunch of arrogant Shits”. These kind of attitudes pervade the NHS and have created a culture of dishonour, distrust and division. Honestly! We’re better than this. How are we going to create the new workforce of the future that works across our currently artificial boundaries if we don’t teach them basic respect? This week a patient came to see me because he was dismayed at having to have seen a nurse at the hospital after suffering a significant condition and wanted to check that I, as a doctor, was happy with what he had been told. I could have laughed it off, but I wanted to stand up for my nursing colleague, who actually has far more expertise in this area of medicine than I do. The advice he had been given was perfect and completely in line with the best guidance available. We must not be afraid to challenge attitudes that are antiquated and out of place. More than ever, we need a culture of honour. A culture of honour is one in which we believe the best of each other, speak well of each other and appreciate our brilliantly necessary but differing gifts and expertise. We need to work out how we work effectively together for the best of the people we serve. We need to connect with each other and rehumanise the system in which we work. When was the last time you met as a cross cultural or multidisciplinary team and simply told each other what you love and appreciate about each other and the work you do? If we can’t learn to be more relationally whole, we will continue to work in the midst of serious dysfunction and strife. Come on – amongst us we have some remarkable gifts of wisdom, healing and hope. Let’s build the kind of culture and community amongst us that stands shoulder to shoulder, changes the story in the media and speaks with one voice to the powers that we are about the a new way of working together through relationship not hierarchy and fear. What might we really achieve together? It is this kind of collaborative clinical community that can change the future of healthcare, not just in the UK, but right across the globe.

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