Dr. Alicia Lieberman is a renowned psychologist, professor, author, and researcher who directs UCSF’s Child Trauma Research Program. As a trilingual and tricultural Jewish Latina born and raised in Paraguay, she has a special interest in cultural issues involving child development, child rearing, and child mental health. In this episode, she explains how she helped develop the TRIADS framework, a model for adverse childhood experiences (ACEs) screening and strength-based counseling based on trust, empathy, consent, and mutual respect.
Dr. Alicia Lieberman is a renowned psychologist, professor, author, and researcher who directs UCSF’s Child Trauma Research Program. As a trilingual and tricultural Jewish Latina born and raised in Paraguay, she has a special interest in cultural issues involving child development, child rearing, and child mental health. In this episode, she explains how she helped develop the TRIADS framework, a model for adverse childhood experiences (ACEs) screening and strength-based counseling based on trust, empathy, consent, and mutual respect.
Here’s where you can learn more about the people, places, and ideas in this episode:
© 2021 Center for Care Innovations. All Rights Reserved.
This is an automated transcript. Please excuse any errors or hilarious mistakes.
Dr. Alicia Lieberman, PhD, is a renowned psychologist, professor, author, and researcher who directs UCSF’s Child Trauma Research Program. As one UCSF publication has said, Lieberman “has spent her career trying to prevent and undo the emotional damage inflicted on very young children in violence-prone homes. Rather than simply decrying this state of affairs, she has instead designed interventions that mend and cement healthy and loving relationships between mothers and their young, troubled children. Moreover, in a follow-up study, she has found that the relationship-based interventions she designed had lasting, positive effects.”
Simply put, Lieberman’s work and achievements are staggering. She is the Irving B. Harris Endowed Chair in Infant Mental Health and Vice Chair for Academic Affairs at the UCSF Department of Psychiatry and the director of the Early Trauma Treatment Network. She has written many critically acclaimed books on child-parent attachment. As a trilingual and tricultural Jewish Latina born and raised in Paraguay, she has a special interest in cultural issues involving child development, child rearing, and child mental health. And as part of the CALQIC program overseen by CCI and UCSF’s Center to Advance Trauma-informed Health Care, she has helped develop the TRIADS framework, a model for ACEs screening and strength-based counseling based on trust, empathy, consent, and mutual respect. In this segment, you will hear Dr. Leiberman as she talks about the importance of trust, dignity and consent in screening for childhood trauma.
I want to linger a little bit on the title of my talk triads framework, an approach to understanding helping, and healing people who experienced trauma. Because I think that it speaks to what Eddie said regarding the centrality of relationships in the way that we approach this initiative. And the implicit message is that screening is not enough that it needs to occur for the purpose of understanding how trauma is impacting health and how we use this understanding to help and heal. Again, the understanding helping, and healing people who experienced trauma and the centrality of relationships in this. Um, and I'm hoping that might talk, um, as I talk, I can help make the implicit message of screening is not enough explicit because that is how [inaudible] and CCI want to implement the framework.
I think we all hold this question of why screen for the ACS in primary care. And as Eddie said, I think perhaps the most succinct answer is that it's because screening can improve healthcare when done in a spirit of compassion and care, much research evidence shows that giving a name to difficult experiences and to the feelings associated with those difficult experiences. What we call speaking the unspeakable is actually helpful in regulating physiology and regulating this subjective experience of emotion and regulating behavioral expression of those emotions. And traditionally for thousands of years, healthcare providers, he find themselves as taking care of the body, the mind and the soul. And I think that we now want to help restore that tradition by why then in the lens of healthcare, to, to move from a bio DCS focus to a holistic model of care based on trust, where they provided and the patient work together in understanding how the patient's life experiences are affecting health and behavior and how to use positive influences to improve wellbeing. And this hope oriented approach we find and research supports helps both the patient and the providers in increasing satisfaction in the healthcare relationship.
We have to acknowledge that reality matters. And the epidemiological data shows that by age 16, over two third of children have experienced a traumatic event. This is a time where the brain is still developing when their sense of self is being formed. And when the understanding of what relationships are about is being created. So they're way that trauma imprints the brain with a sense of unpredictability and danger cannot be or verdict estimated. It's also important to remember that the first five years of life are the years where the brain develops most quickly. And we're simultaneously there is the highest likelihood of child abuse of witnessing domestic violence and of accidental injury often due to parental inexperience or actual neglect. And the brain is developed to respond to danger and to, uh, pain by freezing, fighting, or fleeing. And these experiences that are first emerging in childhood last, the rest of our lives. And yet there is always the opportunity to work with them, to reframe them and promote healthier responses.
The continuum of stress responses go from normative stress in response to everyday challenges. And that actually increases resilience because it keeps us alert and responsive to manageable demands. Now with COVID 19 and with the fires where the [inaudible] facing an increase in the range of stresses that go from burdensome, like Stan sheltering in place, uh, economic hardship, uh, feeling, um, worried about how we're going to cope to actual traumatic stress like illness and death, which overwhelm or coping responses, and make us respond with a persistent increase in stress hormones without a return to homeostasis so that this chronic elevation becomes toxic and outer zone emotions. So that were angry, depressed, anxious, and respond often either with aggression or with withdrawal or with a numbing of Arctic sense of empathy towards ourselves and towards others. And these awareness of their range from normative stress to toxic stress and the effort and the value that the primary health provider, the health care system has in helping patients identify their toxic stress and move towards the middle of the continuum or towards finding ways of making burdensome stress more normative in his response. That is I think the challenge that we're experiencing right now, and for that, I think we need to remember that stress lives in the body and that being seen and heard by a trusted person actually promotes trust and offers relief.
That is what enables us to grow in response to trauma. Uh, there is a wonderful song that you might know by Leonard Cohen and them where he talks about ringing the bells that can still ring on giving up our idea that perfection is possible and saying that ISA cracking everything. We are all wounded. And yet it is through our woundedness that we can help ourselves and each other. And we have to remember that suffering can stimulate a search for meaning compassion for others and emotional growth. And that is in the caring relationship that we have, that we can promote healing. And primary care is a place where that can take place. These, these, the spirit of the triad. It is, uh, an air force first and foremost, to give meaning, to use a holistic approach to healthcare that helps the patient understand, grasp their frame for why we do screening by explaining to them that ASIS affects physical and emotional health.
By that they have coping resources, sources of strength that will help them overcome their experiences of the stress, and they can become active partners, their treatment plan, and the triad then involves three core ingredients. They screening for ACEs, which shows is done with an empathic interest in the sense of what happened to you, assessing distress by asking supportively how the patient understands those early experiences of adversity and trauma as influencing how they are feeling in the heat on now and how they are behaving in response to distress, and then helping them identify who helps them and what helps them and use those strategies as integral components of the treatment plan.
None of this occurs in a vacuum on the elements of the triad framework, which are the screening and response occur in the context of a holistic approach that involves five elements. And as Eddie said, Sandra is my meal will tell you how those five elements are represented in the website and the five elements in both creating an environment that is calm, self safe and welcoming, both for patients and for ourselves and staff and our foundation as the second element of values and policies that are informed by an understanding of trauma and resilience, the environment, and the foundation become the context for educating patients about the connection between trauma and health and the role of protective factors and connecting them to resources for safety and healing, and that it UKs intern becomes the context for the screening screening for what happened to them. How do they understand what happened to them is impacting them and what, and who helps them.
And in response to the findings of their screening, their provider, uh, acts in acts our response that involves expressing empathy, empathy, addressing immediate safety and collaborating with the family on referrals to promote safety, connection and healing implicit in everything I said, I think is a response to a question that is often asked, which is concern of many primary care providers about retraumatizing patients in the process of, uh, screening for ACEs. And, um, I think that the fastest way of explaining why ACEs screening embedded in the context of also asking about distress and also asking about strengths in an environment that promotes calm and welcoming attitudes is that trauma is unpredictable, uncontrollable, overwhelming it shatters expectations of safety unpredictability, and it creates shame and guilt, the triads approach and the framework in which the triads approach is embedded. That's the opposite of all of that. So that it actually correct Strom, Arctic expectations and affirms that patient's dignity because it is done with consent.
It creates a manageable environment where there is a dialogue that is scaring and, um, invested emotionally between the provider and the patient. It gives meaning by explaining the rush now for the screening. And it gives the patient permission for maintaining control by asking for example, how are they, how are they feeling as we ask the questions and by saying to the patient that they can opt not to respond and is very clear in everything we do that what we're doing is for the decided to help. And that the patient is being empowered by becoming a partner in the treatment plan.
I think in doing all this, we have to remember that there are dangerous to caring that you, as primary care providers are in the front lines and that you hear and see a lot of difficult and overwhelming situations that can lead to burnout and to, by cardiac traumatization, those responses have always been real. They are now more than ever real because as primary providers, you are encountering your, all your own challenges in your everyday lives while having to remain responsive to your patients. And I think here, we need to remember self care to ease patient care and self-care is essential to remain effective on that. We need to practice what we teach our patients about cultivating time out protesting or private life, seeking out consultation and support from our colleagues and building support systems at work. We I'm sorry. Um, we also need to remember that there's a crack in everything and that mistakes can be repaired, that we are all learning together.
That's more changes mater, and that everybody can be therapeutic without necessarily being a therapist. And actually sometimes the most humble people in an organization can create the most transformational care through their investment in the people that they connect to. I think one thing to remember is that often the clinic staff with the least organizational power are the ones who are asked to do their screening, an orphan, that person, things that they are just supposed to kind of give the patient, the forms to fill out. And that eats the doctor who was going to have the therapeutic role in how to interpret the forums. And I think that it's exactly the reverse that the person doing the screening, regardless of hairdo or his position in the organization by being the first point of contact is the person that gives to the patients the message of how much the clinic cares and how interested the clinic is in the patient's experience and on how they are responding to those experiences.
And I want to end by reminding ourselves that we can all make a difference. One provider, one clinic, one healthcare system. At that time, I was driving around Santa Cruz before the pandemic. And so our graffiti that said, if nothing changes, nothing changes by an anonymous street philosopher. And it reminded me of what can Epstein said in creating his trauma transformed initiative, that educates systems of care to become trauma and resiliency informed. What will change when a system becomes trauma-informed everything on, I'm hoping to go back to that graffiti on, right? That quote underneath that the first one, if nothing changes, nothing changes so that we can provide hope. Thank you very much.