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 residents. “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?).
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 them 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.”