Front row: Bria Davis, Edwin Weaver (TRI), Linda Grabbe, Elaine Miller-Karas (TRI), Jordan Murphy (Community Advanced Practice Nurses Clinic), Barbara Gibson (Safehouse Director) flanked by teacher trainers. Taken at Emory School of Nursing where the CRM Teacher Training took place March 9-13-2020.
Linda Grabbe knows about the repercussions of childhood trauma. That’s because she spent 15 years as a family nurse practitioner in Atlanta homeless shelters where she worked with women, children, and teens.
“The Community Advanced Nurses Clinic is a little jewel of a clinic in Atlanta,” says Grabbe, a clinical assistant professor at Emory University’s Woodruff School of Nursing since 2005. “And it was there that I saw the connections between childhood physical and mental abuse, substance use disorders, and physical and mental health problems. Most of the women I saw had a complexity of issues that went way beyond post-traumatic stress disorder. Now I understand that they had experienced developmental trauma. How can a baby develop trust if the caregiver is a source of danger?”
She had read about ACEs science a couple of years after working at the clinic. Because her husband worked at the Centers for Disease Control and Prevention, which is headquartered in Atlanta, she knew about Dr. Robert Anda, who, with Dr. Vincent Felitti, is a principle investigator of the seminal CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study). She got his number from her husband and called him. This was in 2002, when ACEs was still under the radar for most health care professionals.
The ACE Study is the landmark study of 17,000 adults that found a relationship between 10 types of childhood traumas, such as living with an alcoholic or depressed parent or experiencing abuse or neglect, and the adult-onset of chronic illness, violence or being a victim of violence. Many other types of ACEs—including racism, bullying, a father being abused, and community violence—have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)
The ACE surveys — the epidemiology of childhood adversity — are one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, how toxic stress is passed on from generation to generation, and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.
“I live this every day, and I think you’re onto something here,” she told Anda. He responded by introducing her to Dr. Shanta Dube, one of the lead authors of the study who met with her a few times. Armed with the knowledge of ACEs science, Grabbe carried out qualitative research with women trauma survivors in drug treatment and found an overwhelming experience of childhood interpersonal betrayals among the women. She presented her talk, “The Triad of Childhood Trauma, Mental Illness, and Substance Abuse: Applying Trauma-Informed Care,” at the 2013 American Psychiatric Nurses Association, and gave research presentations at North Carolina’s first ACEs Summit in 2015. She also arranged a series of Atlanta’s first trauma-informed care workshops by the National Center for Trauma-Informed Care that were held from 2011 to 2014.
Grabbe says that she, like many other health workers, was suffering from secondary traumatic stress. “I was shaken by the stories I heard at the homeless shelters and the tremendous trauma my patients had experienced their whole lives,” she says. “They were beaten by their parents, sexually abused by relatives, and exposed to family violence. Referring to their sexual abuse, some women said, ‘I didn’t know it was child abuse and I really needed that attention.’” Any attention was better than being uncared for and ignored.
She says it still astonishes her that it’s taken 20 years for ACEs science to begin to permeate public consciousness and is only now gradually achieving recognition by health care professionals. “But still, most nurses and physicians have no idea what the ACE Study is,” she says. “We do a lot of education by teaching trauma-informed care and showing the film, Resilience.”
She grew up on the idyllic islands of Kauai and Oahu, where she earned a nursing degree at the University of Hawaii because she “always knew I could get a job in nursing.” Later, she moved to Washington, D.C., to get big-city experience.
While there, she worked at George Washington University Hospital when President Ronald Reagan was shot and taken into the ICU. She says that being in an ICU itself causes trauma, not only for the patients but also for the health workers who treat them.
After working as an ICU nurse at Emory University Hospital, she earned advanced degrees: a master’s in nursing education, a post-master certificate to become a psychiatric nurse practitioner, and a doctorate in nursing.
But with an itch to travel, she took her family—her husband and three young children—first, to Kazahkstan, where she was a Peace Corps Medical Officer treating Peace Corps volunteers shortly after the break-up of the Soviet Union in the mid-90’s. She moved again with her family to the Ivory Coast in 1999, where she was a nurse practitioner with the U.S. Embassy. Unfortunately, a civil war was brewing during her two-year stay, but it gave Grabbe insights as to how people under great stress can still be resilient.
That’s what motivated her to learn about and become a practitioner and teacher of the Community Resiliency Model (CRM) developed by Elaine Miller-Karas, author of Building Resilience to Trauma: the Trauma and Community Resiliency Models, founder of the Trauma Resource Institute, and a mentor to Grabbe. She helps people understand the biology of their reactions to stress and trauma, and then use CRM’s body-based techniques to expand their capacity for emotional balance. Through CRM training, participants learn skills to track sensations connected to their wellbeing or resilience. They can also use an “ichill” app for CRM.
During her training as a psychiatric nurse practitioner, Grabbe searched for models that would help her homeless and addicted patients.
“There are good body-based models for psychotherapy, which may be the most effective approach for trauma,” she says, “but hardly any of my patients were receiving any kind of therapy—they are just too marginalized. There are thousands of people in our communities who have high ACE scores who will never get the years of psychotherapy they deserve. CRM is a self-mental wellness care tool and is exquisitely trauma-sensitive—so it can help enormously.”
Grabbe and an Emory colleague, Kate Pfeiffer, also developed a one-hour introduction to CRM designed for the secondary trauma experienced by nurses during the COVID-19 crisis.
Grabbe says there’s evidence that the model works. In December 2019, she published a study in Nursing Outlook about a clinical trial with 77 nurses in two urban hospitals that demonstrated a significant improvement in wellbeing and resiliency and reduced secondary traumatic stress after a 3-hour CRM training.
Grabbe says she’s “passionate about teaching CRM to anybody who will listen. I learned to teach the model from Elaine Miller-Karas, and we teach together now, reaching national audiences.” In Georgia, she and other CRM researchers have trained at least 4,000 people.
“We teach it to incarcerated or homeless women and youth, and kids in trouble with juvenile justice,” she says. “Also, police officers, first responders, corrections staff, and healthcare workers. It gives people a common language and specific techniques to stay emotionally regulated. I don’t think anyone has done that with them before. It’s like giving a gift. For trauma survivors (which is most of us), there’s something very healing about it.”
As for working during the pandemic, she’s teaching a clinical group of nursing students at Emory via Zoom. The group has been going —virtually—into a drug treatment center and has had conversations with some of the key stakeholders there. Under Grabbe’s direction, the students taught and coached a large group of women who were in treatment about CRM, live, on their computers in their apartments during the shut-down.
“It’s simple, but so powerful because you can teach it quickly,” says Grabbe.
Right now, she’s working with other Georgia CRM teachers to get the model out to all the nurses and teachers in her state because of the pandemic. Reaching children and families who are struggling is critical.
“This work is the most important thing I’m doing right now and have ever done," she says.