Trauma-Informed Care and the Future of Wellness
University of Vermont Health NetworkPlattsburgh, NY
Trauma-Informed Care and the Future of Wellness
University of Vermont Health NetworkPlattsburgh, NY
Forensic psychologist Dr. Aron Steward explains the importance of trauma-informed care to the future of children’s health, and the health of our society.
Melding her expertise in psychology and criminal justice, forensic psychologist Dr. Aron Steward explains the importance of trauma-informed care in serving high-risk populations. Dr. Steward sheds light on how pediatrics, criminal justice reform, and alternative therapies can work together to bring greater equality to our communities.
The history underneath stress behavior
Dr. Aron Steward is the Chief of Psychology at the University of Vermont Health Network. From 2015-2019, she managed the Juvenile Detention center for the state of Vermont. She spends a lot of time in the inpatient psychiatric unit, and specializes in the reduction of high-level interventions, such as seclusion of inpatients. Eloquent, energized, and passionate, she describes her complex work in simple terms: “I’m always focused on trying to reduce violence wherever I am,” she explains.
This focus is how Dr. Steward introduces her work as a forensic psychologist. “It doesn’t frighten me to work with people who are dangerous. Our culture views anger, aggression, and violence as criminal behaviors. I view it as mental health behavior arising from trauma.” In other words, behaviors we are taught to view as individual dysfunction are often symptomatic of generational or systemic traumas. This understanding is foundational to Dr. Steward’s work, and it’s the undercurrent that flows through her extensive background in medicine, law, and psychology.
Dr. Steward speaks at length on seeing through behaviors to the trauma underneath; understanding those behaviors and their origins in the brain is essential to working constructively with her clients. Based on Adverse Childhood Experiences research, Dr. Steward points to a few places in brain development that are critically impacted by toxic stress or traumas. “One of those areas is impulse control,” she says, “which is directly related to consequential thinking and behavior prevention, as well as reactivity.” While mainstream narratives around mental health may say that a convicted felon is simply a “bad person,” trauma-informed practice says otherwise. “The real outliers are folks who are criminally violent and cannot identify having a trauma history,” Dr. Steward says.
“A trauma brain is hyper-vigilant, reactive, and paranoid, in the sense that it is always on guard,” she explains. “Therefore, the trauma brain is much faster to react and protect than someone who is not in trauma or has not had substantial trauma.” This essential awareness of trauma history, and thus the best way to treat patients and clients, finds its roots in the landmark Adverse Childhood Experiences (ACEs) study, first conducted in 1998.
“The ACEs study undeniably showed a substantial link between number of traumas and the health conditions of the participants over a long period of time.”Dr. Aron Steward
What determines ACEs?
This trauma-informed approach may be unfamiliar to some, but Dr. Steward’s equanimous perspective has its roots in data — specifically, the ACEs study undertaken by the Center for Disease Control (CDC) and Kaiser Permanente from 1995 to 1997. The study found that ACEs contribute to negative adult physical and mental health outcomes, and affect more than 60% of adults. Chronic illnesses, like heart disease, obesity, and alcoholism can be linked to ACEs. ACEs research is part of advancements in medicine that endeavor to look at life, “not as disconnected stages but as integrated across time,” writes Dr. Bessel van der Kolk in an ACEs summary for the American Academy of Pediatrics (AAP). Adverse childhood experiences can include: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, household substance abuse, household mental illness, parental separation or divorce, or an incarcerated household member. Further, ACEs are more likely to affect people living in poverty.1
There are many illnesses the medical community did not think were linked to trauma before ACEs. “The medical community was really clear for a long time that medical issues were directly linked to genetics and the way you care for your body,” says Dr. Steward. “The ACEs study undeniably showed a substantial link between number of traumas and the health conditions of the participants over a long period of time.”
The effects of stress on brain development
Using ACEs to understand and inform care requires a nuanced understanding of stress. The study cites brain research that identifies different types of stress. We can experience good stress, which experts categorize as positive or tolerable. “Good stress” aids the development of resiliency. We can also experience negative or “toxic” stress; stress that is too great for a child’s undeveloped coping mechanism to handle without the support of a “buffering” adult relationship.2 Continued exposure to toxic stress, which can begin before birth, has serious consequences for brain development and can affect parenting ability. Van der Kolk claims that “adults who have experienced ACEs… can exhibit reduced parenting capacity or maladaptive responses to their children.” ACEs can become a generational vicious cycle.
Toxic stress impairs the brain’s ability to regulate emotions, and the stage that precedes regulation: emotion identification. In her work with youth, Dr. Steward sees substantial emotional dysregulation.“Youth who have had substantial trauma are both impulsive and emotional,” Dr. Steward says. “Emotions hit more rapidly and strongly for people in trauma. So it becomes very difficult for kids to identify that they’re having feelings, identify what those feelings are, and then manage and regulate them.”
Therefore, traumatized youth and adults are often both impulsive and emotional, due to the influence of trauma on brain development. These dysregulations lead to, “a whole host of behaviors,” Dr. Steward explains. She lists self-harming behaviors, property destruction, criminal activity, and substance abuse as some of the most common and recognizable. “The brain without trauma has created obstacles and barriers to behaving unsafely. The trauma brain doesn’t have these barriers.”
ACEs-informed care in action
Dr. Steward explains in her own terms what ACEs has done for the medical community: “For a long time we thought that people who were sick or mentally ill were weak because they hadn’t been strong enough to avoid adversity,” she says. “The ACEs study said that actually, a lot of these scenarios are preventable, if we ensure that children are safe and have fewer adverse experiences in childhood. So it becomes more of a cultural and systemic conversation, rather than an individualized conversation where some people are weak and some are strong.”
It seems that key to preventing ACEs lies in an interdisciplinary approach to both health care and criminal justice, and Dr. Steward’s work does just that. Forensic psychology is the field where mental health intersects with law, and Dr. Steward identifies it as, “all of the aspects of psychology that treat populations that have mental illness and are involved in the court and criminal justice systems.” Her work in forensic psychology draws on the findings of the ACEs study and its subsequent integration into medicine, psychology, and justice. Further, Dr. Steward’s background exemplifies the dexterity needed to meaningfully work with ACEs populations; she holds a PhD in counseling psychology, and is continuously building her toolkit of alternative therapies. These alternative therapies include everything from art therapy to bird watching, all with the intended outcome of regulating stress in the body and brain.
Dr. Steward describes the effects of the ACEs study as varied and complex. “There are pockets in the country where the ACEs study has changed the way we practice,” Dr. Steward explains. The AAP corroborates this claim in a 2018 report: “The ACEs framework has served as a useful tool for raising awareness of the prevalence and impact of childhood trauma, and has thus helped to create opportunities for advancing both science and practice.” But, Dr. Steward, continues, “there are places where [the study] hasn’t changed anything, because no one knows about it. And then there’s a lot of places where people have become familiar with ACEs but they don’t know what to do about them. They don’t know how to prevent further childhood adversity.”
Dr. Steward first identified forensic psychology as her calling while working in a downtown jail during her PhD program. “It’s an incredibly cold environment,” she says. “It was an old complex with traditional holding center values, which were to count the inmates and keep them alive, and that’s it. And I felt every day that I was the luckiest person on earth to be able to work there with people who had story after story of being raised with generationally criminal, mentally ill, or substance abusing families. I prefer to serve people who have lost their freedom, so I can work hard to get them their freedom back by getting them safe.”
Dr. Steward’s conviction on the subject of forensic psychology speaks to her genuine passion for the work. “I realized early on in my career that the populations I’m most interested in serving are aggressive and violent populations,” she says. “I feel most comfortable working with people that have been substantially traumatized, and then have translated that trauma into harming others. In order to get to that population, I have basically only ever functioned in a forensic psychology environment.”
“I believe it’s my calling,” she continues. “Meaning, if I don’t do this work, there aren’t that many other people who are going to do it.”
“There is always a social justice component to my work. I know that if I were in the situation that some of my clients are in I would want someone to help me.”Dr. Aron Steward
Treating childhood trauma as social justice work
The U.S. has the largest prison population in the world, so perspectives like Dr. Steward’s are integral to changing our approach to criminal justice. According to the Vera Institute of Justice, by the end of 2018 there were an estimated 1,471,2000 people in state and federal prison in the U.S.3 In her book The New Jim Crow, legal scholar Michelle Alexander writes that our current legal system does more to segregate our society than to protect its citizens from crime.
In an interview with NPR, Alexander explains that: “People are swept into the criminal justice system— particularly in poor communities of color—at very early ages… typically for fairly minor, nonviolent crimes. [Young black males are] shuttled into prisons, branded as criminals and felons, and then when they’re released, they’re relegated to a permanent second-class status, stripped of the very rights supposedly won in the civil rights movement— like the right to vote, the right to serve on juries, the right to be free of legal discrimination and employment, and access to education and public benefits.” Further, incarceration does little to reform the behaviors that landed someone in prison in the first place, and negatively impacts children of incarcerated adults. Some research indicates that children of incarcerated parents are six times more likely to become incarcerated themselves.4 What’s more, about 60% of criminal offenders that end up in the justice system have at least one mental health problem,5 but may not have access to mental health services in or out of prison.
While the disenfranchisement of the prison population is gaining national attention, perspectives like Dr. Steward’s are still outside the scope of mainstream discourse. “The justice system was built unfairly from start to finish,” she says. “Our society has oppressed and harmed groups of people, and their trajectory in life is poor because they haven’t been treated well.”
“There is always a social justice component to my work,” Dr. Steward continues. “I know that if I were in the situation that some of my clients are in I would want someone to help me.” What does ACEs-informed social justice look like? Dr. Steward offers the example of food security. “ACEs has given us pinpoints to work on in the prevention of the epidemic of health conditions that disproportionately affect people living in poverty,” she says. “For example, if we are able to help children feel food secure rather than food insecure, or help parents access mental health treatment, we can prevent ACEs and thus prevent illnesses later in life.” For patients without access to early ACEs interventions, Dr. Steward practices a range of therapeutic modalities to treat present manifestations of trauma.
Therapeutic tools: “every creative solution you could imagine”
Treating complex trauma histories, particularly with an eye towards reducing high-level interventions or imprisonment, requires tireless experimentation with different modalities based on each individual’s needs. Referring to her work at Vermont’s Juvenile Detention and Rehabilitation Center, Dr. Steward explains: “I want the kids to get better, so eventually you have to try everything—every creative solution you could ever imagine.”
Dr. Steward says her myriad approaches fall into two buckets: trauma therapies and alternative therapies. In large part, these therapies are utilized differently based on cost. “Insurance companies may reimburse for certain trauma therapies, but it can be incredibly difficult for them to reimburse for alternative services,” Dr. Steward explains. Alternative therapies like nature therapy and mindfulness-based stress reduction have been recognized as effective modalities to treat mental health disorders like anxiety, depression, or PTSD. A study in Psychosomatic Medicine concluded that mindfulness meditation produced better immune function and reduced cortisol levels in participants. But significant data does not yet exist to support the efficacy of these therapies.
Further, medical providers may feel pressure to prescribe medications that correct for chemical imbalances in the brain, even though there can be disturbing side effects to long-term use of certain drugs. According to CNN, lobbying activity for the pharmaceutical industry hit $27.5 million in 2018. “Medical providers are often thinking: what’s the next pill? What can I prescribe? And they don’t always think of prescribing walks outside, or swimming in a lake,” Dr. Steward says. “But nature can be the best medicine we have.”
She speaks from experience. Dr. Steward was born and raised on a tiny farm in Vermont. In recent years, she has reinvigorated her study and practice of nature, animal, and wilderness therapies, and she is interested in how nature might be reintegrated into medical care. “I spent the majority of my early years outside,” she says. “Those nature experiences got me through a lot of the trauma that was around me.”
The potency of her own nature experiences, and her drive to find success with alternative therapies, led to the opening of a bird program at a juvenile rehabilitation center. When a friend offered to teach a lesson on birds to Dr. Steward’s patients, she says, “the youth dove deeply into it, and began bird-watching in the rec yard on a regular basis.”
“I was able to see that some kids, who can’t talk to people or don’t want to be around people, can find peace and comfort and be in the present moment if they are in nature,” Dr. Steward explains. “This is so important with the trauma brain because trauma makes it really difficult to be in the present moment. This is one of the hardest skills to learn, because for people with trauma the present is frightening.”
Work with animals may function as nonverbal healing therapy. “There are so many reasons why people may not be able to put words to why they’re acting out,” Dr. Steward says. “Language development is not on board with a lot of early childhood trauma or adolescent trauma. When your limbic system is activated—the survival part of your brain—then executive functioning is shut down. Sometimes when we look at a patient and ask them why they are acting out. Often that person also does not have the capacity to understand or articulate.”
Some youth are so acute that they can be a challenge for a whole team to manage. “I worked with a kid who had a very harmful and traumatic history, and this youth’s self-harm was so serious, but they had no words to describe their choices or their sadness,” Dr. Steward explains.
The lessons in ACEs for all patients
As long as alternative therapies are undervalued culturally, economically, and institutionally in the U.S., many resources will remain unavailable for “our populations who need them the most,” says Dr. Steward. “There are significant populations in our country who don’t have access to nature. Certainly our incarcerated population doesn’t have access. Often it’s the most acute and most traumatized populations being taken out of environments that make them well.” Dr. Steward says that she has “treated kids where nothing else works for them other than animals and nature. We’ve gone through every type of treatment and nothing works, and then you put them outside and they start to get better.”
Dr. Steward thinks that all of us, adults and children alike, can regulate ourselves in nature. “Alternative services like nature therapy aren’t what all kids are offered, but they are what all kids need, and have used for generations to manage energy,” she says. Practitioners working with children who may not have trauma can still prescribe nature to manage all kinds of conditions, from ADHD to depression. Children without ACEs still need to manage energy, express creativity, and learn to identify their emotions.
“I apply alternative therapy to my own life,” Dr. Steward says. “I love my work, but I can’t show up fully for my clients if I take that work home. I go for walks, I try to eat good food, I spend time with loved ones, I give and receive hugs.” Small acts of self-care can create ripples in a system where the mainstream narrative says we cannot be well on our own.
In order to learn more about trauma informed care, Dr. Steward suggests a rigorous research process. “Many people use this phrase,” she says, “and so when I advised people on how to learn about the topic, I encourage them to look for well accredited and credentialed people and organizations. In particular, seek out folks that have been practicing for a long time, have specialty training in trauma and the brain, and are well recommended.” ACEs researched Dr. Bessel van der Kolk gave an in-depth interview in 2013 on trauma, therapy, and the brain that merits a listen.
She recommends that pediatricians “read the ACEs literature with a fine tooth comb and begin to think about what fits in their practice. Does it fit to screen patients and families for ACEs? Does it fit better to educate the staff? Or perhaps they can invest in early childhood programs and engaging their community in trauma prevention curricula.” Dr. Steward stresses that the most important takeaway from the ACEs initiative is that one size doesn’t fit all, and the solution that works in one area or one practice may not work in another.
Furthermore, Dr. Steward suggest that an important element of trauma informed care is practitioners’ understanding their own trauma history, and thus caring for those experiences to prevent vicarious and secondary trauma while caring for traumatized patients. She continues, “Maybe most importantly, the ACEs study asserts that we must view patients’ behavior and mental health from a trauma-informed perspective. This approach ensures that we are not pathologizing and mistreating the response of a child growing up in a frightening or chaotic environment. We have to approach these patients with thoughtfulness, creativity, and resiliency, as otherwise we are at risk of missing the target in early childhood when there is still substantial opportunity for growth and change.” Oftentimes, pediatricians are the first people to professionally work with a child when something is wrong. Dr. Steward concludes: “It is critically important for us to know how to screen for and heal trauma in children so that they have the best chance of health and wellness in adulthood.”
[1] Van der Kolk. Adverse Childhood Experiences and the Lifelong Consequences of Trauma. 1998 ↑
[2] Center on the Developing Child at Harvard University. Key concepts: toxic stress. 2014. ↑
[3] https://www.vera.org/downloads/publications/people-in-prison-in-2018-updated.pdf ↑
[4] Megan Cox, The Relationships Between Episodes of Parental Incarceration and Students' Psycho-Social and Educational Outcomes: An Analysis of Risk Factors (Philadelphia: Temple University, 2009). ↑
[5] William R. Kelly. Why Punishment Doesn’t Reduce Crime. Psychology Today. 2019 ↑
Emily Graf is a freelance writer, wilderness educator, and English teacher living in Colorado. She is passionate about telling stories that promote equal access to quality health care. She can be contacted at emgraf11@gmail.com for inquiries.
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