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Where There’s Smoke, There’s Fire

Posted By Kaitlin Leckie, Kristine Miller, Wednesday, February 15, 2017

 

During the 2015 CFHA conference plenary, Vincent Felitti likened poor health behaviors (e.g., smoking cigarettes; IV drug use; overeating) to the smoke in a house fire. If you see the smoke as the problem, and use fans to blow the smoke away, you will not only fail to put out the fire, you will fan the flames. Treating poor health behaviors as the primary problem, without attending to the real underlying issue(s), will have a similar effect, according to Felitti.

 

Felitti’s analogy reminds me (KL) of the Process Model of Addiction and Recovery (Harris & Tabor-Wilkes, 2011), whereby the desire to cope with negative feelings caused by underlying pain (be it spiritual, emotional, relational, physical, etc.) drives the decision to adopt an unhealthy or compulsive behavior (e.g., hoarding, smoking, IV drug use, alcohol, overeating). While this behavior may provide an instantaneous but short-lived rush of relief, the resulting feelings of shame and guilt are longer lasting. This perpetuates the experience of pain, thereby re-starting the cycle.

 

The pain that people are trying to overcome often began in childhood, as a result of what Felitti, Robert Anda, and their research team (1998) call Adverse Childhood Experiences, or ACEs. The main categories of these experiences include household dysfunction, neglect, physical abuse, psychiatric disorder of a parent, parental substance abuse or incarceration, childhood maltreatment, and sexual abuse. These experiences can be objectively scored on a questionnaire. Scores range from zero to ten. Ten indicates that the respondent experienced an event in each of the ten categories at least once.

 

An ACE score of four or more (at least one event in four different ACE categories) correlates strongly with increased prevalence of chronic disease in adulthood, as well as a high prevalence of multiple unhealthy lifestyle behaviors, such as smoking, IV drug use, and promiscuous sex (Felitti et al., 1998). In a sampling of findings from the longitudinal ACE study, Felitti and Anda (2010) summarize other strong and significant relationships of ACE scores to biomedical disease, psychiatric disorders, unhealthy behaviors, and healthcare costs.

 

During the plenary, Felitti highlighted that people who are seeking to relieve their pain are mostly interested in feeling relief as quickly as possible. They typically are not thinking about the long-term consequences of their choice. Hence the ineffectiveness of telling a smoker about the likelihood of future lung disease. Instead of inducing behavior change, the response is akin to: "Smoking provides me relief right now, which is what I need.” Until the underlying pain is addressed/treated, the likelihood of people being willing to change an unhealthy behavior they have adopted to help them cope is pretty slim.

 

Aside from understanding this truth, successful intervention should rely on a multi-faceted approach; comprehensive and integrated health care is an ideal way to address and treat pain from the past. Yet, we can do better than that. Particularly in primary care/family medicine, we train clinicians to be proactive, not merely reactive. As such, prevention of ACEs is vital for individual, family, and population health.

 

At our primary care clinic, Southern Colorado Family Medicine (SCFM), the proactive approach we developed to prevent ACEs for our patients is called SCAN: Score, Connect, and Nurture. First, we educated our entire clinic staff about ACEs and then trained our clinicians how to talk to patients about ACEs. We now assess ACEs in expectant parents and parents of 0-18 year old patients, focusing our efforts on breaking the cycle of ACEs often observed across generations. We perform universal assessments on this targeted population because ACEs affect everyone, regardless of sociodemographics. We educate parents about what having experienced ACEs means for their health and what can be done to try to decrease the risk of their children going through some of the same experiences.

 

The SCAN intervention centers on meeting participants where they are. For example, with parents who have experienced ACEs, the clinician normalizes and explains that some people feel they have overcome some of their difficult experiences from childhood but may feel "tripped up” by others. To help meet their specific needs, all families are offered resources by a family resource specialist, a social worker embedded in our clinic by a local community resource organization. Examples of resources offered include parenting education and support with home visits by a community-based parenting specialist, financial assistance, children’s books, and mental health treatment referrals.

 

Of the many success stories we have had throughout the year, one example that stands out is one of our first SCAN families. This couple was expecting their first baby while facing multiple psychosocial concerns. In addition to having minimal social support, they were being evicted from an apartment that was later condemned. Of the ten main categories on the Adverse Childhood Experiences questionnaire, the expectant mom endorsed 9 of them, and the soon-to-be father had experienced all ten ACE categories, a score of 10 out of 10.

 


 

Yet, their ACEs scores and their struggles represent the beginning of their SCAN story, not the end. Both parents also scored highly on a measure of resiliency--also part of the SCAN intervention--indicating they were resourceful and skilled at successfully overcoming challenges. They were scared and voiced a strong desire to parent their child differently than they themselves had been parented. They were motivated to get help in order to be the parents they wanted to be to their child. We provided them with a supportive and understanding healthcare environment, and our Family Resource Specialist linked them with several resources to boost their confidence and enhance their skills.

 

Ultimately, we assisted them in locating safer housing, helped him get a new job, connected them with mental health services, and enrolled them in a parenting education and home visiting program for continued support after the baby was born. The impact of the SCAN intervention, including their perception of our healthcare environment as safe and accepting, was made evident when, after a later traumatic event occurred, they returned to our clinic to seek additional care and support.

 

The adoption of unhealthy behaviors is not the only explanation behind the strong connection between ACEs and later development of chronic disease, as pediatrician Nadine Burke Harris explains in her TEDMED talk on the profound ways in which the ACE study changed her clinical practice. Even so, reframing our way of looking at unhealthy behaviors--not as problems themselves but as adaptive solutions to problems--broadens our perspective and increases the likelihood with which we are able to intervene and help patients to adopt healthier behaviors.

 


References and suggested resources:

www.acestudy.org

http://www.cdc.gov/violenceprevention/acestudy/

Burke-Harris, N. (2014). How childhood trauma affects health across a lifetime. TEDMED 2014.

Felitti, V. J., & Anda, R. F. (2010). The relationship of Adverse Childhood Experiences to adult medical disesae, psychiatric disorders, and sexual behavior: Implications for healthcare. In The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Ed. Lanius, R. & Vermetten, E. Cambridge University Press.

Felitti, V. J., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences Study. American Journal of Preventive Medicine, 14, 245-258.

Harris, KS, Smock SA, Tabor Wilkes, M. (2011). Relapse Resilience: A Process Model of Addiction and Recovery. Journal of Family Psychotherapy 22 (3), 265-274.



Kaitlin Leckie, PhD, LMFT, is the Director of Behavioral Medicine at the University of Texas Medical Branch’s Department of Family Medicine in Galveston, Texas. 

Kristine Miller, D.O., is a faculty physician in Pueblo, Colorado, at Southern Colorado Family Medicine Residency, where she serves as the Clinic Director and Director of Osteopathic Education. 

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