[00:00:00] Dr. Jeremy Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
This episode is brought to you by PAR. The TSCC and TSCYC screening forms allow you to quickly screen children for symptoms of trauma. Both forms are now available through PARiConnect; PAR’s online assessment platform. You can learn more at parinc.com.
All right, y’all, welcome back to another episode of The Testing Psychologist podcast.
Hey, this is the first episode in a little mini-series on trauma-informed assessment with Dr. Julia Strait. I’ve been meaning to talk about trauma on the podcast for a long, long time. And, honestly, I had a hard time tracking down an expert. I’m so thrilled to have Julia on for this two-part mini-series where we’re going to be talking all about trauma and assessment.
So part one which is what you will hear today really focuses on the definition of trauma. So we’ll talk about acute trauma versus developmental or complex or ongoing trauma. We’ll talk about trauma and what it looks like in kids versus adults in terms of outcomes and presentations and so forth. One thing we’ll also get into is the idea of concept creep. So this is the idea of how you delineate between “real trauma and just events that were traumatic” if that’s even a thing. So, as you can see, just asking that question is an interesting sort of philosophical question to consider that has real implications. So, we’ll dig into that quite a bit as well as how we define trauma. Is it according to someone’s personal experience or diagnostic criteria or what?
[00:02:11] So, in part two, we’ll focus more on the assessment component. I will talk more about that when the episode is released in a week. But for today, we’ll do a nice deep dive into the nature of trauma, how it’s defined, and what we might be looking for in our assessment process.
Let me tell you a little bit about Julia. Julia is a psychologist. She specializes in treating young women with everyday stress, as well as more pervasive emotional difficulties like depression, anxiety, and of course, trauma.
She’s a nationally certified TF-CBT therapist, that’s Trauma-Focused Cognitive Behavioral Therapy. She has specialized training in mindfulness, self-compassion, and acceptance-based therapy approaches as well. She does a lot of assessments and she conducts training around the country for schools that are trying to integrate a more trauma-informed approach to their work.
So Julia earned her bachelor’s degree from the University of Texas and master’s and Ph.D. from the University of South Carolina Gamecocks. She did her post-doc at Child Welfare and Trauma-Informed Care at the University of Tennessee Center of Excellence for Children in State Custody. She has worked as a teacher, professor, researcher, and supervisor in schools, clinics, and universities across the Southeast United States.
[00:03:37] In her free time, she likes to listen to podcasts, go outside, eat Cayson and do yoga and Pilates. She has two kids and an awesome dog. And she also blogs for Psychology Today. The link for that is in the show notes.
All right, before we get to the episode, as always, I want to invite any beginner practice owners to check out the beginner practice mastermind which is a group coaching experience just for beginner practice owners. So, if you’re looking to launch your practice in 2021, this might be right for you. This group will be starting in March 2021 with six psychologists. The group is really aimed at building accountability and helping you solve those problems that might be tough to solve on your own. If you’re interested, go to thetestingpsychologist.com/beginner and check it out.
All right, let’s jump to my conversation with Dr. Julia Strait.
[00:04:53] Dr. Sharp: Julia, hey, welcome to the podcast.
[00:04:55] Dr. Julia Strait: Hello. Thanks for having me on.
[00:04:57] Dr. Jeremy Sharp: Yes, of course. Thank you so much for reaching out. It’s nice when guests pursue me instead of the other way around. So, I really appreciated that.
[00:05:09] Dr. Julia Strait: Yeah. Well, I’m a fangirl of the podcast and podcasts in general. So I was like, hey, I think I can talk about something, right?
[00:05:17] Dr. Jeremy Sharp: For sure. No, I love it. And then, as we got into some conversation, we figured out that we have a connection in Columbia and South Carolina which is very cool.
[00:05:26] Dr. Julia Strait: That’s right. Best city in the world. I feel like, I don’t know, maybe Gamecocks.
[00:05:35] Dr. Jeremy Sharp: Maybe too. We’ll leave it at that. I love it. We’re here, we’re going to be talking a lot about trauma-informed assessment. I’m really excited to dive into this. I know you’ve done a lot of work in this area, a lot of presentation and education. This is a topic that shockingly has not been covered in-depth on the podcast yet. So, I’m really thrilled to be able to have this conversation here today.
[00:06:03] Dr. Julia Strait: Well, yeah, I think that’s widespread. We did a study two of years ago, a survey of all school psychologists which you would think in schools it would be a bigger topic- which it’s becoming bigger, but we did a big survey and like, 80 to 90% of school sites said, “Yeah, we’d like to do this stuff.” I feel like I have some knowledge to offer. But a very small percentage of them felt that they actually had training or support enough to do it. And so, hopefully, that’s changing.
[00:06:33] Dr. Jeremy Sharp: I hope so. Well, and hopefully this will be a part of that change as well, and just exposing more people to the info.
[00:06:38] Dr. Julia Strait. All right.
[00:06:39] Dr. Jeremy Sharp: So let me start just with a standard question to open these kinds of podcasts which is, why is this work important to you in the first place?
[00:06:51] Dr. Julia Strait: Great question. This is the origin story question, right?
[00:06:56] Dr. Jeremy Sharp: Yeah.
[00:06:57] Dr. Julia Strait: Superhero. Well, I’d be lying if I said that it was not personal at all. Definitely, I don’t necessarily have a trauma background, but I definitely have had people close to me who have, and so that’s always been in the back of my mind. My original career was I was a high school teacher and I worked with a lot of kids who had varying degrees of traumatic things and circumstances. I was really always fascinated and wanted to work more with kids on that level which is why I went back to school.
I went to the University of South Carolina in the great city of Columbia, South Carolina to study school psychology so that I could unite this interest. When I got there, I was like, I’m just interested in everything, and my advisor convinced me to do more of the research side, neuro-psych. And I think, looking back, I was like, well, this is a sure bet. These things are objective. This is less wishy-washy. I want to stay far away from the emotions and the counseling and the trauma like that, it’s interesting, but it’s just hard to deal with it.
And so, I really heavily pursued neuro-psych and cognitive development research and all kinds of just avenues that way. But along the way, it kept coming after me. So I feel like everywhere I went, trauma kept coming after me. So, in my first practicum in the schools, I had a very easily LD only right? And we had a case, we were sitting in a meeting for report feedback and this girl, we were prepared to say she has a learning disability, and at the meeting, 6 people showed up that we didn’t even know were in her network. one was from family services, one was from it, and we had no idea. Her records didn’t show anything. And it turned out she had this long history of abuse. And so we had to say, “Let’s go back to the situation room and revise.” But everywhere I’ve gone, people are always like, “Oh, we don’t have that here. You don’t have to worry about that here. Maybe you’re just not looking, right?
So, that’s really fascinating in the fact of just human psychology where people can convince themselves like, “Oh, yeah, what I do is totally separate from them” which I had to kind of convinced myself like, no, neuro-psych is really totally separate. Of course, it’s not. The brain, all of that. So getting ahead a little bit, but I came to my senses a couple of years later and did just a full postdoc at the University of Tennessee Center of Excellence for Children in State Custody, we call it the COE. And it’s part of the UT health science center. I don’t know if listeners, like if you’re in the school psych world or clinical, they have an APA internship there at the Boling Center for Developmental Disabilities, but our branch was… we only worked with kids who were in custody or at risk of coming into state custody.
And so, pretty much everything I know, I learned there about how to actually intervene, how to assess. And we did tons of assessments for kids all the way like 2years and up who had come into state custody and were having either developmental problems, emotional problems, the whole range, that’s where pretty much I learned everything I’m going to talk about today. And people there were absolutely amazing like just a big group of psychiatrists, nutrition people- a very multi-disciplinary team. So that got me very interested in it. And when I went into Academia, which was what got me back to Houston, I chose to study ACEs and some of the trauma literature a lot more. I kind of shifted and bridged that.
[00:10:36] And we did a lot of studies with my students on like college students who had had these traumatic experiences and how were they coping? And also, how are their executive functions? How has their cognition, so how can we bridge these things? And those things are still actually going on at the university that I’m working with students on. So this year, I decided to just do private practice because I really wanted to get back to how we were in Memphis, like actually getting to see the kids, actually getting to work with people, that was really important to me.
So now I do a lot of assessments and therapy, not all with kids with trauma, but like I said, if you know what you’re looking for, it starts to pop up everywhere. It’s like when you buy a new car and you’re like, “oh, all these people have Jeeps.” Or once you’re trained in trauma, you’re like, “Oh my gosh, look at all this stuff going on that I didn’t even think about as trauma before.” So, yeah, it’s pretty prevalent.
[00:11:33]Dr. Jeremy Sharp: Right. Well, I know that that’s going to be a major topic that we cover. And yeah, it really gets at that question, I think that we’d like to… just the way our brains work, …we’d like to separate things. We’d like to say like, “Oh yeah, this is a trauma case, or this is an LD case, or this is autism, or this is ADHD,” but the direction that the field is growing and it seems like these categorical models just don’t really make sense for diagnosis and conceptualizing folks. So, that question like what is trauma and how do we find it is just getting more and more important.
[00:12:10] Dr. Julia Strait: Yeah, absolutely. When I was thinking about today, like, what are we going to talk about and what do I want to make sure that I say, I think that is a really important point. What lured me into psychology in the first place was, “Oh yeah, I can put people into these boxes and they’ll make sense.” and then I can do something about it and I’ll have this control and this understanding. But the categorical models like you said, just don’t fit with trauma or anything else. But I think, especially with trauma, I do a lot of training with school personnel and I just want to reiterate, the very first question is always like, well, we don’t diagnose PTSD in the school, so we have no use for this. And it’s like, well, regardless of what diagnosis, which we’ll talk about the difference between the diagnosis of PTSD versus just traumatic experiences, regardless of what box you’re going to put them in, to me, the goal obviously with all cases but especially these guys is actually finding the best recommendations, the best resources to plug them into. And so it’s kind of like a moot point of what diagnosis they have.
[00:13:09] Dr. Jeremy Sharp. Sure.
[00:13:10] Dr. Julia Strait: So that’s not really the point. But that being said, of course, we have to work within the constraints of our system. So we’ll talk about that. But yeah, I think, paint by number was a really alluring thing to me. I could just put this person in the autism box and…
[00:13:26] Dr. Jeremy Sharp: I think for a lot of us because we want to be helpful and at least early in our careers and maybe later in our career. The way to be helpful is to know what you’re helping and categorical systems really lend themselves to that, at least they seem.
[00:13:44] Dr. Julia Strait: Yeah, of course. And it’s very easy. And that’s how our brain works, right? Like, “Okay, we need to put this in a category so that we can respond to it appropriately.”
[00:13:51] Dr. Jeremy Sharp: Right.
[00:13:51] Dr. Julia Strait: But I think that I mentioned before when we chatted just informally a metaphor that I started to think about for trauma is, instead of thinking of it as a box, I think of it as… so you’re taking your paint by number, but then someone’s spilled like the whole water cup on your painting and now, you still have some of those colors and you still have some of those outlines, but there’s no honoring that bell, there’s no putting that water back in, and there’s no say in where it stops and where the other thing begins. So that comes up a lot too. Like is this symptom right here caused by trauma or by something else?
[00:14:27] And it’s like, I don’t know, I don’t have a crystal ball and there’s no counterfactual. So remembering that I think is really important which most I think like it’d be us, clinicians, understand that about most diagnoses nowadays. Like you said, it’s not a nice little box. I think especially with trauma, it is like someone dumped this huge bottle of water all over your painting and you can’t… I’m just imagining my four-year-old crying because you can’t undo it. And so you’ve got to now look at it as more of this mosaic that’s bleeding together and it could still be beautiful. It’s still as beautiful in its own way. We just have to learn how to look at it.
[00:15:06] Dr. Jeremy Sharp: Right. Okay, well, we’ve got a lot to talk about. We’ve teased the audience too much already.
[00:15:13] Dr. Julia Strait: Okay.
[00:15:14] Dr. Jeremy Sharp: So let’s just dive in. Let’s start at the beginning. So talk about how you define trauma and the different kinds and what it looks like. Yes, let’s start at the beginning.
[00:15:29] Dr. Julia Strait: Yeah, so there’s a 10-hour seminar on that, you know.
[00:15:33] Dr. Jeremy Sharp: Yeah, I know.
[00:15:36] Dr. Julia Strait: It really is so nuanced, but you know, I always go back to SAMHSA-Substance Abuse and Mental Health Services Administration. I had to practice that this morning. I knew I was going to mess up. But seems to have this kind of definition that they put out that guides research, and I think that’s the best one to go by. And they explained it as trauma is not one thing, it’s not the event, it’s not the symptoms, it’s three parts. So it’s the 3E’s. So, it’s the event itself. It’s the experience of the event which many people by now I’ve heard, it’s how you perceive it and not necessarily the objective proof of it, and then also the effect. So just like our other categories that are capturing the whole idea of functional impairment in your daily life.
So you have to have all three for us to consider that ‘trauma’. Although, I’m not going to argue with someone if they say like, “Well, I feel like this was traumatic.” If I’m in therapy and someone says that, I’m like, “Okay, let’s explore why you think that, and obviously, that’s impacting you.” That’s a different question from, ” Do you meet these criteria?” But of course, if someone feels like they’ve experienced something traumatic, then who am I to argue with that?
That being said, I do think there’s this idea of concept creep. So, when we call everything trauma, what’s our bar there? So if you look at assessment instruments, there might be a cut score on a certain measure which we understand as psychologists. It’s the severity and the frequency. It’s how much it disrupts your life. But a lot of people lay public, for example, like we don’t tend to think of it that way, we just think of like, Oh, well it was really scary, and it was a big deal or that there was violence and it’s very kind of nebulous idea.
And I think it’s just interesting to think about. And again, I’m not going to be the one to draw the line. I don’t claim to have that power, but I think there are different questions you have to ask like, are you asking if you meet the criteria for PTSD because that is sort of an easy question that I can put you into that box. But if you’re asking like, has that cup of trauma water spilled on you a little bit? Okay. Well, like I said, if you’re saying that I did, then let’s figure out what the effects are. But I think that is a helpful starting point. The event, how you experienced it, and then the effects. And when we assess that, we look at all three of those things.
[00:18:00] Dr. Jeremy Sharp: Yes, I like that definition. It’s kind of an alternative definition, I guess, and just looking at like the DSM criteria. There are some parallels for sure but breaking it down makes it a lot simpler I think.
[00:18:15] Dr. Julia Strait: Yeah, it’s just a little broader because PTSD criteria, they’ve changed it quite a bit from DSM-IV, but of course, you can look it up and try and memorize it. That criteria in (A) that exposure piece, so have you been exposed to an incident? That’s the event, right? So it kind of maps on. So we know that there’s a number of events and I didn’t want to talk about a little bit the difference between single incident trauma versus complex or developmental trauma which is probably a whole another rabbit hole. Do you want to go down that now or do you want me to wait?
[00:18:48] Dr. Jeremy Sharp: No, I think that’s important. Yeah, when we were talking about what is trauma, I hear a lot of like big T versus little t, I hear a lot of like chronic versus acute, there’s this [00:19:00] developmental versus complex versus single. It’s all the same ball of wax. So yeah, if we can untangle that, it’s okay.
[00:19:07] Dr. Julia Strait: Yeah, when I talk about this to teachers and stuff too, I always have this big, loose Venn diagram of all these things. And I think they’re all poised and ready to take notes on where the points are that I’m going to tell them. And I’m like, ” Okay, spoiler alert, I don’t know where all these things end and the other one begins,” but all those things you just said are things that people use to refer to it right? And even sometimes we hear the word crisis kind of put into that as well which in the schools we’d make the distinction of like a crisis like an acute single event that the goal is just recovery in the immediate aftermath.
But can a crisis then turn into something traumatic? Yeah. If you look at all those effects. So, we have to remember that the PTSD criteria, the idea of trauma, big T trauma really came from war veterans, and so, [00:20:00] not that it’s one event. My brother is a veteran. I understand that it’s not just one thing. He had some chronic exposures that were not optimal. [00:20:10] So not to say that’s a ‘single event’, but it is an event trauma or a shock trauma in that there was a before. You had a life before that, and you had ideas about the world and about relationships before, and so now that’s been disrupted. And so, that kind of trauma, school shootings, a hurricane, that’s a lot of stuff we’re dealing with in my area, pandemics- even though it’s an ongoing incident, that really a lot of kids there was a before and there will be an after. And many adult clients I deal with, maybe they had a sexual assault or rape or someone was murdered, these kinds of things where of course it’s going to be super disruptive. But you can put a marker there, like, okay, I have something to compare it to.
And where we get into the other side of it which is kind of the other version that I think of, the chronic or the developmental or the complex trauma, which is all sort of, like you said, the same ball of wax, to me, that’s the traumas in which there was no before or there was a very brief before. But technically we think of complex trauma as like there are three kinds of components and it’s early, so early in your life and childhood usually, chronic- so ongoing, and within the primary caregiving system. So someone who was supposed to love and take care of you, but did not. And so those are kind of those components of the other kind, which is there was no before. And that’s the kind that can really disrupt relationships, attachment, internal working models of the world, your views of yourself. It’s a similar thing, but it can have a lot of different implications for treatment and for recommendations.
[00:22:02] It used to not be a ‘fit’ like in DSM-V, they’re thinking about putting in developmental trauma disorder and they didn’t and people were mad. What an ICD 11, there is complex trauma as a diagnosis. So if you use like your EHR systems or whatever, that is a diagnosis you can put in for ICD 11 and there’s even a scale that I just recently found and I’ll give it to you for the show notes, but it’s called the ITQ, the International Trauma Questionnaire, and it really gives a nice conceptualization of complex. So, first, it asks about PTSD criteria DSM-V style, and then if you meet that and in addition have these three extra things, then they will call that complex trauma. And that I believe the three extra things are, one of them is disruption of relationships, of course, one of them’s affective regulation problems, and then I think the third one is that really severe self-esteem like self-blame kind of negative beliefs about self.
And so those are the extra things. You get PTSD, plus you get all these other things. So that’s definitely different things. And I will say, it’s kind of a caveat that most of the research about trauma’s effect on the brain or on school outcomes or on life outcomes. And most of what I talk about to people is based on that latter kind, like chronic maltreatment in the early caregiving system.
[00:23:20]Dr. Jeremy Sharp: Yeah, I was going to say just to jump in for a second. It sounds like maybe you’re going down this path, but I would love just as a kind of naive, non-expert in this area to know if there are differences and outcomes and expectations I suppose for that developmental or complex trauma versus an acute single-event trauma.
[00:23:48] Dr. Julia Strait: Yeah, for sure. Like I said, a lot of the research that we have especially on young people and I should say most of my original training and work is with young people, although I work with a lot of adults now in private [00:24:00] practice, a lot of that experience that I have was from young people and young adults. So, I say that because we know, for example, that kids with complex trauma are more likely to have… like I said, those attachment disruptions, ….they’re actually more likely to have speech language, cognitive types of developmental problems because if you can imagine…, so I didn’t really talk about milk treatment as a kind of Venn diagram, but within that maltreatment world, I think we automatically think of physical and sexual abuse which of course are very detrimental, but like 70 or 80% of CPS cases are neglect. And there’s actually a big if you go to Harvard… I forget what it is …Center for the Developing Child, there’s a big push now to look at neglect because those outcomes for kids who are neglected can be worse for things like cognitive development and speech and language because think about like, if you’re not getting exposed to words and books and loving, caring relationships, if you’re not being constantly… that co-regulation of emotion that goes on between the parent and child, that back and forth rate, if you’re not really getting that or if you’re getting it inconsistently, so those things, I think attachment relationships and some of the developmental piece can be kind of extra risk factors or extra outcomes, I guess. I’m not sure which side, but so we definitely know from research and just from experience with clinical populations that the relationship piece and the developmental piece can be more severely affected in the case of developmental trauma versus a single incident.
[00:25:42] Dr. Jeremy Sharp: Yeah, that makes sense. So you talked earlier… I really want to ask a little bit more about this idea of concept creep. So, I’m guessing that folks out there have experienced something like this where there’s this question of [00:26:00] what really ‘counts’ and that’s a hard place to be in. I think we probably all come into clinical situations with expectations or maybe heuristics or some framework to say, okay, this is trauma, this might not be trauma. But either way, whichever side we fall on, it’s the idea of does this really ‘count’? Like if someone says it’s traumatic, but it doesn’t really…
[00:26:33] Julia Strait: Yeah, I see much of that. And it’s like, Oh whatever
[00:26:36] Dr. Jeremy Sharp: Yeah, well, this is a hard thing.
[00:26:37] Dr. Julia Strait: Yeah, like we don’t want everything to be.
[00:26:41] Dr. Jeremy Sharp: Yeah,I would like to talk through that a little bit more.
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All right, let’s get back to the podcast.
[00:27:48] Dr. Julia Strait: Yeah, that’s a sticky question. It’s so hard because, on the one hand, I see why it would be beneficial to capture more people in that definition because we can help more people. So I always think of it like in special education which was where I was originally trained. It’s like, yes, we would love for everyone to get these services. But when you have a question of limited resources, like where are we going to put our most severe, our most intense resources? And so I think of it on a continuum. Like, I don’t know that there’s a nice cutoff. And for lack of better criteria, I think that PTSD criterion (A) which is the exposure to the event, there’s a lot of literature on that and what’s considered. So the wording there I think is actual or threatened death or sexual violence, or for little kids that can be learning about something like that done to their parents or witnessing it. For law enforcement and EMS and those kinds of people, it can be exposure through work. So I think there’s a long list you can find on the internet of things that count. I know in children sometimes there are things that surprise me like, Oh yeah. I didn’t think about that. Like dog bites, [00:29:00] like being attacked by a dog that might be super threatening, they felt like their life was threatened.
Major medical procedures, that’s one we don’t think about often either, but talk either chronic or just really major, scary medical procedures, or like I’ve had kids who woke up in the middle of surgery, something very, very, very frightening. And they used to have that criteria in there of like you had to be like terrified at the time. And now I think it’s so hard to quantify that that they’ve kind of dropped it. But in the DSM, it’s technically actual threatened development or sexual violence. And I feel like I’m forgetting a part of it. So it is the high kind of level. I’m thinking about when I was younger, I had an English teacher Ms. Anita, and I use the word tragic in an essay and I remember her being like, you have to be careful with that word because technically, tragic means that there’s some kind of death involved. And I remember feeling like, wow, I just started to learn about the boundaries of words.
[00:29:57] For some reason, that reminds me of the trauma question where there has to be this element of like your actual life or your sexual or bodily integrity is being threatened. But again, that being said, for example, in therapy, I’m not going to argue with someone if they feel like that’s helpful to them. I’m not going to take that away. But it’s different for assessment. So yeah, to meet the criteria, I’m going to look at whether it was to that level, right? Like if I’m going to put the word PTSD on the report, I’m going to look at that criteria. And like I said, even with complex PTSD, technically for ICD 11, all the skills that go with that, they have to meet that criterion A too.
[00:30:37] And so I think that is like an ‘easy answer’ for the diagnosis made easy folks. But of course, I work with a lot of teenagers in therapy too who have started to notice like TikTok and Instagram and stuff. It’s like, I’m so glad that there’s a community out there that’s supportive of trauma and anxiety, everything, but I think we also have to be careful like, if everyone has suffered trauma, then is it trauma anymore? I mean, reality is not a condition of the diagnosis. It doesn’t have to be. Right now everybody’s going through it. I saw a study yesterday that came out in December where they looked at nine different countries during the pandemic and it was anywhere from 7 to 54% of the adult population is feeling some symptom of PTSD right now. I believe that. I definitely have people who are high arousal and they’re getting reminders of things. So I don’t know that there’s a really nice answer to that. I would say it’s easier when you’re saying to like a parent, well, this is the criteria for the disorder, but it’s not a rule-out.
[00:31:50] So like, just because they don’t meet that criteria, I’m not going to say, well, you don’t need therapy for it, or you don’t need these services. It’s really nice that at the private practice can say that. And [00:32:00] you know, even in special ED in schools. There is no category for PTSD. But in the school, it’s like if you’re going to be behavioral and descriptive about it, so do they meet or ed or something? Then put them in there. But in California schools, I think sued a couple, well now it’s been 5 or 10 years. Hampton School District, a bunch of kids sued the district because they weren’t providing services for kids who had been part of gang violence and shootings and things like that.
[00:32:32] I think that’s getting better. Like, I don’t think they actually didn’t make a new category, but they have been more responsive in terms of trauma services at school.
[00:32:41] Dr. Jeremy Sharp: Got you, got.
[00:32:42] Dr. Julia Strait: That’s a long answer.
[00:32:43] Dr. Jeremy Sharp: No, it’s a good answer. It’s important I think because as much as we may be want to get away from these definitions and categories and so forth, it still matters in some ways. I think I have examples on both sides, right? So like, personally, we have… so our daughter, our second kid, she had some complications, and she was in the ICU for, I think, 7or 8 or 10 days or something. So I’m trying to think about how to tell the story. The short story is that going back to the hospital, hearing any beeping I think I kind of had PPS, even though that doesn’t meet the definition right, for like the DSM necessarily, but then on the other side, I think we all see clients maybe older, maybe teens who say like the kids excluded me on the playground that day, and I’ve never been the same sense. Is that a trauma? I’m just thinking out loud trying to talk to you.
[00:33:57] Dr. Julia Strait: Yeah, of course. And I was going to kind of like to tip to it because I don’t want to offend either way. I don’t want to offend someone who’s listening who is like, no, I felt like that really was, but then I don’t also want to offend someone who’s been through some of the horrific things that I have seen who was really frustrated by the fact that like, no, I’m sorry. I want to name so many things right now that I can think of these kids that I’ve seen that are just like, Oh my gosh, you can’t even deny that. So like, is it offensive? Not offensive. But is it kind of changing how we view them? If we say, well, yes also like not being picked for your team is traumatizing. But again, I think it’s totally a continuum and there are some measures. So there’s a measure called the Macy’s out of Harvard and they consider peer like bullying, they added that like as another ‘ACE’, which was the adverse childhood experiences, which is a very like rough estimate of traumatic. It’s only 10 things. So, I’m going to talk about that.
[00:35:01] They add that in as trauma. And again, gang violence, community violence, racial discrimination a lot of things can be considered on that continuum. Again, it’s easier if you’re trying to make the cutoff for PTSD because you can kind of say like, okay, well, do you have these symptoms to a frequency and severity that we would consider? And are there multiple people saying that not just you, like, maybe you’re a parent and a teacher, of course, like all those methods. I think that’s a really sticky question that if you ask 10 researchers and psychologists, DO you know what trauma is, they’ll all say maybe something a little bit different.
I have a professional Instagram where I only follow mental health things and I do get a little discouraged sometimes when I see so many things about like, hey, if you have these symptoms, it might be trauma, and sometimes it’s like a little meme about like, if you get nervous, when you go to the grocery store, I don’t really know what the [00:36:00] intent is behind that. [00:36:01] It’s great that people are trying to be compassionate. But I see what you mean about concept creep. Like psychologists are already made fun of for having so many measures and concepts and constructs. It is I think a danger to go the other way. And I’m trying not to use the phrase water it down because I know that’s not the greatest phrase. But I mean, you can’t make it so applicable. That doesn’t apply to anyone.
I went to an NIH Child Abuse research training a few years ago in New York City and got to meet this guy, John Knutson, he is one of the first people to study abuse and disabilities in that overlap. And he even said in the training, he’s old school, he’s like fairly seasoned, and he kind of made some people mad at the training because he was going over physical abuse and disability stats. And people were asking questions like this, like, what counts? Like if you got hit once or? And he said, well, if you start pathologizing everything, then what are we even studying anymore?
[00:37:03] I don’t want to misquote, but it was something like that. Like if everything is a trauma, then what’s the point? If it’s completely normal, is it a pathology? And so I think that’s important to remember as well. He’s one of the OGs. So I feel okay talking about that, but I don’t want to exclude anyone.
[00:37:21]Dr. Jeremy Sharp: Right, I think in these conversations, we always run the risk of coming across as a monster who is minimizing somebody’s experience. And of course, that is not the intent at all. But I hope folks understand as we work through some of these almost philosophical questions. It’s just like, how do we think about this?
[00:37:46] Dr. Julia Strait: Yeah, it gets existential pretty quick.
[00:37:48] Dr. Jeremy Sharp: It really does. But ultimately, then it’s like, okay, so then how does that lead to how we might help people?
[00:37:55] Dr. Julia Strait: Yeah, that’s the original thing you said, right? Like we got to put people in categories at some point because we have to help them and because of the way our system works, which is reflected in all these rules and everything because that’s the way our brain works. At the end of the day, we do sometimes have to make a decision. And so, limited resources can only go to so many people.
[00:38:17] Dr. Jeremy Sharp: Right, exactly. Well, I appreciate you waiting through that.
[00:38:23] Dr. Julia Strait: I’m still waiting. All the time.
[00:38:25] Dr. Jeremy Sharp: Yeah, we’re just waiting. So I want to ask you, I know that there are so many instances in the mental health world, diagnostically and assessment wise of disparities and differences in different groups, be they racial, ethnic SES, geographic, whatever it might be, did those things exist in the trauma world as well where certain groups are either over or underdiagnosed or undertreated or left in that way?
[00:39:02] Dr. Julia Strait: Yeah, I’m so glad that you mentioned that because I was reviewing some things last night. Like I said, I was studying what I want to make sure I say. I was coming across all these stats that I hadn’t thought about in a while, but one of them was, so a lot of this research has stuff comes from kids who were maltreated, and when you look at the stats, just of the prevalence of abuse and neglect, for example, just like baseline, like the event piece, right? So if you’re looking at the exposures, there’s a long history of research there. There are some racial and SCS disparities in abuse and neglect reports. But you notice I said reports or substantiate the cases. And so, I’m actually at the NIH Institute, I was at a couple of years ago, this lady, Kathy Widen, who’s amazing and she does all this research on trauma and she was talking about how there are some more recent studies that actually say that there’s a surveillance bias, meaning like those…
[00:40:03] So some children who are in underrepresented minority groups or low SES communities, they’re actually monitored. So they’re already involved in systems, right? Like sometimes they’re already involved in the judicial system, or maybe their parents are, or they’re involved in, CPS for some other reason for another kid. So there’s maybe a monitoring bias that affects that because there are some statistics and these are a little old now I think that from the 90s and the 2000s. But it’s something like 7% of kids, I’ll have to fact check this later, around a little under 10% of kids at some point in their life will have some contact with CPS. And that just might be like someone calling and it’s nothing, right? So a lot of cases get one report and there’s nothing. But when you get to two or more reports, that’s when you start seeing those ill effects. But kids who are from black American communities in the nineties were getting referred at a huge rate higher than that.
[00:41:01] I don’t want to misquote, but it was like really close to half. At some point in your life between zero and 18, at that point in time, if you were from an underrepresented minority group, you have been much, much, much exponentially higher rate of referral to seek yes. And I say that because even though that’s not the only exposure to trauma, think about all the things that come with that. So you’re referred to CPS now, you’re in this system, you’ve got people watching you. This might lead to additional systems that you’re involved in. Maybe now the government is watching your parents more closely and there are other factors that come into that and so those kids tend to get plugged into that system really early. And we all know about all these pipelines that exist. So I think that’s definitely a problem. But there is some evidence to suggest that, I don’t know if it’s actually occurring more. So think of your affluent families. I know the area I’m in, we live in a pretty diverse area, but a lot of our families in private practice are more affluent and everything.
[00:42:03] And I mean, when I preferred to call CPS for those families, I don’t know, just anecdotally those investigations get shut down pretty quickly, it’s like, Oh, it’s probably nothing, I think there is a bit of a bias, right? Like we’re not looking as hurt as certain groups. And definitely, I think a lot of our kind of implicit biases and all that come in . When you look a step further like in special education, for example, kids who are in state custody, I’m kind of using as a proxy for trauma and I understand that’s not everyone, but that’s my background, kids who are in state custody or in foster care, in the ‘system’, or juvenile justice systems kind of in that pipeline, they’re way overrepresented in special education. And it’s certain. So they’re way overrepresented in emotional disturbance categories because it’s like, okay, behavior, classroom go straight there.
[00:42:58] But they’re underrepresented things like intellectual disability learning disabilities because those things get overshadowed. We actually did a study in Memphis for that. We looked at all our kids that we had diagnosed with ID, which a lot of them were teenagers, like what?
[00:43:14] Dr. Jeremy Sharp: Like when did they get that? And these kids…
[00:43:14] Dr. Julia Strait: Yeah, you know 50s IQs, and we were the first people diagnosing them at 15, 16 years old because they had been in the behavior classroom, they’ve been highly noble. And so, yeah, I think it’s any more prevalent than we think it is in all communities, but be like, we’re looking at different variables when we look at different populations, which I don’t know if that’s really equitable. And then those kids are getting plugged straight into like ed services which all well and good. But if you have an IQ in the s60’s and you’re just getting behavior services that are geared toward typically developing kids, what does that say? So they all get missed for early intervention.
[00:43:56] Dr. Jeremy Sharp: Sure.
[00:43:58]Julia Strait: Definitely there’s some biases there that need to be looked at for sure.
[00:44:02] Dr. Jeremy Sharp: Yeah, I know in our work, we have a contract with a local DHS department from a nearby County, and a lot of the work that we do with those evaluations is almost undoing some of the prior evaluations or diagnostics. I see so many kids who come through as like 9 or 10 or 12 or 14-year-olds, and they have ODD, ADHD, conduct disorder, and through the course of the evaluation, a lot of it is like, “Hey, I think this is maybe trauma, could we consider that and pursue treatment for that instead of these other like medications or like placements or more restrictive kind of punitive environments or whatever it might be?” And it’s heartbreaking to see these kids.
[00:44:59] Julia Strait: Although it’s awesome that you’re like shifting the lens, I think that’s the deal, right? so that’s I guess what we’re kind of called to do, and when we have a situation like that. It’s cool that you’re trying to like shift everybody’s… there’s this saying in the schools has gotten popular now of like, don’t ask “What’s wrong with you? ask What happened to you? I know that’s like come to be kind of a cliche, but I think that’s really important to shift the view. A lot of parents coming in like, Oh, he’s manipulative, she’s borderline, and that’s not just the trauma obviously, but sometimes a lot of the hardest part of our job is like, well, could we look at this from another angle?
I have even started putting in my reports. I didn’t use to give a lot of personality tests but in private practice, I feel like it rounds out. it gives a lot of context, and so I’ve been doing personality stuff with younger kids. And I always now put in there after I explained like the impasse year or whatever we did, I put like, ” It’s important to know that these traits and symptoms are understandable given the child’s history and context. They should not be viewed as stable traits, but as targets for events or something like that.” I always put in there, we need to be seeing that as something that we can help them with and not like, oh, well, there it is. This is the problem within the child. And you say like, this is the problem that’s in the kid and they’re possessed. We actually have a lot of people in Memphis whose parents would come and say they’re possessed because that’s kind of cultural,
[00:46:20] Dr. Jeremy Sharp: I grew up in the South. I know.
[00:46:22] Dr. Julia Strait: Yes definitely, so like they’re possessed or there’s something wrong with them. I hear the word manipulative like a billion times a day.
[00:46:29] Dr. Jeremy Sharp: So often.
[00:46:30]Dr. Julia Strait Yeah. But if you look at that word, manipulative… so they’ve learned in an adaptive way to get their needs met by trying to exert their will on other people. I guess if you see it in an adaptive sense, they’re really good at getting what they need because no one gave it to him when I was growing up.
[00:46:51] Dr. Jeremy Sharp: Sure, sure. It makes me think of, I don’t know if you’re familiar with, the Ross Green stuff, the collaborative and proactive solutions, and just that philosophy of kids do their best generally. Kids are doing their best. And whenever I hear manipulative, it’s just a trigger I guess, to say the kids probably just doing their best. We can talk through that afterward. I know we could keep going as sort of the preamble and the philosophy and what is trauma and what isn’t trauma, but the hope, I mean, we spend a lot of time on this, but the hope for anybody listening is just try to define things a little bit and at the same time, bring up some of these complexities that are hard to sort through from a clinical standpoint if we’re just like, again, generally thinking, what is trauma? what does that look like? How do we conceptualize this? So, thank you for spending so much time on that.
[00:48:01] Julia Strait: Hopefully that was helpful. And like I said, there’s lists online you can do especially with kids, like what are some possible things? And it doesn’t mean they automatically count, but we would say like either potentially traumatic events. And that’s often how I write it in the report, like, which will probably get so, and so is exposed to several potentially traumatic events. And we can’t say whether or not until we assess those other pieces, the experience and then the fact.
[00:48:31] Dr. Jeremy Sharp: Sure, well, I wonder if we might transition a bit then to the assessment process and what this looks like in real life.
[00:48:40] Dr. Julia Strait: Sure.
[00:48:40] Dr. Jeremy Sharp: Okay, everybody. Thank you so much for listening. Like you heard at the beginning, this is part one of a two-part series, so make sure to tune in next week for part two. We’re going to be talking all about the assessment process. So what this looks like during an interview, what measures Julia uses for trauma-informed assessment, how it plays into the report and feedback as well. So you don’t want to miss that.
if you haven’t subscribed to the podcast, now’s a great time to do so to make sure you get those notifications and automatic downloads when new episodes are released. Like I said at the beginning, if you are interested in some group coaching and accountability to launch your practice in 2021, You might check out the beginner practice mastermind group just for testing psychologists, and you can get more information at thetestingpsychologist.com/beginner. Okay, everybody. Y’all take care and tune in on Thursday for another EHR review. Until next time.
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