The cause of trauma, says John Constantino, chief of behavioral and mental health at Children’s Healthcare of Atlanta, “doesn’t have to be a bomb going off.”
Indeed, prolonged stress or a psychologically overwhelming life event can be equally as damaging. And the result might be post-traumatic stress disorder (PTSD), but it could also be a “wholesale detachment from anything having to do with the stressor,” Constantino says.
Treating trauma across a lifespan was the topic of the 2023 Annual Hamilton E. Holmes, MD, Memorial Lecture.
Panelists during this year’s virtual lecture included Constantino, who also is a professor of psychiatry and behavioral sciences at Emory School of Medicine; Antonio Graham, assistant professor of medicine and geriatrics, Emory School of Medicine; and Veda Johnson, Marcus Professor in General Academics and Pediatrics, Emory School of Medicine, and director of PARTNERS for Equity in Child and Adolescent Health.
Nurturing relationships
Johnson shared the case of a family she had seen in which the children’s behaviors seemed to fall on the autism spectrum but were the result of trauma and neglect (details withheld to protect their identity).
The children showed no emotional attachment to anyone — they didn’t smile, the baby didn’t coo — but they were observant and could communicate with each other. The mother was clinically depressed and had lived under domestic violence for years. She fled the violent father, and the children were left in the care of a teen who could not give them the support or attention required.
The treatment? Love, nurturing and support from appropriate caregivers.
“Whenever the youngest was awake,” Johnson said, “we recommended that someone hold, talk and sing to them, bringing them into the center of everyone’s spheres.”
Under this positive attention, the children developed language and the baby began smiling and cooing.
“Children are resilient to an extent, but not in and of themselves,” Johnson said. “They need nurturing relationships to overcome trauma. We don’t focus on the trauma as much as the solution to the trauma, which is relational health.”
Surfacing trauma
Graham told of a World War II veteran he treated who had been celebrated on the local news because he was about to turn 100. Photos from his time in the service had been unearthed, and he and Graham were looking at one where the veteran was standing on a riverbank somewhere in Europe.
“We were talking about how handsome he was, and in the middle of this he goes from laughter to tears,” said Graham.
The photo had triggered a memory.
At the time, the military had separate units for Black soldiers. “His African American unit was downriver from their white counterparts,” Graham said. “Everyone bathed in the river, did everything in the river. So there were feces that floated down from upstream. He hadn’t really dealt with how bad that felt, to be subjugated and treated in that way.”
Graham had cared for the veteran for years, whose main complaint up to that point had been that his daughter obsessed over his care.
“He always said he was fine,” Graham said. “But on that day, at 100 years of age, he had opened space for his traumatic experience. Even on the other end of the lifespan, these traumatic events are with people.”
Healing communication
Healing comes about in the context of one or more relationships that are safe and meaningful, the panelists agreed. As Constantino said, “The memory of a traumatic event needs to be communicated, managed, expressed, resolved.”
For example, trauma’s aftermath may take the form of “acting out” behavior in children.
“Acting out is when you can’t say it,” Constantino said. “Conversion into language is the foundation of mastery of these things. Whether it be with the family, a therapist, a good friend … first, communicate. If there is no avenue for that, there is almost no way to master it. Best is language, communication, sharing the experience with another human.”
Johnson added that, with children who have experienced trauma, “We can’t care for that child in a vacuum. We must take care of the whole family: parents, grandparents, other caretakers.” Social determinants of health also impact entire communities.
Many men “of a particular age,” regardless of race or culture, have been taught to “keep their heads up, bear through it, don’t talk about it,” said Graham. “I encourage my patients to tell friends and others who might be hesitant, ‘I have a therapist. Everyone needs a therapist.’ In the VA Medical Center, we have group therapy, which works well with PTSD.”
To ensure equitable access to treatment, mental health parity is a necessity, Constantino said. “We don’t ask cardiovascular surgeons to squeeze their operations into 20 minutes. There really is no shortcut to doing this well.”
Care providers need to work on how to have conversations around trauma within primary care visits, Graham said. “This is just as important as treating hypertension and diabetes.”
Continual validation
Racism, a common cause of trauma, comes in many forms, said Johnson, from institutional to internalized.
“Internalized racism is the one I spend an enormous amount of my time trying to prevent,” she said. “There has been a resurgence of racism in our country. We are seeing children who think they are less than what they are. When a baby is brought into my office, I impress upon the family that their child has the capacity to change the world. I tell them, ‘Your baby has 80 billion to 100 billion brain cells. These neural cells may not all be talking to each other yet, but you can help that along. Talk and sing to them, give them a safe, secure environment, and validate them over and over again.’”
The micro level, said Graham, is where real change and healing can occur. As a faculty advisor to college students, he helps them address their fears and anxieties head-on. “I ask them, ‘What do you believe? Do you believe you can do it? That’s all that matters.’”
“It’s not that we don’t have to try to change systems and structures, we do,” he added. “But our power is in these one-on-one interactions.”
The Annual Hamilton E. Holmes, MD, Lecture
Hamilton E. Holmes, MD, was the first Black student to graduate from Emory School of Medicine. He received his medical degree in 1967 and went on to be an orthopedic surgeon, associate dean at Emory School of Medicine and chairman of the orthopedic unit at Grady Memorial Hospital. The Office of the Dean and the Office of Multicultural Affairs for Emory University School of Medicine annually host a lecture in his honor.