Can “trauma informed care” help eliminate disparities?
Published: June 28, 2019
Physical therapist Shawn Tucker provides care that is informed by adverse childhood events (ACEs), trauma and toxic stress, all of which can contribute to the development of chronic health conditions in adulthood. Trauma informed care seeks to address the root causes of unhealthy behavior by helping to resolve previously hidden and unexplained conflicts. Do populations who experience more ACEs have higher prevalence of chronic conditions, and can toxic stress help explain health disparities in the obesity pandemic? With Rolf Taylor.
Rolf Taylor: Hello, you’re listening to the Health Disparities Podcast from Movement Is Life, conversations about health disparities with people who are working to eliminate them. I’m Rolf Taylor, and today I’m discussing health disparities and the role of physical therapy with Shawn Tucker, who is a licensed physical therapist in St. Louis, Missouri, correct?
Shawn Tucker: That is correct.
Rolf Taylor: Now, Shawn, you don’t actually describe yourself as a physical therapist, you describe yourself as a holistic integrative medicine provider. Right? Now what does that mean?
Shawn Tucker: Well, good morning, and thanks for having me. And I’m really looking forward to delving into some of these ideas and discussions so we can critically look at where we’re at with healthcare disparities, especially racial disparities in the country. Holism is a philosophy and holism whether you’re performed complimentary medicine, and bring that to the patient, or whether you’re participating in practicing traditional evidence-based physical therapy, holism is a is a sense of really seeing the person mind body spirit, and really accepting that there’s this innate connection between practitioner and patient that has its own intelligence, and allows for one to totally appreciate, you know, what’s going on with that individual, including their social determinants, not just where their pain is. So that’s holism. integrated medicine actually is a movement in our country, that dates back now 35 to 40 years. And it has to do again, there’s a holistic component, integrative medicine, but at the end of the day, as a physical therapist, I also when I work with folks, I integrate traditional Chinese medicine principles. And I practically integrate those into my education with patients and my treatment with patients through the use of practices like Chinese Qigong, and Chinese Tai Ji Tshwane.
I, also, as an integrative practitioner, I integrate osteopathic and other non-Western body work and energy work practices. And then, finally, I integrate with an understanding of what being a trauma-informed practitioner is, and how that’s so important, if I’m going to really step in and make a difference in patient populations that have traditionally suffered from structural racism and has a lot of social determinants in the place that lead to healthcare disparities to that population. Then my center in St. Louis, we consider ourselves a holistic, integrated healthcare center. So, everybody on the team, whether a chiropractor or a massage therapist, they are that by licensed but they’re bringing more to the table.
Rolf Taylor: So, when you say when you say trauma-informed, you’re talking about communities that we know there are wide health disparities, particularly, for example, in inner city, African American communities. And we know those communities have higher stress levels, we know the stresses are social determinants of health. So, when you say trauma informed, are you are you referring to kind of the more difficult obstacles that individuals are facing throughout their lives?
Shawn Tucker: Trauma can manifest in many ways for the human, for the human individual or for the human population, human community. Trauma-informed means that I as a practitioner, can first of all understand the link between, let’s say, adverse childhood events, major events, neglect, multiple loss of caregivers, lack of lack of adequate housing, or sexual or physical abuse as a child. That science is in there that as those traumatic events not only lead to issues during childhood and adolescence, but even as people become adults, we’re seeing a huge link in terms of disease severity and development of different diseases earlier in life that are linked directly to having those traumas.
Rolf Taylor: So, you’re saying that, in part, early life trauma or early life stress can explain or partly explain why we see a higher prevalence for example of obesity in those communities?
Shawn Tucker: Absolutely, absolutely. As well as often a person who’s gone through, again, has a high ACE score and has had a life with a lot of trauma, or is currently living in traumatic situations.
Rolf Taylor: So, ACE score is adverse childhood event score?
Shawn Tucker: Right, which, by the way, as a trauma-informed practitioner, I have an ACE screen, a paper tool that I will often, randomly, give to patients, not every patient receives it but, specifically, if I work with the patient and during our initial evaluation, I pick up on certain comorbidities and co-mortalities I’ll have them perform an ACE score, so that we can actually see if they’re dealing with specific high levels of traumatic, toxic stress. I want to get back to your other question, though. And I think what you were asking is, the idea of like early childhood adverse actions, and how those can manifest and let’s say obesity as an adult. And I think that’s true but also what my research is in right now is looking at, you know, it’s interesting. Some folks, when you say self-care, they just instantly can step into an experience and understanding and comprehension of how to perform self-care, how to change their behavior. For other individuals, it’s so challenging and I think that sometimes, the stress component that comes out of trauma, and then creates a psychological barrier, that that makes it much more difficult for that individual to find a space of self-love or self-preservation, or take time for self in order to really step into effective self-care strategies, which we know that a lot of the chronic diseases that we see that are more prevalent in minority communities, that these diseases are often better managed, and actually, we can slow down or prevent the progression of these diseases, by improving sustainable behavioral self-care strategies. So, that’s another link to that and that really gets into the psychological result of trauma.
Rolf Taylor: So, we’ve talked a bit there about the origins of some of those problems and some of those disparities that we’re looking to eliminate. And Movement Is Life, as a movement, is all about encouraging and advocating for increased physical activity and I know you’re a big champion of Tai Chi. So, I’m interested in why Tai Chi, specifically, is such a useful path to physical activity, can you talk a little bit about that and what kind of results you’re seeing with the people you’re working with?
Shawn Tucker: Traditional Chinese medicine, our best understanding of that starts with an idea that there is a holistic view of the individual human and of the human society. So, I like Tai Chi, and I like teaching Qigong and sharing those activities with patients, especially in some of the programs we’re doing in St. Louis, specific to addressing healthcare disparities, because at the very essence of Tai Chi and Qigong, it’s relaxed, it’s slow down. It’s get grounded, feel yourself get grounded into the earth. And what I found is that no matter what population I’ve worked with in terms of empowerment in terms of creating a critical consciousness, people get critically conscious when they can slow down and find their center. And until folks slow down and when I’m working with, let’s say an Operation Change, which is a beautiful program developed by Movement Is Life. It focuses on of all things improving self-care and sustainable behavioral change and African American women dealing with arthritis. Physical activity that’s going to stick has to start with dismantling what can be internal conversations, internal roadblocks to stepping into self-care and self-love. So, why do I like Tai Chi and Qigong? Not only does it improve posture, and it improves immune system, and there’s a lot of science behind it but more importantly, it’s a tool, it’s a space that I can invite my patients into, to step into themselves in a safe place of self-nurture and self-cultivation, and a centered space, that then maybe they can break through into really stepping in and addressing maybe some deeper psychological issues that prevent them from taking care of themselves.
Rolf Taylor: So, what is it about things like the balancing aspect of Tai Chi that is particularly beneficial?
Shawn Tucker: Balance is never static. To be balanced and completely still, is to be a still life, which has a certain deadness to it.
Rolf Taylor: Like sitting on the sofa and watching TV is still life.
Shawn Tucker: Right, right, right. So, when we talk about balance with Pilates, and we talk about balance in terms of yoga and Tai Chi, the mind is engaged in, okay, there’s biomechanical balance, and there’s weight shift balance, but there’s also a balance of, you know, how do I lift and extend my head up into the air while I sink down into the earth? So, there’s a sense of expansion balance. And when we talk about expansion, especially in Tai Chi and balance, when the person is really contracted, then everything’s kind of stuck, but when you can get people to expand and soften, now the ability to balance is more profound, especially in dynamic situations. And then, there’s also the piece of balancing, you know, the need to care for self and others. And we see, especially in the African American female community, there’s been such a historical, such a cultural imbalance where African American women often are taking care of everybody else and don’t have a balance of taking care of selves. So, as we learn, biomechanically, what moving in a balanced way feels like when we start to work posture, really what being more balanced in one’s posture feels like. we can also start to talk about and realize what having balance in one’s life between caring for others and caring for self is like. So, you know, combining these biomechanical balance experiences with life balance.
Rolf Taylor: So, there’s obviously great benefit to that kind of approach, those kinds of classes, just as there is great benefit to improving your diet, but sometimes that comes with quite a high price tag. And so, when it comes to looking at addressing disparities, how does that play out in things like an outpatient setting or accessing those services, particularly for minorities?
Shawn Tucker: I think it plays out traditionally unfortunately, as a lot of times lack of access to health clubs, lack of access to not having disposable income to pay for classes, things of that nature. And has kept, you know, some populations, some aspects of minority communities from being able to participate in Tai Chi or other movement systems or just general exercise for medical benefit. But in the outpatient setting, I’m excited to say that in the state of Missouri, where we have a very high Medicaid population, where in the past this Medicaid population had no access to physical therapy as outpatient adults and had no access to complimentary medicine therapies or trauma-informed Care. The Regional Health Commission and the Integrated Health Network along with the state Medicaid provider, have developed now a funding source to offer complimentary medicine, physical therapy. These types of activities specific to the Medicaid population and the uninsured, not even Medicaid, but just the uninsured, poor population of Missouri access, especially if they’re dealing with chronic pain, as opposed to simply taking opiates, which clearly isn’t working. So, as I’ve talked to different groups like Integrated Medicine for Us, they’re nice group of people all around the country that really focused on how do we bring integrative medicine, to the folks that are most vulnerable? In terms of economically poor Medicaid primary, how do we get this kind of medicine out to them? And I’m excited to say, in the state of Missouri, we’ve figured out a way to pay for it, because it comes down to how do you pay for this service?
Rolf Taylor: And that’s been principally through Medicaid?
Shawn Tucker: Right?
Rolf Taylor: Yeah. So, that sounds like progress in Missouri.
Shawn Tucker: It definitely is to be able to now, and what’s needed is that, you know, there was an issue in Missouri, and as a private practitioner for the last 20 years, I’ve continued to see people with Medicaid, they don’t have insurance, and I’ll simply see them as pro bono, as does some of the local hospital outpatient facilities. But in one piece of policy and framework in Missouri for us to be able to now create access for these clients for these patients of physical therapist intervention, as well as holistic integrative team approach, including complimentary medicine services, and specifically targeting those that are really struggling with chronic pain, this is a huge win. And I’m very excited about this being possibly a model that other red states and Midwestern states as well as purple, and blue states can all get behind. Because I think we’re going to show in a couple years, the huge, huge, huge results, amazing results in terms of applying this holistic, integrative approach, which includes physical therapist on the team, to address big needs and some of the most vulnerable folks in our community.
Rolf Taylor: Then that’s feeding back into encouraging people to take on the self-care philosophy because it’s not a prescriptive way around just saying hey, you’ve got to take care of yourself, but you’re really connecting people with their motivations.
Shawn Tucker: You know, in my experience, every individual needs a different amount of exposure, dosage of education, reinforcement of education, series of experiences, and professional and social support to break through into solid sustained levels of self-care, especially when they’re dealing with one major life-threatening disease or multiple. So, when I ran a program about 15 years ago, called Living by Design, now, there are some individuals that it would take them seven months of interacting with us. Coming into our clinic, having acupuncture, joining this class getting in some social service, before they had a fundamental shift in who they were, and how they were going to take care of themselves, so that it presented as a measurable change. And where they could start to really see where their self-care was actually improving their health.
Rolf Taylor: So, is that breakthrough moment when people discover a path to self-care through a path to self-love?
Shawn Tucker: Exactly. You know, there’s not, oh, this population needs 18-week intervention order for that to occur but I can tell you, it doesn’t happen in a week or two, it doesn’t happen in 12 weeks. Sometimes it takes 5 and 6 and seven months. and I think that’s where the program that I described it’s going to be, that’s that starting in out of federally funded health clinics, as well as some of the programs I’m involved in, in St. Louis, or with Operation Change. You know, it starts with having commitment of being available and being able to support that person, while they’re, again, learning whatever they need to learn to be able to step into that new level of self-love and self-care. And, so, I think as a physical therapist and traditionally physical therapy is very much has been, okay, someone presents with an acute issue or even a chronic issue and there’s a movement issue, and in three weeks, they’re going to be here and in five weeks, they’re going to be here, and we’re going to make sure they at least understand a program, but it’s very short term. Right. But the reality is, if we really want to offer a wellness, self-focused management of chronic health issues, then it takes an ongoing. I think, we’ve got to start thinking, Oh, this is going to be an eight-month or 12-month process of intervention, support, education, and dosage for those individuals, and I’m going to make a statement, that’s obvious, probably most of the people listening that folks that have a history of trauma, that have a higher ACE score, are probably going to take longer to step into that turnaround space of self-care, self-love than the other human who has maybe not had the same level of trauma, currently or in their history.
Rolf Taylor: So, someone from a more privileged background, is not going to have that high ACE score, necessarily?
Shawn Tucker: Not necessarily. But in someone who’s black, and grows up in a lower middle class or, you know, poverty situation may have a very low ACE score.
Rolf Taylor: It sounds like knowing that score is very, helpful for actually planning a CAP program.
Shawn Tucker: It absolutely is. And I know that the physicians that have heralded this work about really understanding the need to screen and test ACE, and then understand it as you’re treating the adult. I’ve really been feeling like over the last 15, 20 years, they’ve been kind of shouting into the wind and no one really hearing it. But I really think that we’re at the cusp of as a healthcare community, of stepping in and really understanding these variables, and using them to improve the health of our communities and ourselves.
Rolf Taylor: So, final question. We talk a lot at Movement Is Life about the importance of diversity, actually in the medical practitioner population. And we’re very aware that, for example, with orthopedic surgeons, the number of women orthopedic surgeons, I think, is 5%, and African American orthopedic surgeons, I think are less than 1% of all surgeons. Now, is it the same with physical therapy, and what are your thoughts on how that can be changed?
Shawn Tucker: Short answer is yes. When we look at the overall demographics of licensed physical therapist and physical therapist assistants in the US, the numbers are overwhelmingly white, white and female. Over the last 25, 30 years, we’ve actually seen men almost become equal to women in terms of going into the field. We haven’t seen since the ‘80s an increase in Asian Americans, African Americans, Latina or Latino Americans, we haven’t seen the percentage of populations increase in the field. And I think it’s a cycle of if African Americans historically, we know, and even in current day, get exposure and access physical therapy intervention much less than their white counterparts. Then, as young African Americans are thinking about a field it doesn’t exist, it doesn’t even seem like a plausible option, they don’t understand what it is. So, I think it has to start at really the grade school and high school level. I think if we could have more physical therapists, if we could have a physical therapy volunteer team that went into, especially to inner city schools that are primarily minority, and those physical therapists could show up and play a role of prevention and education and treatment, then that could very much start to improve the desire of African American and Hispanic adolescents in high school to think about physical therapy as a profession.
Why is it so important? Because the more that we have physical therapist of color and of different ethnic backgrounds, at the end of the day, a lot of people are going to feel more comfortable. And we’re going to be able to trust the experience of being cared for, if they’re cared for someone who they identify with racially or ethnically. as well as I think that any profession that’s been predominantly white, when we get a greater diversity, we’re going to be able to have a deeper understanding of how to address, you know, issues specific to, let’s say, structural racism in healthcare. So, I hope I answered the question. We’re not there yet but I think that a lot of schools at the academic level, they’re very interested.
Rolf Taylor: So, it’s almost like we’ve got to get this much more into the mainstream, we’ve got to get people thinking about this is an approach. I would imagine that the outcomes that you’re seeing with this kind of intervention are at least equal to a pharmaceutical intervention.
Shawn Tucker: Absolutely, absolutely. You know, in St. Louis, at least 40% of Caucasian children, high school athletes, they get injured at some point during their high school career, will access a physical therapist, will get sent to physical therapy, will get sent to outpatient sports rehab. I would say when you look at that same high school athlete who is going to a predominantly African American high school, where there’s less access to all types of services, those individuals are maybe 3% are going to participate in some kind of physical therapist led rehab. So, I think the real opportunity is to look at how we create access to outpatient sports rehab, and orthopedic rehabilitation services for athletes of color? Especially those that are going there in school systems that are that are that are less well funded, which it is unbelievable that we can have a community of a couple million people and in that community have such disparity in terms of the individual schools, and where kids go to school and what services they get versus other schools. It’s unbelievable in our country.
Rolf Taylor: It’s yet another disparity that should be a scandal, but we somehow have allowed to become more or less as normal. And that’s part of I think what we’ve got to address.
Shawn Tucker: It is, and the exciting thing is that groups like Movement Is Life that haven’t just pigeonholed one thing or another but are looking at the big picture. The opportunity is wow, okay, we’ve got this education, racial disparity, we’ve got this health disparity, we’ve got this disparity in terms of physical therapists having a lack of minority physical therapists, wow, one strategy and we’re addressing all the issues at once and that is solid policy. And that’s the kind of stuff that I want to be involved in, you know, as I move ahead in my career,
Rolf Taylor: Fascinating insight Shawn, thanks so much for joining us today. We covered a lot of different subjects, and I think each of those would deserve a deeper dive at some point. So, let’s talk again.
Shawn Tucker: Thank you.
Rolf Taylor: Thanks for playing on the disparities podcast.
(End of recording)
download pdf transcription of this episode