The Life Experiences Clinic and Curriculum

The Life Experiences Clinic is a unique opportunity for Columbia-Bassett students entering non-psychiatric specialties to become practiced at aiding patients in coping and flourishing with daily life despite histories of emotional trauma.  It is not about care of patients with major psychiatric diagnoses, but rather is designed to aid future practitioners in recognizing the all-to-frequent roots of emotional trauma underlying physical illness in people who often show little in the way of overt distress, yet who offer subtle hints of emotional struggle. 

Rationale:  The Why, the Goals and the Rationale:  In many studies, research has labeled roughly 60% of patients coming to primary care practitioners in the United States as having “psycho-social” rather than "physiologic" problems.  For some practitioners and policy-makers, this has been a statistic revealing lamentable waste. Such patients may complain of back ache, chronic fatigue and such things, and they may be labeled as having something amiss not in their bodies but “in their heads.” 

Lurking in the wings of healthcare, though, is a wealth of data from the parallel universe of public health research – data like the numerous Adverse Childhood Experiences studies, which in cross sectional design repeatedly show that emotional trauma is associated with worse outcomes in physical health.   Dovetailing with these studies is work by Dr. Bruce McEwen of Rockefeller University and many others, showing that at the molecular level, long term physiologic changes in the endocrine and immune systems, as well as epigenetic modifications, may ensue from severe or chronic emotional trauma. 

When these two bodies of information are juxtaposed, a new narrative can emerge:  that our patients are frequently burdened by unaddressed emotional trauma, often removed by many years from the present, having effects which may be obscure to them even as they have profound life impact.  Still, many of these sufferers follow an instinctive inner wisdom, and seek healing: they come to us, because society sees us as healers.  When we see them, they use the language that they possess to say that they are not flourishing – which might be an ache or fatigue, and might also include a reference to a prior event or relationship made fleetingly in passing.  For such people, problems may not resolve with typical medical remedies and they may recurrently return with the same complaints.  In response, some practitioners dread their presence, and inadvertently may add to the shame that so often underlies emotional trauma, by swiftly labeling their ailment, perhaps offering a prescription, and breathing a (guilty) sigh of relief as they depart.  This is the industrial ethos that has partially and gradually impinged upon open-hearted care over the past five decades of American healthcare policy.

If US healthcare is to emerge from its profile of under performance, if we are to reverse society’s increasing distrust and dissatisfaction with medical care, if practitioners are to heal from the dissociation and despair we self-diagnose as “burn-out,” it will only be when all of us – from primary care givers to the most rarified sub-specialists – become recognizers and healers of these emotionally traumatic life events which afflict so many.  It is in this sense that our SLIM curriculum dovetails with Life Experiences curriculum.  With each failure to give permission to a patient to give voice to life experiences that obstruct their flourishing and whipsaw into their physical health, we deepen the disconnection between emotional and physical health - and we practitioners may grow daily sadder at heart ourselves (again, "burnout").  By contrast, if we can figure out how to provide safety and kindness for the buried suffering of these many people seeking healing from us, we can also fortify ourselves.  Because that is what healing in its truest form has always been – a meeting, a mingling, a caring, a respect for magic and mystery.

In our curriculum at Columbia-Bassett during the Major Clinical Year, we seek to embrace this mystery using the tools that science currently has to offer, by creating a safe environment for practitioners, for students and for patients to explore the Adverse Childhood Experiences and other well-characterized forms of emotional trauma.  Many barriers exist between the substantial population-attributable risk of emotional trauma and the understaffed workforce of behavioral health professionals – for example, a recent study from UCLA showed that 21% of their patients had significant behavioral health issues but only 4% had accessed behavioral care.  Given this challenge, our approach is to train our students to possess the capacity to recognize, gently approach, and meet standards of behavioral health care in identifying, and triaging as appropriate, patients with emotional trauma that has detrimentally affected their health.  Just as a general practitioner must decide whether to treat or refer a new patient diagnosed with heart failure, the key is defining the cases for which a psychologist or psychiatrist is essential versus those for which we non-behavioral practitioners can both be of help and not cause harm.  To reach this decision point, we must know how to create safe spaces for our patients, how to support their responses, and how to discuss with them the spectrum of treatment options. This sensitivity and insight is an important goal of the Columbia-Bassett training.

 

The How:  Our intention is that all future Columbia-Bassett students will receive specific training in the core topic of emotional trauma, its signs and symptoms, and approaches to its therapy.  We will share evidence and techniques with Columbia-Bassett students across all four years of training, with the aim of offering safety and openness to patients.  Further, the emphases on personal philosophy, on meditation and yoga, and on creation of safe containers within our own work are aimed toward this central concept of supporting flourishing in both patients and practitioners, and discovering the regenerative joy which can ensue between them.

Using established approaches as examples, we are piloting models for the Life Experiences Clinic along the lines of an existing model of a general internist working collaboratively and with supervision from behavioral health expertise.   We have available a psychologist who is faculty to the Columbia-Bassett Program, who has training in a model of collaborative behavioral health, and who provides active consultation to primary care preceptors and students.  Additionally, after the encounters with patients, the preceptor and student have an opportunity to meet with a psychiatrist supervisor to learn from the patient encounter. 

We believe this experience exposes students whether they are going into neurosurgery or primary care to the wellspring of joy in caring for others, which is all too often lost in the time-pressured, fee-for-service environment that prevails in US healthcare.