transcript

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Speaker 4:
[00:30] Every year, millions of people go through harrowing medical experiences. From chemotherapy, to a stay in the ICU, to a difficult childbirth, to the frustration of dealing with chronic pain, these experiences can leave scars on our minds as well as our bodies. Today, we're going to talk with a psychologist who studies medical trauma and works with patients recovering from serious illnesses. We'll discuss what kinds of experiences can cause medical trauma, how common is it, and why is it so often overlooked, what mental health symptoms can it cause, are there interventions and treatments that can help people heal, and if this is something you're experiencing in your own life, where can you go for help? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. Jim Jackson, a licensed psychologist and research professor of medicine at Vanderbilt University Medical Center. Dr. Jackson is the co-founder and director of behavioral health at Vanderbilt's ICU Recovery Center, one of the world's first centers devoted to diagnosing and treating survivors of critical illness. He is a leading researcher on how serious illness affects the brain and mental health. He's published more than 150 research papers, and his work has been covered by media outlets, including the New York Times, Scientific American, the Atlantic, the Wall Street Journal, CNN, and PBS. His new book, published in April, is called Reclaiming Your Life from Medical Trauma, Recognize the Symptoms, Find the Treatment That Works, and Heal Your Brain and Body. Dr. Jackson, thank you for joining me today.

Speaker 2:
[02:21] I'm really delighted to be here. Thank you for having me on.

Speaker 4:
[02:25] Let's start, as we often do, with a definition. What exactly is medical trauma? And when people think of traumatic events, they often think of things like war or abuse, but can relatively common medical events cause similar traumatic reactions?

Speaker 2:
[02:41] I'll tackle the second part of your question first and the first part second. I do think for a long time, people have had pretty specific notions of what constitutes trauma. And those notions have included things like combat and sexual abuse or sexual assault. And of course, of course, those things are hugely traumatic. But I think it's important to note that there are a range of experiences, including in the medical domain, that are also traumatic, that are also often hugely traumatic. And those problems are often overlooked. When we think of a definition of medical trauma, it's a little bit complicated. There are a variety of ways that people talk about this phenomenon. But in general, I think of medical trauma as the emotional and physical and even the cognitive distress that is born out of difficult medical experiences and also difficult medical encounters. I think there are two mistakes that we fall into when we talk about trauma that some people could fall into. One would be to see it behind every tree because it's not behind every tree. It's not the cause of every ill. One would be not to see it anywhere. That's a mistake because trauma exists. I have tried in my book and in my work to thread the needle. Not to see trauma again everywhere, not to overdiagnose it, but not to minimize it. I think the experience of many in the medical arena is that their medical trauma has been minimized a bit.

Speaker 4:
[04:17] Yeah. What are some of the most common types of experiences that cause medical trauma? I mentioned a few in the intro, but did I cover the waterfront?

Speaker 2:
[04:26] Yeah, you did cover some key ones. Critical illness would be an obvious one. When people are on a ventilator, they're in that category of the sickest of the sick as many of our patients are. That is frequently a cause of medical trauma. A difficult cancer journey is often a cause of medical trauma. An emergency c-section is a cause of medical trauma, a surgery that didn't go well. Those are obvious things. I think there also are more subtle things. A chronic illness that has this drip, drip, drip, this constant quality doesn't go away, derails your life, might not result in PTSD necessarily, but the people living with it consider it traumatic. The experience of being minimized, being a person who is encountering gaslighting again and again and again, that I think can be traumatic. These experiences are often not only traumatic for patients, but also for families, for families who are not living the trauma, but they're observing it. So a huge array of experiences, some of them not the ones that we think of, some of them obvious.

Speaker 4:
[05:43] That raises the issue of whether a family member can experience medical trauma as a result of living with somebody who has gone through something like this. I mean, is that also common?

Speaker 2:
[05:53] It's quite common. Two decades ago or so, there was a great paper by a French intensivist, and the first paper was about the impact of critical illness, not on patients, but on family members. That paper and others since then have demonstrated that rates of PTSD are almost as high, in some cases even higher in family members than in patients. I see this quite a bit. I interact with patients and families at the clinic, and sometimes the patients say, I don't remember any of my experience in the ICU, and I'm so glad. Their family members say, I remember every moment of that experience, and I'm so sad. And I think we need to honor not only the experience of patients but also of families and to acknowledge that in many ways medical trauma can be not just an individual problem, but very much a family problem.

Speaker 4:
[06:54] How common is medical trauma? Do we have good estimates of its prevalence?

Speaker 2:
[07:00] There are hundreds and a few thousand papers that I would say are broadly about medical trauma. And many of those are epidemiologic studies that look at prevalence rates of things like PTSD in particular. If you look at PTSD, not the only problem that develops from medical trauma, but one, the rates are astonishingly high. If you look at the ICU, for instance, where millions of people go every year in North America, typically about six million people are admitted to the ICU, the estimates of PTSD would be somewhere between 10% or 12% on the low end and 20% or 22% on the high end. If you look at birth trauma, relatively significant rates of PTSD exist and those get higher as people move toward, again, difficulties like emergency C-sections. If you look at cardiac arrests, PTSD is common. If you look at anaphylaxis, if you look at cancer, in some cases, these rates of trauma are very much in line with the rates of things like PTSD that we see in combat veterans. So it's a not insignificant problem. I try to be conservative when I discuss it, but it's not uncommon in the literature and in my own experience to see significant PTSD in one in five patients in a given population of people who have encountered difficult medical situation. And of course, those rates depend on things like risk factors. If you've had trauma before, before the event, you're more likely to have it after. If you're in a high risk group before, you're more likely to develop it after. It's a hugely common problem.

Speaker 4:
[08:50] So that it kind of indicates that you can, you have some idea of who might be at risk for medical trauma. So people who have had PTSD or other types of trauma before, are there other characteristics that you would look for before somebody undergoes, say, a significant medical procedure where they are likely to come out with trauma?

Speaker 2:
[09:09] Young age is often a concern. You know, in many cases, young age is considered a good thing. You know, I miss my 20s. Young age is a good thing. But the younger you are, the more foreign the idea of being very ill is. When you're 60 or 70 or certainly 80, if there are significant medical problems that you encounter, you're bracing for those, right? You know about those, right? Like you've lost some friends already, whatever the case. But if you're 20 and you land in the ICU, if you're 30 and you're now contemplating death, the dynamic is very different for you than it is for someone in their 70s or 80s. So when I'm in the ICU seeing patients as I do, a couple of days a week, I'm always particularly concerned not only about the 85-year-old, but about the 35-year-old. Because for them and for their family, for their parents and their children, the thought of things not ending well is much more arresting than it is for someone who reflects on 80 years of a life well lived.

Speaker 4:
[10:21] Well, that certainly makes sense. Now, in your book, you talk about seven categories of medical trauma. Can you briefly summarize what these are?

Speaker 2:
[10:32] Sure. When I talked about seven categories, I referred to the sorts of things that often are the forms of medical trauma, the causes. And again, those can be things like a surgery that happened, a medical event that happened. They can be things like an illness that developed. They can be things again, like the experience of being dismissed or minimized by a provider. I've tried to move away from a situation where medical trauma is caused by just one thing. In truth, it's caused by a wide variety of things. And those experiences, again, major surgery, the development of a chronic illness, a difficult experience with health care, they may lead to medical trauma or they may not. And I think that's important. There are a lot of paradoxes that we see. And by that, I mean, there are some people who have exposure to a gigantic dose of trauma, and they seem pretty okay. And there are some people who were exposed to quite a mild dose, what we might consider quite a mild dose of medical trauma. And they're not. And I think that mimics what we see in the veterans that I have worked with over many years, where some people are on multiple deployments, exposed to a great deal of combat, seem to be relatively okay. And some people have relatively mild exposure to a shelling or a rocket landing near their base. And they develop significant PTSD from this. So I think it's important to be rigorous on the one hand, in how we define trauma. On the other hand, to be slow to gatekeep. I think we really don't want to say to someone, this experience doesn't quite measure up, doesn't quite count, because you were only in the hospital for four days, and you have to be in the hospital for 44 days. These are very individual experiences that people have, and sometimes they're surprised by how traumatic those experiences are.

Speaker 4:
[12:47] So is there a checklist of symptoms that you look for when you're diagnosing this?

Speaker 2:
[12:55] In my head, I'm always interested in what the functional impact is. I think that's how psychologists think about this, and the DSM reflects it as well. Now, of course, there's no diagnosis, no formal diagnosis, which is medical trauma. But at the end of the day, I think we're really concerned about the impact. Not simply do you have nine out of 14 symptoms, or 17 out of 20, or whatever it might be, but rather, how do these symptoms show up in your relationships? How do they show up in your relationship with your body? How do they show up in the way you engage your family? How do they show up in the way you engage your work? And often the way that medical trauma shows up is in particularly profound avoidance. It's not the only way, but it's a prominent way. And that is patients often don't want to go to the doctors because that's like returning to the scene of the crime, last place they want to be. They don't want to go to the OBGYN's office to engage the stenographer because that's where they found out that that baby they were looking forward to having didn't have a heartbeat anymore. And they don't want to have that happen again. And in some cases, they don't want to go to the ER because that's where they had a heart attack. And the insidious impact of that is that if you need to go to the ER, but you decide not to go to the ER, a lot of bad things can happen. Many years ago, I'll share a quick anecdote. I had a little car, we had moved in Nashville. I had a little car, and one day the check engine light came on. And I was in a hurry. I didn't want to deal with it. And so I had a post-it note in the car. I put it over the check engine light and I just kept driving. And it seemed fine, seemed very fine. And one day, three or four months later, my car broke down by the side of the road and the engine seized up. And a day later, I sold it to the scrapyard for $50, as I recall. And this is a phenomenon, this avoidance that we see with some of our patients, which is, hey, you really need to deal with this. But for a variety of reasons, you're choosing to put it off. And I understand it. I can empathize with it very well. But the more you put off things that you need to address, the worse the outcomes are going to be. And I think that's what we see in medical trauma. Avoidance is a common phenomenon and an unhelpful one.

Speaker 4:
[15:33] You mentioned a moment ago that medical trauma is not in the DSM. Is that a problem? Should it be its own category in the DSM?

Speaker 2:
[15:41] I don't know if it should be. PTSD is certainly a category in the DSM. And anxiety and depression, which are the two other primary problems that we see on the heels of medical trauma, are in the DSM. Those are probably the three horsemen of the apocalypse, if you will, as it relates to medical trauma, anxiety and depression and PTSD. So I don't know that it needs a separate diagnosis, but I do think what we need to do a little bit more fully is to recognize that many of these DSM categories do indeed apply to people on the heels of medical trauma. And I think often, because well-meaning practitioners, well-meaning physicians, for instance, because they don't have a mental framework for what medical trauma is, they're often not asking a patient after a difficult medical event, are you anxious? Are you depressed? Do you have symptoms of PTSD? Sometimes that conversation takes place right after the event, right? Right after a distressing event. But we know that PTSD by definition doesn't develop a day after that event, right? It doesn't develop a week after the event, it takes some time. So often, by the time these problems have developed, people are no longer in the clinic and no one is really asking about them. And for that reason, they fly under the radar. And often patients, I would say this, often patients, particularly in the context of a surgery or a life-saving situation, they're grateful, in the moment especially, they're grateful, I survived this transplant, right? I have a new lease on life. And only later did they realize, oh, by the way, now I have some brand new problems that I didn't have before, right? Now I'm having nightmares after the surgery, I didn't have them before. And patients often feel like they're in quite a quandary. And that quandary is, I think I'm supposed to be really grateful for being alive. I think I'm supposed to be really grateful to my oncologist for saving my life. And if I'm supposed to be really grateful, maybe that means I shouldn't be complaining, right? And they talk themselves out of the difficulties they're having because they somehow don't seem legitimate. And I think an important message, an important message to your listeners is, if you're struggling, give yourself space and permission to struggle, right? Don't push those negative feelings out of your awareness just because you feel like you need to be filled with gratitude all the time. Acknowledge them and attend to them. We can help you address them. Two things can be true at the same time, right? You can be grateful to be alive and you can be angry and you can be sad. And that's important.

Speaker 4:
[18:39] We're going to take a short break. When we return, I'll talk to Dr. Jackson, about treatments for medical trauma and where people can go for help.

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Speaker 4:
[19:49] So let's talk about treatments. If somebody has medical trauma or maybe thinks they have it, where do they go for help? What are the treatments that work?

Speaker 2:
[20:00] As a proud psychologist, I of course believe the psychologists have so much to offer. We're not the only ones who do, of course, but we have a lot to offer and as it relates to trauma, we have a lot to offer. Now, it's important again to remember that medical trauma doesn't always result in PTSD. It typically doesn't. Even in the references that I made where there might be 18 percent of ICU survivors who have PTSD, not very good at math, but that means that 82 percent don't. Most people don't, but the number who do for those, it's a huge problem. I think if you have PTSD, thoughtful treatments for PTSD are likely effective. Prolonged exposure can be effective. Cognitive processing therapy can be effective. Interpersonal and psychodynamic therapies can be effective. There may be nuances. There may be differences that reflect the vagaries and uniquenesses of medical trauma. But I think in general, thoughtful trauma treatment is probably effective for medical trauma. With that said, if you force me to pick one therapy that I particularly like for people after medical trauma, it is acceptance and commitment therapy. That's been the approach with my patients that seems to resonate the most. Again, not necessarily for people with PTSD, but often for people whose lives have been really derailed and they are very different than they used to be and they are trying to figure out how to make sense of things. The acceptance aspect of acceptance and commitment therapy is hugely valuable. So I love that you can find acceptance and commitment therapy practitioners. You can find practitioners who treat trauma. There are many of them. Now, patients struggle, and it's unfortunate because you go online, you Google a psychologist, a list of literally thousands of people come up, it's not really easy to pick them. People don't typically have medical trauma in their list of expertise, but I do think that's changing. I think that's changing over time.

Speaker 4:
[22:24] Let's talk for a little bit about acceptance and commitment therapy. I mean, I get the idea of accepting the idea that you have this problem, but what are you committing to?

Speaker 2:
[22:35] Yeah, it's a great question. You know, my own journey, as I discuss in the book at length, is that I have OCD, and I developed OCD. I would say I really developed it in spades in 2018 as a 50-year-old adult. I think looking back, I had probably had elements of it three decades before, but it really had been quiet. And when it came back again in spades, I went to see a psychologist who is amazing. And I said some version of, let's get rid of this. This should be no problem, right? Like, let's get rid of it. And she kindly, in so many words, said, I'm not so sure that that's what we do. I'm not sure we really get rid of it. You don't just pull it out like a weed, right? And so she invited me to begin to accept it, and to deal with all the ramifications of that. And it took me a year, maybe a year and a half, to even consider really accepting it. You know, this change can take a long time. When I did, things really began to change, and the commitment element of that was, I'm going to find a way to commit to live my life with this new challenge in a way that reflects my values. I'm going to commit to a life that reflects my values, and I'm going to commit to finding a way to live a rich life and a full life, even with these problems that I didn't ask for, that I don't want. And that's been a beautiful thing, that both and-ness of things, both and, and in my interaction with my patients, it's that both and that is often especially powerful. And that is, I've got a new problem now. I've got a new medical challenge now. I didn't have cancer before, but now I do, or, you know, I wasn't on oxygen before, but now I am. I mean, you could fill in the blank. And, and I'm going to find a way to live a rich life, even with these difficulties that I didn't want. Early in the pandemic, we started a program, a support group program for long COVID patients. We've led five or 600 support groups by now for people with long COVID. And very often, the dynamic was patients were saying, I'm going to be okay once this long COVID goes away. Once it goes away, I'm going to be okay. And I understand the appeal of that, but the truth for many of them is actually it's not going away, right? It's not going away. So if you're waiting to be okay for it to go away, you're going to be waiting actually a long time. So how can we, it's not as simple as just flipping a switch and changing your mind, but how can we invite you to consider the idea and then eventually embrace the idea that actually I can choose to be okay right now, right? Even if it doesn't go away. And when patients have figured that out, that I can be okay even if this never goes away, then you've really cracked the code and then you see them begin to really thrive.

Speaker 4:
[25:48] So what do you wish that health care providers, both physicians and mental health providers, knew about medical trauma? Do you have any advice for clinicians who want to incorporate an awareness of this into their work with patients?

Speaker 2:
[26:03] I've got so many thoughts about this and I know we're limited in time. I would really invite my physician colleagues, my health care colleagues, to be much more curious about this issue, to focus a little less uniformly on medical outcomes and to focus a little more thoroughly on mental health outcomes. In the ICU, where I've done much of my work, I've seen this dynamic where patients survive the ICU, and there's almost this thought that our work is finished, right? Like they're not on the ventilator anymore, they're breathing on their own, they've made it through this battle with sepsis, our work is finished. I would invite my medical colleagues, whatever the disease might be, to think, in some ways our work has just barely begun, right? It's far from finished. It's fantastic that they're alive, and some of our patients have said, and no doubt will say to me, well, sure, I'm alive, but if I knew I would have these problems, cognitive impairment and PTSD, anxiety and depression, no job, limited ability to work, I actually wish that I never would have made it out of the ICU. I mean, people say that. So deciding to ask a question which is, how are you doing exactly? And do you feel any conflicted feelings? And what's going on? And are you sad? And all of these sorts of things could take place quickly in the context of a busy PCP's office. And I think there needs to be more space for checking in with patients with mental health challenges following a physical difficulty. Let's not make it an add-on. Let's make this a central part of our process, engaging people's mental health. For my mental health colleagues, I would say, come on in, the water is fine. By which I mean, there's this huge issue. There are a relatively small number of us tackling it. Please join us. Come on in. The water is fine. There are people with medical trauma, they want help and they need help. And to my psychologists, friends, and colleagues, you are uniquely equipped, you are uniquely equipped to be a cairn in the lives of these patients that points them toward a rich life. You're uniquely equipped to be a guide. You're uniquely equipped to help them. No one is more equipped than you. They need your help. So come on in, the water is fine. And let's work together to transform the lives of people and families stuck in the throes of medical trauma as we help them try to find ways to reclaim their life.

Speaker 4:
[28:50] You know, I think it's interesting that you lead an ICU recovery center. How unusual is its existence and what are the other things that you work on there?

Speaker 2:
[29:01] Yeah, actually, that's a great question. So, in the United Kingdom, probably as early as the early 2000s, there were at least a few recovery centers devoted to treating the unique constellation of problems that develop after the ICU. And my good friend, Dr. Carla Sieven, great pulmonologist and intensivist researcher, she and I joined ARMS in 2013, and we formed the ICU Recovery Center at Vanderbilt, which I think was the second clinic of its kind in the United States, dealing again uniquely with the challenges of ICU survivors. And from a mental health standpoint, those include anxiety and depression, PTSD, sometimes OCD, sometimes psychosis, things of that sort. But typically, the three horsemen of the apocalypse, from a cognitive standpoint, often involve cognitive impairment. So in this clinic, we have a pharmacist, we have a pulmonologist and intensivist, we have a psychologist, me, and we engage people from a multifaceted standpoint, often helping them transition into finding resources. We have a social worker, by the way, Jenna McDonald, I should mention that. But on the heels of identifying problems, we often send them back to their community with a game plan, help them find resources. And when they find resources, they often do quite well. And one of the resources that in my mind is critical for these patients is support groups. So there are not thousands of support groups. But at Vanderbilt, we have at least a few, and there are a few around the country devoted to the needs of ICU survivors. We have a Medical Trauma Support Group as well, all offered virtually. And what I've learned, this isn't new news. But what I've learned is that when people have more support, they do better, right? When they have less support, they do worse. And it's almost that simple. You know, there aren't that many axioms that I quickly subscribe to in psychology or elsewhere. But one of them, one thing that is axiomatic is, if you're having a mental health challenge and you have less support, it is harder, right? It's reliably harder. And if you have more support, it's easier. And when we plug people into support groups with others whose stories are similar or perhaps the same, you see a light bulb go off and it's beautiful. And there is this dynamic of, I found my people, right? Like I've been encountering, I mean, I heard this just the other day from a patient. I've been encountering people from the point of view of the patient. This is what they say. I've been encountering people who say, it's been six months, you should be done with this now. You should be doing better now. You should be over your depression now. Really? You've got PTSD? Well-meaning friends and family. Those are painful things that patients hear. And when they engage people who equally have heard those things and have found the courage and the resilience to shoulder on, when they see people speak with such beautiful vulnerability about their struggles, they feel like they've found their people. And these groups are laboratories, they're much more than that, but they're laboratories for our patients to learn and to grow. And if there was one thing I could give, if there was pixie dust that I could sprinkle on, medical trauma survivors, it would be to create rich and textured and helpful circles of support for them, because it is critical to their growth.

Speaker 4:
[32:57] So just to wrap up, what are you working on now? What are the big questions that you would still like to answer?

Speaker 2:
[33:05] There's so many. This field of medical trauma is in many ways in its infancy. When I decided to try to write this book, this Medical Trauma Book, I thought surely someone has written a book for patients about medical trauma and I thought, I'm probably a little bit late to the party here. As I often have been in my life with good ideas, it's a great idea and then I think, oh gosh, someone else did it. So a psychologist from Cincinnati, Michelle Flom, had written a great book about medical trauma a decade or so ago aimed at practitioners. That book's available. It's helpful. But no one had written a book aimed at patients. And so, you know, there's a book now, it's about to be in the world in April, but I think our work is really only beginning. You know, I've got a lot of projects going on at any one time. There's no next thing exactly, but it is to continue finding ways to lean into the challenges that people experience following medical trauma. And I think especially for me to convince my medical colleagues that this is a huge problem that they need to address. When I talk to people about it, honestly, to medical colleagues, they're hugely open to the idea. When they hear about it, they say, of course, that makes sense. But I have found that for many, unless you invite them to think about it, it's not necessarily on their radar. So I think one big area to improve is in this vast community of physicians, let's raise awareness and I think also another area would be, let's figure out if there are particular treatments that we need to tailor for people with medical trauma beyond the standard, beyond the usual that will help transform the lives of people with medical trauma.

Speaker 4:
[35:02] Dr. Jackson, I want to thank you for joining me today. I think you've given our listeners a lot of very helpful information.

Speaker 2:
[35:09] It's really been a privilege to be with you. Thank you.

Speaker 4:
[35:13] You can find previous episodes of Speaking of Psychology on our website at speakingofpsychology.org or on Apple, Spotify, YouTube, or wherever you get your podcasts. If you like what you've heard, please subscribe and leave a review. If you have comments or ideas for future podcasts, you can email us at speakingofpsychologyatapa.org. Speaking of Psychology is produced by Lee Weinerman. Thank you for listening for the American Psychological Association. I'm Kim Mills.