Summary of a recorded Seminar

Below is a transcript of a recorded seminar. Provide 3 APA references Draft a detailed summary throughout the presentation so that I get Full credit for this week's seminar. All right, so today we are talking about trauma and trauma-informed care, and unfortunately, this is something that in your practice you are going to come across a lot of, trauma and PTSD. unfortunately has… there's a lot of it in our… in our country. There is also a lot of comorbidity with other psychiatric conditions when people do have trauma history. So we're going to talk a little bit about that today, and what trauma-informed care actually means. That's kind of a buzzword these days, but what does that actually look like? So, trauma… This is a word we've talked in the… in previous units about how, you know, social media is a double-edged sword when it comes to mental health, because it's, you know, increasing awareness, it's kind of normalizing some of these things, but it's also taking clinical language and using it for things that maybe do not actually meet clinical criteria. Trauma is one of those things. Trauma is not… you know, something that's mildly distressing, or mildly annoying, or, you know, upsetting, for a short period of time. Trauma is… A significantly emotionally disturbing or life-threatening incident or event that has lasting effects on the individual's functioning, whether that's mental, physical, social, emotional, spiritual, something that causes significant distress or inability to maintain their prior level of function. With trauma, these can be things that the patient themselves experiences, or it can be something that they witness. So somebody who maybe isn't in the car accident, but they see a car accident happen. You can also have what we call secondary trauma. Which is not as common, but it's fair… it happens often in healthcare providers. People who, you know, are, like, therapists, you know, we are… caring for people who have significant trauma, and we hear in great detail about things that happen to people, and so sometimes we can end up developing trauma symptoms, or, you know, PTSD-type symptoms, even though we weren't the ones who physically witnessed the, or lived the experience. Adverse childhood events, or ACEs, are particularly elevated with certain populations, and they are, the ACE score is… it essentially assesses the number or frequency of Traumatic events that happen in childhood. So, things that can be traumatic that are included in the ACE scoring algorithm, physical abuse or assault, sexual abuse or assault, childhood neglect, living with a family member that has mental health or substance use disorders. Sudden, unexpected separation from a loved one, so if a parent or a caregiver goes to jail, or if somebody close to them dies. Poverty, racism, discrimination, oppression, violence in the community, war, terrorism, etc. Aces are higher, statistically, in Black, Hispanic, and multiracial populations. People with less than a high school education, people with low income, or who are unemployed or unable to work, and then people who identify as gay, lesbian, or bisexual. Those populations all are statistically correlated with higher ACE scores. So what do the, ACE, or Adverse Childhood Events, actually do in the brain? So, we know that childhood trauma in particularly has damaging effects on children's brains. So, we've talked about, or I've talked about in previous units, that first thousand days, or that first 3 years of a child's life, that is when the most critical brain development is happening. That is when they are… the brain grows faster during that time period than any other time in life. So when there's chronic exposure to cortisol or stress, adrenaline, norepinephrine, all of those things, and then combined with maybe You know, not having exposure to oxytocin, if, you know, there's a lot of neglect going on, not having good nutrition, things like that, that also happen in some of these instances. It really creates poor brain development in children, and these children, as adults, tend to have higher rates of anxiety, depression, anxiety. We see a lot of emotional regulation disorders. Learning disabilities, and a harder time being successful in the workplace as an adult as well. There was a study, called the Philadelphia Urban Study that was… that utilized ACE scores And it found that the more the child is exposed to stressful or traumatic instances, the greater the risk for chronic health conditions. And, health… what we call health risk behavior, so things that are going to you know, impact their potential physical health later in life. So when they did this study, and they assessed ACE scores, people who had higher ACE scores were two times more likely to smoke. Two and a half times more likely to have an STI, four times more likely to have COPD, 7 times more likely to consider themselves alcoholic. 10 times more likely to have injected street drugs, and 12 times more likely to have attempted suicide. Those are some pretty significant statistics. So that's why when we're talking about childhood and really trying to protect children emotionally, making sure that they have all of the things that they need to be successful and healthy. This is a large reason why. Because we know that the exposure and the experience in childhood really does predict later physical and mental health, as well as potential success, as, you know, a member of society. So, definitely really, really impactful. information. Sometimes people who have higher ACE scores develop what we call maladaptive coping mechanisms, or, you know, ways to cope with the emotional or physical pain that are maybe not the best for them. That's likely where these street drugs, the attempted suicide, the alcoholism is coming from, because Those people are… essentially, they're trying to numb the pain. They're trying to erase memories, they're trying to repress things. And that can have really damaging effects on them. It impacts relationships as well. So, you know, when you have emotional dysregulation, or you have a hard time feeling and processing your emotions, you are going to be more angry, you're going to be more aggressive, you're going to have a harder time with conflict resolution. Those things can really significantly impact your relationships with other people. A lot of times these people also have a high tendency towards having a lot of shame, or a lot of guilt, even if it's inappropriate guilt, even if they had nothing to do with the circumstances. They still tend to have a lot of shame, and so they do try to numb, and, you know, escape from those emotions. Let's see, so how does trauma actually affect the brain? So… When you're working with trauma, definitely helpful to be familiar with the different regions in the brain and how they are connected to the symptoms that patients are experiencing. I actually kind of wish our programs incorporated more, like, neuroscience, because it is really helpful for understanding how some of these symptoms present and where they're coming from. But when we're talking about trauma, there's really 3 primary areas that are impacted by trauma. The whole brain absolutely is affected. If you look at brain scans of people who have experienced trauma and then people who have not. you can physically see differences in the size of the brain. Even when you account for, like, height, weight, you know, all that kind of stuff, the size of the brain is actually different between people who have experienced trauma and people who have it. So, the three sections specifically that we're looking at are the prefrontal cortex. So, prefrontal cortex, this is where your rational thinking is. This is where your emotional regulation is. This is also where a lot of your fear response comes from. So, when we look at brain scans of people who have PTSD, this prefrontal cortex is actually shrunk. It has a reduced volume. Anytime you see reduced volume in the brain, that means that there are fewer neural connections, because there's less brain matter, and fewer neural connections result in… most of the time, result in psychiatric symptoms. So, there's a clear difference in that prefrontal cortex. The hippocampus, which is also… this is responsible for your memory, and this is what the brain uses to try to make sense of the trauma. This is how memories, or where memories are consolidated. And so, when somebody is consistently exposed to trauma. This part of the brain actually shrinks, so it makes it more and more difficult for the person and their brain to differentiate between what happened in the past and what happened currently. This is really important when we start thinking about, you know, being hypervigilant, which is one of the PTSD symptoms. The brain is constantly scanning for threats, so if you are unable because your hippocampus is physically shrunk. If you're unable, on a physiologic level, to differentiate between what happened to you in the past and what's happening currently, everything is going to look like a threat. Or, that threshold for what is considered a threat is going to be a lot lower, because your brain can't differentiate between now and what happened in the past. So that's something to kind of, just remember and be aware of. And then your amygdala. So your amygdala is wired for survival. When it's more active, it's hard to think rationally. And your amygdala activates, it actually kind of swells a little bit when you are stressed. So the more active the hype… or the more… yeah, the more hyperactive the amygdala is. the more signs of PTSD are present. This is why, this is the mechanism why when you are stressed out, or when people are, you know, in acute trauma, or when they're in shock after something significant happens, this is why people cannot think clearly, because that amygdala, the wiring for survival, it's kind of clouding the judgment, because it's wired for survival. It's not thinking about you know, emotional response. It's not thinking about logic, it's thinking about, am I breathing? Am I eating? Do I have enough oxygen? You know, it's… it's very, visceral, and very primal. This is, like, probably the most primal part of your brain. So, when people are stressed out, they're not going to make the same decisions that they would make when they're not stressed out. So that is also something to think about, even when you're thinking about, like, your self-care, or you're navigating difficult decisions for yourself, when you're stressed out, you can't think clearly. It's physically impossible, because that amygdala is… is hyperactive. So, in, In trauma, the brain processing is a little bit different than kind of what typical brain processing is. So, in normal brain processing, we are kind of our… our primal brain is always looking for threats, right? We're always looking for that tiger that we need to run away from. Usually this is, you know, the information gets filtered through our limbic system. This is where our instinctual, like, fight-or-flight mechanism, kind of gets decided. When the threat is perceived, the amygdala alerts your hypothalamus, that's where the stress hormones get released from, so, you know, your… your adrenaline, you know, your… we're gonna go into the hormones here in a few minutes, all of those things, and that really gets your body's, or your nervous system, kind of up and awake and ready to respond. You… that's where that fight, fight, fight, flight, or freeze kicks in, is because of that, triggering of your nervous system. When you have prior trauma, that… That, process is kind of stunted, because your brain is like, trauma, we're outta here. And so the parasympathetic nervous system kind of automatically gets activated, and that's where you get that numbing or dissociation. So a lot of times in PTSD, you will see more of the freeze response than the fight or flight. Because the brain is like, we know what happens when this goes on, we're shutting down. And part of that is protective, because when you are in that numb or dissociative state, you don't consolidate or you don't record memories the same way, and so if the brain thinks, hey, there's something that could be really distressing or scary happening here, we don't necessarily want to remember that for the future, moving into that dissociated state can be Somewhat of a protective mechanism. So, the HPA axis, we're going to talk about this in, on the next slide, but this is a great, kind of a great graphic to explain how this works. So the HPA axis is really instrumental in pretty much all of our psychiatric diagnoses. So, we're talking about it here in the context of trauma, but even in anxiety and depression, this is really kind of the regulating mechanism for anxiety and depression, as well as trauma. So the stress response system is what controls our physical response to stresses. When our physical responses to stresses kind of take hold. It's really… it's a feedback loop, right? And so, when you get stressed out and you start getting those stress hormones, it makes it harder for your brain to logically think, and so a lot of times, you know, we'll work with patients on you know, especially in CBT, trying to change thought processes and things like that, that doesn't work as well when the stress response system is overactivated, or when it's not kind of calming itself down. So what happens when you get exposed to a stressor is that your… your body still responds by releasing, you know, your corticotrop… I always mess that up… corticotropin-releasing hormone, which then signals adrenocorticotropic hormone, and then that stimulates cortisol release. Cortisol is not necessarily a bad thing. Cortisol is actually helpful for regulating the stress response. You know, if you're on social media, you'll hear, like, every other influencer talking about, reduce your cortisol, your cortisol's too high, elevated cortisol causes this. Elevated cortisol is actually biologically necessary, because that release of cortisol is… it helps stimulate that negative feedback loop, so when the cortisol gets released. It tells your body to essentially stop making the stress hormones. What happens when you're chronically stressed, or you have PTSD, is that eventually your body gets sensitized to this, and so it actually stops producing, the cortisol, and stops responding to your stress hormones. So instead of this feedback loop working appropriately, you just get this, like. It's like your body isn't recognizing what's going on, and when you have extended or chronic exposure to these stress hormones, it causes a lot of inflammation, and a lot of our psychiatric symptoms come, or they are related to inflammatory processes. So, we actually want to have cortisol present, we just don't want it to continually be present. And that is, unfortunately, kind of what happens when you have chronic stress or PTSD. So, kind of diving into that HPA axis, this is the feedback loop that controls your reactions to stress. And it's not just about the stress response in the terms of, like, psychological stress, where you're cognitively or consciously aware of stress. This is also going to be regulating body processes, so your digestion is one of them. That's why a lot of people have, like, a GI or urinary response to stress. They either feel like they're going to pee their pants, or, you know, they have to go to the bathroom right away, because your digestive system responds to your stress hormones. Your immune system is regulated by the stress response system, your mood and emotions, your sexuality even, and your energy expenditure. So this helps to kind of regulate your body's battery in a lot of ways. the HPA axis is the… it's essentially the interaction between your endocrine and your nervous system. So it's how your hormones are being… Instructed or, or, dictated to by the nervous system, and vice versa. The brain areas that the HPA axis influences, amygdala, hippocampus, the hypothalamus, those are the three main things that help facilitate the activation of the HPA axis. And interestingly, there's a lot of new research coming out about the gut flora and gut microbiota, and I just was recently reading, an article when I was working on my D&P project about this, where The current theory, actually, is that certain microbes in your GI system actually release chemical messengers that activate certain, it sends certain information to your brain through the HPA axis. And through different nerve impulses and things like that. So your gut is literally communicating with your brain via the HPA axis, which is pretty impressive. And also indicates that we really need to be focusing a lot more on the gut and, nutrition and things like that, because gut health is directly correlated to mental health. So, because of this new information that's coming out. So, definitely something, To be aware of and kind of work with your patients on if they're, you know, really anxious, or you're trying to kind of mitigate stress. Working on gut health can be really, really helpful for that. The hypothalamus, sends fear signaling impulses to activate that… the sympathetic nervous system. So we talked about that a little bit in the last slide. Increased production of cortisol is what mediates those alarm reactions and helps your body adapt to the stress. The downside is that your immune system, or your immune response is suppressed when your cortisol level is, you know, elevated and cortisol's trying to do its thing. So when you have a lot of stress, or you have PTSD, A lot of times, people are a little bit more prone to getting sick because their immune system is just not quite as functional. Let's see, that goes more into… It just goes more into what we just talked about. Okay, so, we talked a little bit about cortisol dysfunction. The trauma stimulates that fight-or-flight response, because of the norepinephrine and adrenaline that is released. So, when you have increased norepinephrine, you actually see, more consolidation of memories, which is kind of a good thing. So, if something stressful happens, you want there to be a consolidation of memories, because that's how your brain is going to actually process the memory and kind of store it In PTSD, you have increased norepinephrine, Which consolidates those traumatic memories, and then you get increased fear conditioning. So, you… in some… that kind of contradicts what I just said, I didn't explain that very well. So you want to have some consolidation of memories. When you have trauma. you're… it's almost like too much of the memory gets stored. So, instead of having this be something that's kind of a moderate memory or moderate fear response, you get an increased fear response. Almost like a… like a hypervigilance type thing. Like, you're… it's remembering a little bit too much. As time goes on. Non… unrelated stimuli can get attached to that initial stimuli, and so that field of, you know, that ripple effect of that memory, can become greater and greater and greater. So, you know, even though this is what happened over time, the brain starts trying to scan for things that kind of mimic or resonate or could be attached to that, and that's where you see people start getting more and more avoidant and things like that. In a normal stress response, the cortisol reduces that norepinephrine, and then the, the memories are not Consolidated in a way that is distressing, if that makes sense. In order to help with this, you can use alpha-2 agonists, so that's why prazosin and clonidine are really helpful in PTSD, because they help decrease that hyperarousal state, and it allows for more of the psychological treatment to occur. So, I always tell my patients, like, you can absolutely do therapy without medication, and it will prob… it will still work. But if you do use medication, because it helps reduce that stress response. And it helps, kind of, increase your neuroplasticity it just makes it easier for the work that you're doing in therapy to actually stick. So, it's kind of like swimming with concrete shoes, right? Like, you are going to make it, you can still swim, but it's a lot harder than if you didn't have concrete shoes on. So, can be really helpful that way. Effects of trauma, so, when you have a traumatic response, you can have… or a traumatic incident, you can have a… what we call a balanced response. This is where the person is, you know, they're uncomfortable, but they're resourceful, they're able to see that this is temporary, that it's not something that they need to be kind of chronically upset or stressed about. Maybe if they need a little bit of support, they'll reach out to friends or family, community. Maybe they'll educate themselves, and then they kind of move into the healing phase where they're, like, constructing their narrative about what happened, they have their grief period, and they kind of incorporate that traumatic experience as just a A piece of their life. When you have an unbalanced response, this is where the trauma disorders come in. So, you can have acute stress disorder or PTSD. The difference between the two is how long the symptoms last. So, if it's less than a month, it's acute stress disorder. If it's greater than a month, it's PTSD. in these symptoms, or in these, diagnoses, you can have, you know, the flashbacks, you can have numbing and avoidance, you can have hypervigilance, you can have dissociation. Complex PTSD, which occurs when there are multiple or repeated traumas throughout a person's life. You might see more mood disorders, anxiety disorders, personality disorders, brief psychotic disorders even. There's also a huge overlap in somatic disorders with PTSD and trauma. Chronic pain, chronic fatigue, fibromyalgia, even hypertension, IBS, endocrine disorders, sleep disorders, very large or very strong overlap between the two. So, there's actually been research that has found that for chronic pain, integrating psychotherapy and trauma support groups increases the effectiveness of their pain management. So. absolutely can have a very, profound impact to also focus on the somatic symptoms. There is a, or there are therapeutic techniques or specific modalities that focus specifically on somatic work. it's something that I think is really important. I personally haven't been able to, at this point, spend a ton of time doing trainings and things like that. It's something I'd like to do, because there is a very strong correlation between the two, and there's a lot of people who would really benefit from that. when you… regardless of whether you have acute stress disorder or PTSD, the treatment is going to be a combination of education, psychotherapy, medication. Emdr is not something that I don't know many nurse practitioners who do EMDR. Not to say we can't, it's just not something… it takes a lot of training, very time-intensive and very expensive training to be certified in doing it, and so, not many nurse practitioners do it, but you can, technically, if you're trained in it. But that's kind of the gold standard for trauma therapy, and it's a very interesting concept. I've had patients who have done it, and it works finely well. And then I've had other patients who say they didn't feel like it helped a whole lot, and so I think a lot of that probably has to do with, the practitioner who's doing it. But, So EMDR or CBT, you know, and then you can also add in adjunctive treatments, so like we talked about medication, sometimes hypnosis, body or energy work, acupuncture, things like that can be really helpful for PTSD as well. Alright, so what is trauma-informed care? So, trauma-informed care essentially is just trying to realize the… essentially the widespread impact and the prevalence of trauma in today's world. Also trying to understand how we help patients heal from it. The concept of trauma-informed care as a kind of modality or a theory, an idea, is that we want to recognize the signs and symptoms of trauma in patients and in their families. We want to actively avoid re-traumatizing, which to me, I'm like, don't we… shouldn't we be doing that at baseline? But apparently this is a new concept, and this really shifts the view from what's wrong with you to what happened to you. And historically, this is kind of where psychiatry and psychology have kind of, like, split, where they don't tend to see eye to eye, because psychiatry is very biological-based, right? It's like, okay, where is the dysfunction? What are we trying to correct? Whereas psychology is, okay, what experiences have you had that shaped you into where you're at right now? Or what happened to get you to this point? And so the… the goal with trauma-informed care is really to kind of bring those two ideas together. Principles of trauma-informed care, so safety, obviously, number one, that should be regardless. Ensuring that patients, their families, and staff in our clinics feel safe, both physically and psychologically. Trustworthiness and transparency, so decisions are made with transparency with the goal of building and maintaining trust. this is, again, something that kind of seems like it should just be automatic. If we are promoting our patients' autonomy and trying to help empower them. we should be transparent. There should be that trustworthiness. Peer support, this is a great concept that, Personally, I haven't seen it in any organizations other than community-based mental health, but the idea with peer support is that people who have shared experiences are integrated into the organization, and they're viewed as part of the care team. So they take their lived experience, most places, like in Washington State, they actually do have to go through a certification program. But they take their lived experiences, their education, or their certification, and then they act as Kind of like, like an additional layer of therapy support, but they're not providing therapy. It really kind of takes that benefit from group therapy and, puts it more into a one-on-one capacity. So the idea is that somebody who has lived through something and has experience kind of getting to the other side of it is able to help model and mentor somebody who's actively going through the same thing. Collaboration with mutuality, so there's no hierarchy of power. Clients, staff, leadership, they all engage in shared decision making. Patient empowerment, voice and choice, we've kind of talked about that. And then also recognizing cultural, historic, and gender issues, biases, stereotypes, and historical trauma. So there's four key assumptions in trauma-informed care realization, so that's just understanding that trauma can impact families, groups, organizations, and communities. That coping strategies should be designed to, help deal with adversity and overwhelming circumstances. Understanding that trauma plays a role in mental health and substance use disorder, so there is a very high comorbidity between PTSD and substance use disorders, so we really want to try to be systemically addressing this so that we can help prevent, get early intervention for trauma, to help You know, give people the best outcomes long-term. Recognize that people in an organization or system can recognize the signs of trauma, that screenings and assessment, are there to help with traumas. workforce development, employee assistance and supervision practices. Trauma-informed care response, so programs, organizations, and systems apply the principles of trauma-informed care to all areas of functioning within that organization. Mission statements, policies, manuals, all create a culture based on beliefs about resilience. So, you know, really promoting the idea that even if you have trauma, you don't have to stay in the place that you're in, you're able to kind of heal and move past it. Resisting re-traumatization, so recognizing how organizational practices might trigger painful memories. This is something that the mental health community tends to do really well with. In my work with perinatal patients and, you know, pregnancy and things like that, this is something that you know, other few… I've noticed other areas of medicine or healthcare could really… strive to improve on, especially with birth trauma and things like that. There are a lot of, providers and organizations that don't realize how triggering, certain policies and language and experiences can be for, people who have birth trauma. So, definitely something that, from an organization perspective, should be emphasized as well. So with trauma-informed care, we're really working to shift from, you know, that problem-focused perspective, like, hey, what… how broken are you? To what is… what is the reason for this response? How did you get to this point, and how can we help you heal from it? So rather than seeing, you know, overly sensitive or reactive behavior, we see somebody is being triggered by their trauma. If somebody refuses to accept help, we're recognizing that maybe they have a lot of shame or guilt, or maybe they don't feel like they're worthy of help. If people are avoiding people, maybe we start recognizing that they're trying to avoid being re-triggered or being stressed. If somebody appears disengaged, we recognize that this could be from experiencing dissociation, from trauma, rather than, you know, not wanting to get better and not wanting to participate. So, for the clinician, what we need to do is involve patients in the treatment process, which is something we've talked about probably a little bit in every seminar, giving patients their voice through the treatment process. We are not dictating the care to them, we are providing them with options and allowing them to You know, essentially choose what feels the best for them, or what they are most comfortable with. You know, informed consent is a huge thing. Just because we are the healthcare providers, and we may have an idea of what we think is best, that doesn't necessarily mean that it actually is the best for that patient, because if a patient doesn't feel comfortable with it. it's not going to work as well. And, you know, it's going to cause distress for them. So we want to… we want to operate in a way that honors our patients' beliefs and how they want to be treated. Engaging peer support workers, so that is also a key component. Screening for trauma, so there is some… I don't want to say controversy, but there's, kind of a back and forth about whether or not we should be universally screening for trauma with all of our patients. The people who are in favor of it, saying that screening every patient for it. Allows us to kind of catch it as early as possible, helps us understand the patient's trauma history in the context of everything else that they're going through, helps us target interventions, And decreases the risk of bias, because we're screening everybody. The people who are opposed to this say that patients should have the ability to get to know their providers and trust them before they're sharing sensitive information. You know, it says that they… it kind of removes the patient's choice, it may re-traumatize the patient. It might hinder progress if there's not appropriate interventions or referrals in place. So kind of the consensus is that the treatment setting should guide the screening process. Screening should definitely benefit the patient, rescreening should be avoided, and ample training should be provided to the providers before they start issuing the screenings. So in my practice, the way that this looks is that I do universally screen for trauma. when my patients, before they even start their appointment, they have to fill out all of their intake paperwork in advance of the appointment time. On the intake paperwork in the history, it asks them if they have a history of any traumatic events. It asks them the type of trauma, so was it physical, emotional, sexual, was it neglect? And that's all it asks them. When I am with them, and we're talking about things, before we even jump into the assessment, I let them know. you know, if anything comes up throughout our discussion today that makes you feel uncomfortable, or awkward, or you're just not ready to talk about, let me know and we can skip over it, because today we're really trying to get a broad overview of what's going on. If there's anything that's more sensitive or that does bring up those uncomfortable feelings, we can talk about that in future visits, when you're a little more comfortable and we have more time to kind of dive into that. Then, once we actually get to that section where I'm talking about trauma, I will confirm what they put on their form. Okay, I see that you have a history of trauma, it looks like you had some sexual abuse, and I will ask them, you know, do you feel okay answering a couple questions about that? And most of the time, they say yes. And I'll say, okay, was it, you know, in childhood? Was it adulthood? Was it somebody you knew? And that's really kind of all I do in the first visit. if at the end of, you know, the evaluation, I think that maybe that trauma is a factor, the next time that I meet with them, I will say, you know. I'll let them know, like, hey, you know, the trauma you experienced, they might be part of a… part of what's going on. Would you be okay if we talked about that, you know, in the next visit or two, so that we can maybe see if we need to… to treat that specifically? Most people are okay with it, sometimes people say, no, I'm not ready to talk about it, and that's okay. We kind of work around it. But there are definitely ways that you can get the information that you need to know without necessarily making your patient feel uncomfortable or re-traumatizing them. You also want to make sure that you have referral sources and partnering organizations. So, making sure that you have good resources that if, you know, your patient does need EMDR and you don't do it, you have somewhere you can send them. Also making sure that, you know, there are community-wide trainings. So, can you offer a training about trauma-informed care, maybe to primary care offices, or OB offices, or, you know, any of these other providers that maybe would benefit From having the mental health or the psychiatric perspective about trauma.