E85: Dealing with Medical Trauma with Dr. Katie Gorman-Ezell

00:01 Announcer: Welcome to the Standing Up to POTS podcast, otherwise known as the POTScast. This podcast is dedicated to educating and empowering the community about postural orthostatic tachycardia syndrome, commonly referred to as POTS. This invisible illness impacts millions and we are committed to explaining the basics, raising awareness, exploring the research, and empowering patients to not only survive, but thrive. This is the Standing Up to POTS podcast.

00:29 Jill (Host): Hello, fellow POTS patients and terrific people who care about POTS patients. I'm Jill Brook and today we have an episode of the POTS Practitioners. We are speaking about medical trauma with our Standing Up to POTS counseling expert, Dr. Kathleen Gorman-Ezell. You may recall her from our episodes on medical gaslighting and grieving an old life lost. She is a licensed independent social worker who specializes in treating individuals with mental health diagnosis. She is also an assistant professor at Ohio Dominican University, where she researches the interaction between chronic illness and mental health. She earned her BA in psychology from Wittenberg University, her MSW from the University of Michigan, and her Ph.D. from the Ohio State University. And she is one of several board members at Standing Up to POTS who helps conduct research on POTS and publishes papers on POTS. So she really knows this space. Dr. Gorman-Ezell, thank you so much for speaking with us today.

01:36 Dr. Gorman-Ezell (Guest): Oh, thank you so much for having me. I'm excited to be back.

01:39 Jill (Host): Well, so this is a topic that I see mentioned all the time in support groups - this topic of medical trauma - but I was hoping that before we dive into medical trauma, do you think you could even just define the word 'trauma,' 'cause I feel like it gets thrown around a lot, but I don't actually know, like what's the difference between trauma and just like, a really terrible experience?

02:05 Dr. Gorman-Ezell (Guest): No, I think that's a really great question. So, any emotional response to a terrible event can be considered trauma, right? So people can experience trauma when they feel like there is an intense physiological, physical or emotional reaction. I think that's where things then become a little bit more gray, right, because someone could have a miscarriage, for example. That's considered trauma. Somebody could be in a bad car accident. That's considered trauma. Somebody could be at the hands of someone abusing them. That is trauma. But the real delineating line is how intrusive that trauma is and how it impacts a person on a day-to-day basis. So for some people, you know, we're all resilient to a point. And so, depending on what's going on in our life, sometimes that bad event may bother us for a couple weeks, but then we don't think about it a whole lot again. For others of us, that bad event may enter into our minds constantly, and we may have a lot of intrusive thoughts and it may be difficult to sleep. We may get physiological reactions when we see triggers that remind us of that event, when those things happen, and they start to interfere with daily life. That's when we open up more of the mental health diagnosis of trauma and start to look at treating it in a different way.

03:23 Jill (Host): OK, so that makes sense. So what I'm hearing is that it's a pretty broad possibility of experiences, so it could be something that happens to you at the doctor's office, it could be an experience with like a treatment or a drug or a surgery. Is that...?

03:41 Dr. Gorman-Ezell (Guest): Absolutely. And I think you're kind of coming into more of the idea of medical trauma or medical traumatic stress. And I think what's different about medical trauma is that the trauma results from some type of a medical procedure or within a medical setting. And so the medical piece of things then are responsible for the traumatic reaction.

04:04 Jill (Host): Right. And there's just so many things that can be worse than unpleasant when it comes to medicine. And so, I imagine that even when something goes right, even when you have a procedure or you get a treatment and everything goes the way it was supposed to go, there's still so many terrible side effects or terrible experiences or fear, or blood, or I mean even, like getting the insurance company to cover it. Like, I actually was wondering if I was mildly traumatized by mail from my insurance company because I think, as our listeners will know, it took me 17 years to get a diagnosis and another three to find a treatment that works. This treatment was miraculous for me, and then my insurance wouldn't cover it. And I really thought that I was not going to make it without this treatment. And so, so I fought a yearlong insurance battle with them, and I would keep getting denial letters and it got to be where just looking at an envelope from them in my mailbox I would start shaking. And I thought, weird, I think this envelope now has power over me. And it's still to this day. If I get an envelope from them I kind of have a reaction. So it's just amazing to me how many different things can be involved in a medical experience that can be so terrible.

05:28 Dr. Gorman-Ezell (Guest): Absolutely. And what you're describing would actually be called a 'trigger' so that... that envelope is going to trigger that trauma response. And so, when that trauma response doesn't go away after just a few weeks, then we're looking into more possibilities of things like acute stress disorder or post traumatic stress disorder. And acute stress disorder is very similar to PTSD. The main difference is the intensity and the duration of it. So acute stress disorder occurs when the trauma is less than six months, whereas it transitions more to post traumatic stress disorder once that trauma has occurred for at least six months or longer.

06:10 Jill (Host): OK. So, you work with a lot of people who have complex medical issues. How often do you see medical trauma in the people that you work with?

06:22 Dr. Gorman-Ezell (Guest): You know it's a little bit challenging to quantify for a couple of reasons. So, the first reason is that according to the CDC, at least 2/3 of all children are going to experience a trauma before reaching adulthood. Now that's just in general, right? So, if you couple that then with kiddos who are experiencing medical trauma, it becomes even greater. So, what we know from the few studies that are out there is that a lot of experts have not agreed on the threshold at which a medical incident can become a trauma unless it meets the criteria for PTSD. But here's what we do know is that at least 20% of kids with chronic medical conditions experience medical trauma. We know that the caregivers of those children experience what we call vicarious trauma at a rate of 25 to 40%. And interestingly, something we don't often talk about are the siblings of those kids. At least 22% of them tend to experience a medical trauma as a result of what's going on in their families. Unfortunately, we don't have a lot of data for adults. It's just not out there.

07:38 Jill (Host): So if I heard you correctly, the trauma to the caregiver or the parents is actually happening at a higher rate than to the child, is that correct? And does that mean they're shielding the child from some things or what's going on there?

07:54 Dr. Gorman-Ezell (Guest): I think you're absolutely right. Yes, I think there's definitely some shielding going on. I think there's a lot of things that maybe adults understand in a different way than a child understands. I think a lot of pediatric hospitals do a nice job of trying to cater to the child but aren’t as great sometimes at explaining things to the caregivers in advance, or the caregiver is learning at the same time the child is, and so they're trying to put up this strong front for the child. In the meantime, they're kind of watching everything going on. At times they’ll sedate the children, but obviously the parents aren't going to be sedated. So that's also going to happen. So I think because of that there is a higher rate of vicarious trauma. As you were mentioning earlier with your experience with the insurance company, a lot of times it's the parents who have to advocate on behalf of their children. It's the parent who's responsible for filing the insurance claims, fighting with the insurance companies to get treatments covered, doing a lot of outside research, you know, outside of what they're hearing in those appointment rooms. And so I think because of that, the parents are incredibly invested and tend to experience more trauma.

09:02 Jill (Host): Ah, OK, yeah, 'cause, I was going to say, do you mind giving like a few more examples of things that you have seen traumatize either a patient or a caregiver or a parent or like a sibling? Like part of me is like, OK, how does the sibling get traumatized?

09:18 Dr. Gorman-Ezell (Guest): Sure. I think I'll go a little personal here. I have two kids who both have chronic medical conditions. One of my sons has intractable epilepsy, which means they can't find a treatment to treat his seizure disorders. And my other son has an idiopathic type of constipation they have not been able to figure out. So in order for him to have a bowel movement, we have to put a catheter through his belly button directly into his colon on a daily basis.

09:48 Jill (Host): That sounds rough. Wow.

09:49 Dr. Gorman-Ezell (Guest): So yeah, so I'm just going to give you some personal examples and then I'll also give you some things that I've seen in my office. But it's interesting because both of my children handle the traumas in very different ways. So, my son, who has the seizure disorders, actually has had brain surgery and he's spent probably months in the hospital at different points in time. And for him, he tries to kind of bury that. He doesn't like to think about it. So when he thinks about the hospital, what he tries to think about is, oh, I get to lay in the bed and play video games all day and order room service is kind of his joke about it. Whereas my other son who has had a lot of invasive procedures with his belly is very traumatized by it. In fact, the hospital that he goes to for a lot of his procedures uses images of butterflies in their marketing, their branding, and their name, and so anytime we're driving somewhere or he sees a butterfly, he immediately shuts down and gets very upset. Because for him, that butterfly image triggers the memories of all these invasive procedures that he's had done. So, you know, how does that then affect other people? Well, you know, they do have an older brother. And so what happens is whenever we know one of the younger boys is going to be going into the hospital, that starts to make his older brother really anxious, because he doesn't know what's going to happen to them. He doesn't know if he's going to be able to visit them, especially in the times of COVID right now, you know, everybody is very strict about visitor policies. So is it going to be 4 weeks before I see my brother again? He knew that his one brother had brain surgery, so what does that mean, you know, for him? And so, I think siblings start to get really, really concerned and I think they can also sense the stress that maybe other family members and caregivers are experiencing as well, and knowing that that probably means a little bit less time for them because they have to focus on the child who's in the hospital. So not knowing what that's going to look like. Like, will mom or dad get my sporting events? Or who's going to cook us dinner tonight? What does that look like? So I think the siblings definitely can get triggered that way. And then for the parents, I know, you know, my... my son, who has a seizure disorder, I'll never forget this – when we went in for his brain surgery, he told the doctor he wanted to meet the robot who was going to be helping perform the surgery. And he walked into the OR and met Rosa the Robot and laid down and did his thing, all the while my husband and I were very panic stricken 'cause we knew it was going to be an 8 or 9 hour procedure and there was absolutely nothing we could do, right? And so children also have a tendency to be a little bit more resilient. Now on the flip side of that, my son who's had to have a lot of the catheters and things like that in order to get his cecostomy tube in place, he actually has to have a tube changed out every couple of months. And when he does that, we have to go through what they call intervention radiology. It's a combination of like an operating room and X-ray room and they use that to guide the wire and go where it needs to be. What's awful for him is they will not sedate him. The physicians, you know, are concerned that sedation adds another layer, so they choose not to sedate him. But in the process, I’m left with hearing my son screaming and childlike, trying to give him an iPad for the five minutes the procedure's going on to get through it and, oh, maybe we can go get ice cream and he can't think about anything but the pain. So for all of us when we go with him, it's not a pleasant experience.

13:23 Jill (Host): Wow, boy. It's a good reminder that there's so many things that can go wrong with a human body, and you get used to hearing about one family of issues, and it just is such a reminder that there's so many others. So it sounds like you have one son who kind of is good at joking his way through the experience. Do you think he is experiencing less stress? Or you think he's experiencing the same stress and just showing it differently by joking around? Because in my mind, I have this Indiana Jones character in my mind who can keep making jokes no matter what happens to him and nothing ever traumatizes him. He just keeps racking up more good stories to tell. Like, is that a thing? Is there anybody like that or is there just people who are joking about their stress?

14:18 Dr. Gorman-Ezell (Guest): I think humor can be a really good coping skill for a lot of people. So I think while it helps him, I would say he still tends to experience the trauma. I think... I think a lot of it has to do with how we experience emotional pain. So for some of us we experience it and express it very outwardly, and in the therapeutic community we call those individuals "externalizers." So what we mean by that is if they're angry, they're usually the people who are going to be yelling and others are going to know they're not satisfied and things aren't going right. And I would say that's my one son with the GI issues. My other son tends to be more of what we would call an "internalizer," and people who internalize things tend to think about it pretty regularly but they sort of bottle up those emotions. And in some ways the internalizing is actually more unhealthy than the externalizing, because you're not given an opportunity to work through the difficulties.

15:13 Jill (Host): Ah, OK, because as you were talking about that, what was going through my mind is I think I know a couple of people who are externalizers. However, that has burned them in the emergency room when getting emotional isn't necessarily gonna get you more help by the doctor who might just decide that you're imagining it, where it might get you gaslighted, or it might get you not treated as well. So it seems like an interesting line to walk between externalizing but in a way that is sort of acceptable.

15:52 Dr. Gorman-Ezell (Guest): Absolutely. It's really, really difficult.

15:55 Jill (Host): Wow, OK. What's going through my head right now is probably everyone asking themselves, like, OK, am I an internalizer or an externalizer? And if I'm an internalizer, should I try to be more of an externalizer? Can you change what you are? Can you externalize more and have that be helpful?

16:13 Dr. Gorman-Ezell (Guest): I think you can definitely work on it, but I think you've got to find a way that fits for you. So one of the best things you can actually do when there's been a trauma is to write your story. And I say write it because our brains feel the need to remind us of things, right, over and over and over. It's sort of the example I always use is if I'm running to the grocery store and I know that I need eggs, bread, and milk, right? If I write down my list and I drive to the grocery store, I'm probably thinking about a million other things. Get in the store, take a look at my list, get what I need, check out, go about my day. If I don't write it down, typically what happens is the whole way to the grocery store in my mind I'm saying OK, when I get there, I need to have eggs, bread, milk. Eggs, bread, milk. And then I repeat that to myself until I get each of the items and get to check out. And my brain is doing that from an evolutionary perspective so that I remember what I'm doing. That used to be really important in [inaudible] people days, right, when we had to scavenge for food and things like that, but it's something we haven't necessarily adapted out. And so one of the things that we can do when something bad has happened to us is write down about it and put it in a journal, trying to kind of incorporate all of the different senses because our bodies can actually hold on to some of that trauma and it's so important for us to find an outlet, and whether that outlet is through writing or through therapy or through somatic work. There's a variety of things that we can do, but it's important to get it out so that we can heal and move forward. And I think that that's especially something that's difficult when we're talking about medical trauma, because typically in the mental health world of things we think about traumas and we think about trauma treatment, we usually think about the trauma being pretty much over or at the tail end of things. What's difficult for people who experience medical traumas is that oftentimes it's ongoing because these individuals have chronic illnesses, right? It's kind of like with POTS. I'm sure that people have quite a few experiences with tilt table tests or lab draws different things like that. What's it like when you're somewhere and you're fainting? And then are you worried the next time you go back there you're going to faint again? And so that anxiety starts to build up. And so because of that, it's difficult to treat medical trauma because the traumas are continuous and ongoing.

18:38 Jill (Host): Yeah. And it also seems like so many of these situations, one thing that keeps coming to mind is that you're so powerless in them, at least you feel powerless. Like, the parents or the patient or the siblings - they just have to like, sit there and wait and hope that everything goes OK. And I guess in a minute we'll get to whether you have any ideas for us, but like, I know that for me, I get anxious, but I can feel better if I can like get out and move a lot. It's just... just another example for me is I get a monthly infusion that lasts all day. I pretty often get a mast cell reaction to it, and for a few months in a row those mast cell reactions got pretty bad, pretty scary, pretty much so that I came to dread and be very scared for the next one. And the worst part for me was having to just sit there with my anxiety and not be able to like, move or get out or whatever. And so it's kind of like Robert Sapolsky’s Why Zebras Don't Get Ulcers. He wrote that famous book about how stress is not as bad for you if you can fight or flee or exercise or do what nature intended with all those hormones and all that energy. And so I find that I always think about that and to think about the worst part of this is having to sit still for 8 hours. But do you have any suggestions for those moments when you have to suck it up and sit there and, you know, face your... your next treatment that maybe you're dreading and afraid of?

20:21 Dr. Gorman-Ezell (Guest): Absolutely. So I think, you know, I think you bring up a good point, right. All of us in those traumatic situations tend to experience either fight, flight, or flee. And we usually can't flee from those medical, you know, procedures. We're usually kind of stuck there. And we can try to fight them, but oftentimes it's not in our best interests. So in my mind, I think what ends up happening a lot is what we would call, flight, right? And so a lot of people will dissociate during those procedures. They'll try to think about other things that are calming and relaxing, and I think that's really one of the ways that we can get through these really traumatic medical experiences is to try and have some type of an image or guided visualization, if the procedure will allow for you to use headphones or Airpods or something like that to bring in and actually listen to some calming music, or bring in a photo of one of your favorite places. I think sometimes that type of dissociation can actually serve as a protective factor and help people get through those really intense procedures.

21:31 Jill (Host): And is it correct that, I mean, it would even be justified that, like, there's some activities that normally maybe you wouldn't consider that healthy, like spending half the day on Facebook or something like that. Can you kind of justify things like that that might seem mindless or even mildly addicting if you kind of treat it as something that you let yourself do when you need the distraction?

21:57 Dr. Gorman-Ezell (Guest): Absolutely. I think that's when it's probably the healthiest, the only time it's really healthy to do some of those things, right, is when we're trying to protect ourselves in those really intense situations.

22:09 Jill (Host): Do you think that there are some people who are more likely to get traumatized than others in some of these situations? Like, are there any traits or are there any things that we can aspire to do or, I don’t know, are there any protective factors that might keep someone from getting traumatized in the first place?

22:31 Dr. Gorman-Ezell (Guest): Well, I think you know, we can look at it a few different ways. So first of all, what we know is that the more traumas someone has endured, the more likely they are to be traumatized again by something else, right? So some of it is just going to depend on what that individual has been through. What was childhood like? What was adolescence like? What's adulthood been like? You know, have you encountered a lot of really terrible events? How have you bounced back or recovered from that? So if there's underlying trauma, that's going to make it really, really difficult. And one way for some people to know, like, have I experienced any? There's a really good study out there called the ACE study which talks about adverse childhood experiences, and if you Google that you can actually take a quiz and you'll get an idea of some of those adversities you've experienced and the levels to which they may impact you or future traumas. So part of the answer is that, while we know that previous trauma can result in greater trauma, I think the other way we can look at it, too, is in terms of how people are prepared for what's going to happen, and especially in a medical setting, right? That's very different than necessarily a car accident or something like that. But in a medical setting, and I've seen it more in pediatric hospital settings, so I'm going to probably speak more to that than adults, but it's interesting - when we know there's a planned procedure for a child, a lot of times there's coloring books or books available within that specific clinic to explain the procedure to the child. The other thing that a lot of hospitals do is they employ what they call Child Life Specialists, and those individuals, their job is to bring in hands on materials to explain the procedure to the child ahead of the procedure actually occurring. And that way they can feel what the tubing is going to feel like, smell what the mask is going to smell like that they're going to have for anesthesia. They're going to have a good understanding of when I wake up, I'm going to be in this bed and my mom and dad are going to be here and then the nurse will go get them. And so, they're really sort of planful about the procedure and what's going to happen. And so having that knowledge is really critical for things to go well. The important thing though with that is that especially individuals who tend to be more anxious, they don't have the information too far in advance, just right before it's going to happen, so they have that opportunity to ask questions. Unfortunately, in my experience, we don't get to see that as much as adults, right? So as an adult going through a procedure, you know, the physician or the nurse may come in and give a brief overview of what's going on, but it's not done in the same tender-hearted way then it may be done with a child, and I think that makes a big difference.

25:25 Jill (Host): That's interesting. Yeah, that's good to know how helpful all that really practical stuff is. And... and I'm sorry that you're so familiar with this world, but if you don't mind my asking, is there anything, like when you go into a situation where your child is going to have to experience some procedure or test or something, can I just ask where is your mind? Like, are you in the mode of trying to keep your child distracted or are you looking out to make sure that there's no medical errors or like, what are you doing during that time to try to help everybody get through this?

26:03 Dr. Gorman-Ezell (Guest): Right, right. So I think my first priority are my kiddos, so making sure that they can be as calm and relaxed as possible for their procedures. And so I may say, OK, does that make sense to you? Are you're sure you don't have more questions, you know that kind of thing. And then I think, honestly, a lot of my energy is spent trying to kind of keep my composure because knowing what they're going in for and knowing how upset they get, I don't want to seem flustered to them because I worry if I'm flustered that that may upset them because they're looking to me, you know, to some extent with how to feel. So for me, that may mean, you know, biting the inside of my cheeks, right, while everything is going on so I can keep a straight face 'cause they're looking at me and they're squeezing my hand and you know, I'm squeezing their hand back while also kind of keeping an eye out like you said, to see what's going on and making sure everything's going appropriately. And so, I tend to do that and then ask my questions of the physicians afterwards. Now I don't know if that's exactly the right way to do it, but that's kind of the rhythm that I have found works for us and for our family, but everybody is different. And so for some people it may be easier to focus on the medical stuff because it feels like that you have a little bit more control of than... than the emotions 'cause sometimes emotions, well, oftentimes emotions are very unpredictable. And so, it just sort of depends for each person, I think, what's going to be the healthiest for them in that situation.

27:25 Jill (Host): Wow, this is such great information. Do you have any more advice for parents or kids or patients who need a lot of medical care?

27:39 Dr. Gorman-Ezell (Guest): Well, I think one thing we know is that medical trauma is correlated with poorer medical outcomes. And part of the reason for that is that a lot of people want to drop out of treatment after they've experienced a trauma. They don't want to continue going back there in receiving that. And so because of that, we do tend to see, you know, poor health outcomes and poor adherence to treatment. The other thing that we know about is that a lot of people who experience chronic illness and have had a lot of medical trauma are more at risk to develop mental health conditions, more specifically things like anxiety and depression. And so I think as parents it's really important to be aware of both of those things and that as much as you want to maybe help that loved one or that child avoid the treatment, it's actually going to have a counter effect for them, because they're not going to feel good and they're... they're going to have more and more difficult days, which could result in even more traumatic procedures. I think the other thing to think about is if a child or an adult is experiencing a lot of chronic medical conditions and treatments, it's really important to have an outlet and someone to talk to and to be aware of whether or not there's anxiety and depression. And sometimes, you know, by working with the therapy team, including maybe a psychiatrist or your general practitioner, they can help advocate for the individual patient with the specialists. And when they do that, they may be able to say, hey, you know what, this is really upsetting to my patient. I think it's important that we give them a slight sedative before the procedure so they don't have to be in such pain, right? Because usually when a doctor speaks to another doctor, things tend to happen a little bit more than sometimes when a patient just asks for it. And so, I think there's ways by working with a good therapeutic and PCP team that we can ease some of the traumatic experiences.

29:41 Jill (Host): Yeah, that's good advice. So I'm realizing that I need to thank my parents because I think they probably shielded me from some things early on. And I'm remembering back to procedures or treatments where to me, I got out of a lot of school, and I got to go out for pancakes after, and I barely remember the procedure. And I think that was probably, you know, my parents trying to sandwich it in some good perks so that I would have less of a bad experience. So so thanks to all the parents out there taking... [Laughs]

30:15 Dr. Gorman-Ezell (Guest): Absolutely, yeah.

30:16 Jill (Host): ...taking the [inaudible] for their kids.

30:18 Dr. Gorman-Ezell (Guest): [Laughs] Well, and I think too, you know, that's something we don't want to forget about either is that vicarious trauma, right? And so I think parents are often traumatized as well. I think spouses, caregivers, loved ones can be traumatized too, because not only are they trying to help with everything, but then they're also dealing with the emotional reactions of the patient after the procedure. I remember very clearly the first time they had done the surgery for us to put in the catheter for my son’s colon, and I said to the nurse, "You know, I really don't feel qualified to do this. I do mental health work. I don't do medical stuff. Is there, you know, traveling nurse, you can come over and help us? You know, I've only seen how to do this once. I'm really concerned that we're just going to go home and try this." And, you know, they’re saying, "No, this doesn't really qualify for home health care or something you're going to have to learn how to do." And I remember being terrified, going home and worrying that I was going to hurt my son and what if I put it in the wrong way? And what if this happened or what if that happened? And I think that was my wake up call that wow, this is really affecting you more than you realized. I, to the point, like, I didn't want to be the one to do it. I wanted my partner to do it and he did for a while, but I realized at some point I have to learn to do this, and over time I did. But I also had to confront some of that anxiety that I was experiencing because I was traumatized from watching the nurses do that to him and the pain that he experienced and I didn't want to cause that.

31:48 Jill (Host): Right. OK, so back to this idea of Indiana Jones, right? We all want to be Indiana Jones, right, have a thousand terrifying things happen to us and have it just basically make us stronger, funnier, more interesting. [Laughs] Does that ever happen? Like, you know what, they say what doesn't kill you makes you stronger. Is there a way to try to be on track to just be made stronger by all this stuff instead of to be made anxious by it? Or is it gonna happen however it's gonna happen?

32:21 Dr. Gorman-Ezell (Guest): You know, I think it's going to happen mostly, however, it's going to happen. But I think where this strength comes from is how someone perseveres through it and how they respond afterwards. So I think it takes a lot of strength to acknowledge, yeah, this is really awful and it's not fair that this is happening to me or to my child and I don't like it one bit, and that's OK, but I'm still going to have to do what I need to do so that they can be healthy and I can be healthy. And I really feel like that's where that idea of strength comes because nowhere in any circumstance is trauma a healthy thing. What's important is that we find a way to push through that, and pushing through that means pushing through it from an emotional perspective and a physical perspective and learning strategies to cope with it. And then oftentimes when we treat traumas, you know, we'll do it a couple of different ways. We'll do it within the therapeutic setting by using cognitive behavioral therapy, which is where we change the way we think about something, which then can help change the way we respond to it. There's something we practice called acceptance and commitment therapy, which I think applies pretty well to these medical types of situations. It's the idea that we can't necessarily change what's going to happen. We have to accept what's happening and that someone needs this procedure. But what we can do is we can commit to how we're going to respond to it and how we're going to affirm that person in that difficulty, whether that's in ourselves or within our loved ones. And then there's another thing we can do called EMDR which requires a separate type of certification and that EMDR stands for eye movement desensitization and reprocessing. And what that does is actually doesn't have the individual talk about the trauma, but it has them think about it while doing repetitive eye movements to either a sound or a light. And that can actually be another way for someone to work through the trauma without having to verbalize anything. And then finally, sometimes what we can do is some somatic work, which is a specific type of therapy which the practitioner actually, you know, will talk about things to stir up that trauma reaction or I like to think about it as feeling in the pit of your stomach and then figure out with the person where they feel it and give them exercises to do to help calm down their body.

34:58 Jill (Host): That's great. So you have a lot of tools as a professional is what I'm hearing.

35:03 Dr. Gorman-Ezell (Guest): Absolutely. Absolutely. And I think sometimes, unfortunately, because there's still a stigma around mental health, we don't look at it the same way as we look at our physical health. I wish we did. I think we're getting more towards that, but we're not there yet as a society, I think, unfortunately there's an underutilization of social workers, psychologists and counselors within the medical settings. A lot of the social workers’ role within a medical setting, unless you're in behavioral health, tends to be more on discharge planning and resource management, right? Which is great. We definitely need that. It's important. But I think there's also other strategies we could even do within the hospital, you know, or even within outpatient clinics to connect people with mental health professionals to work through this medical trauma. And so because there's that reluctance due to the stigma, I think a lot of people don't look necessarily at these medical procedures as being traumatizing, but instead just something that everyone has to go through in order to be healthy.

36:05 Jill (Host): Yeah. So if somebody out there has been through some medical trauma and is suffering since and they're hearing about all these different tools that you have, how long does it typically take for somebody who's been traumatized to start feeling better? Are we talking about like a week of therapy, a year of therapy, a decade?

36:25 Dr. Gorman-Ezell (Guest): Sure. Well, you know, and I wish I had a really succinct answer, but it's all dependent on what the trauma is and how traumatizing it was to the individual. And that's where those individual differences occur, right? So we've talked about is that we know traumas build. So someone has had more traumas, it's probably going to take them longer to find that feeling of stability. We also know that being with a trusting care provider is important, so how long is it going to take to build that rapport and to feel safe sharing what's going on with that provider? So it is going to be very, very individualized. There are definitely short-term therapies that can work and then for most people though I would say they tend to do the more longer term therapy, especially when it's ongoing because you're going to want to find a way to continue to work through those difficult times and moments.

37:19 Jill (Host): Well, this is great information and I have to say that even just, like, hearing about, like what you do on a regular basis, like watching other people go through difficult things and work through it and make it work is really uplifting to me. So, thank you for sharing about that, and I'm sure everybody listening has so many of their own examples and kind of just knowing that they're there is a kind of uplifting to me. And so thank you. Anything else that we should say about medical trauma?

37:55 Dr. Gorman-Ezell (Guest): You know, I think that one of the things that can be really, really helpful is to know that you're not alone. And that's one thing I really like about Standing Up to POTS and whether we're talking about this podcast or we're talking about, you know, the online support groups, I just think it's really important to be able to talk to somebody who can get it. And even if that mental health practitioner hasn't had POTS, it doesn't mean that they can't empathize to some degree and that they can't help you through it. And so, I would just encourage everybody to give it a chance and see what you can do to work through some of that medical trauma because otherwise it's just going to get harder and harder.

38:35 Jill (Host): Yeah, I think maybe one thing I'm taking away from this is you should not be letting these traumas build up because each one makes the next one worse. You should try to nip it in the bud, try to be proactive because life is going to inevitably throw some more at you. Is that correct?

38:54 Dr. Gorman-Ezell (Guest): Absolutely right. And whether it's medical traumas, whether it's financial traumas, whether it's car accidents, all kinds of things, right? And like I said before, the big thing that makes it a trauma has to do with the intensity and the duration of those thoughts, how intrusive they are, is someone experiencing what we call hyper arousal where they're kind of on edge all the time, it's difficult to sleep, it's difficult to get things done throughout the day. Maybe they're having nightmares, maybe there's flashbacks of feeling like they're back in that moment. All of those are, to me, red flags that you want to do something to make things better.

39:30 Jill (Host): Great. Well, thank you so much! As always, you are always so full of wonderful information and we really appreciate your taking the time to speak with us and to share your wisdom and the work that you do for Standing Up to POTS. I know that you spend a lot of time volunteering to make life better for the POTS world, so thanks a million.

39:50 Dr. Gorman-Ezell (Guest): Well, thanks for having me.

39:52 Jill (Host): And hey listeners, we hope you do not need any of this information today because your medical journey has been so easy and painless. But I know that's probably not your situation, so we hope this was helpful. That's all for this week, but we'll be back again next week. But thank you for listening. Remember that you're not alone and please join us again soon.

00:33:11 Announcer: As a reminder, anything you hear on this podcast is not medical advice. Consult your healthcare team about what's right for you. This show is a production of Standing Up to POTS, which is a 501(c)(3) nonprofit organ. You can send us feedback or make a tax-deductible donation at www.standinguptopots.org. You can also engage with us on social media at the handle @standinguptopots. If you like what you heard today, please consider subscribing to our podcast and sharing it with your friends and family. You can find us wherever you get your podcasts or at www.thepotscastcom. Thanks for listening. © 2022 Standing Up to POTS. All rights reserved. [Transcriber’s note: If you would like a copy of this transcript or the transcript for any other episode of the POTScast, please send an email to volunteer@standinguptopots.org]