Applied Mindfulness

Dr. Laura Roberts (00:03):

Hi, I'm Dr. Laura Roberts. Editor in chief for the Books Portfolio of the American Psychiatric Association, and welcome to the APA Books Podcast. Today, we're talking with Dr. Victor Carrion. He's the John A. Turner professor and vice chair of the Department of Psychiatry and Behavioral Sciences at Stanford University. He is also the director of the Stanford Early Life Stress and Pediatric Anxiety Program.

Dr. Laura Roberts (00:37):

He's faculty in the school of medicine, and he serves at Lucile Packard Children's Hospital. He's also my buddy. He's also my vice chair. And so it's just so much fun for me to see this beautiful work that Victor and his colleagues have done. His work is multidisciplinary in nature. He's a child and adolescent psychiatrist, but really has embraced his work with kind of a broad, multi theoretical basis and wisdom drawn from behavioral kind of academic research, emotional, biological literature.

Dr. Laura Roberts (01:14):

All of this, bringing it together to understand trauma. The effects of experiencing trauma and how this manifest throughout development, primarily with a focus on children, but I think also on families and through the life spectrum. He also has done beautiful work in terms of developing new interventions for treating children who have traumatic stress. And he himself has developed an evidence-based intervention that perhaps he'll talk with us about Cue-Centered Care.

Dr. Laura Roberts (01:45):

But in 2019, Victor, and then Victor with a colleague John Rettger put together two wonderful books for American psychiatric association publishing. The first is Assessing and Treating Youth Exposed to Traumatic Stress, excuse me. And that came out in 2019. And also a book on Applied Mindfulness with colleague John Rettger came out also in 2019. He was busy. And they both really focused on the wellbeing and resilience of children. So Victor, it's so great that you could join us.

Dr. Victor Carrion (02:23):

Thank you. Thank you, Laura, for having me and thanks to the APA press for having this podcast and having our books out there. I hope that they're helpful to people.

Dr. Laura Roberts (02:36):

Yeah. Thank you. Well, maybe that's a good place to start. What led you to think... Maybe we could start with the traumatic stress book, Assessing and Treating Youth Exposed to Traumatic Stress. What's the Genesis of this particular book and the idea that's informed your work over many years?

Dr. Victor Carrion (02:59):

Yes. Thank you. So when I was in training, it was really interesting because I was having a lot of kids come to see me at the clinic with little notes that said, "This kid has ADHD, please place on Ritalin." So the diagnosis had been made, there was a treatment plan. I was wondering, "Well, what am I training for?" And a lot of kids had more complicated pictures. Yes, ADHD obviously exists. And some of them had it, but a lot of kids had a history of adversity that was responsible for the symptoms that they were having.

Dr. Victor Carrion (03:39):

So a lot of this hyper vigilance of post-traumatic syndrome was really being misinterpreted as hyperactivity. And the dissociation and numbness that some children feel was being misinterpreted as inattention. And then there were very complex cases in which just having ADHD puts you at risk to experience trauma, and then you end up with both ADHD and trauma. And when we look at it at a biological level, some of the networks that are affected in one condition get affected on the other as well.

Dr. Victor Carrion (04:19):

So it became really important to really discern and separate these conditions. And our work started by identifying biological markers. And we did so through studies in physiology that we talked about in the book, and also studies on brain development, brain structure and function. But what became very clear is that there was a real need for these families to have education, to really comprehend what stress and trauma were. And also for treatments that we really had only a handful of treatments, and this is a very heterogeneous type of condition. So to have everyone treated the same way didn't make sense to us.

Dr. Laura Roberts (05:12):

So tell us about this particular book. What does it cover and who do you hope will read it and use the insights from the book?

Dr. Victor Carrion (05:21):

Well, this book, Assessing and Treating Youth Exposed to Traumatic Stress does both. Talks about the importance of the assessment on youth in general. You see that the prevalence is so large, 5% of adolescents will experience a diagnosis of PTSD in their lifetime. But what our work also shows is that subthreshold PTSD, just having some symptoms, can really impact function. So the book gives ideas on how to assess this at different stages of development, right?

Dr. Victor Carrion (06:03):

The preschool or school age, and the adolescents, but also treatment, and the different treatments that are out there and the different treatment that are being generated. We have great contributors in term of the importance of treatment. But one thing is that treatment really has a limited impact on health outcomes. So we have to address other problems that we have in the field. And I'm very proud that the book addresses these.

Dr. Victor Carrion (06:37):

For example, the problem of health access and the problem of a decreased workforce to really take care of all the children that need mental health care. And specifically in this book on trauma, we know that two-thirds of children that need mental health care are not getting it. So some of the chapters that I'm very proud of in this book address the need to have integrated care, integrated with primary care, for example, and also the use of technology facilitated interventions.

Dr. Laura Roberts (07:19):

Just to touch on that one point about integration with primary care, I know from conversations I've had that many primary care providers are very sensitive to these issues, but feel overwhelmed. If they begin to talk in any depth about trauma or family stress or issues around abuse, that it's just going to open up a huge overwhelming set of problems. And so it might feel easier to manage the medical... What they perceive as to be the medical pieces of it, and then work in partnership with a psychiatrist.

Dr. Laura Roberts (07:57):

But many people don't have access to psychiatry or psychological services. So what can you offer in terms of reassuring primary care clinicians that it's okay to explore these issues? How do you help them not feel overwhelmed? And what would you suggest in terms of building just a slightly larger therapeutic repertoire for primary care providers around treating traumatic stress in the children that they see?

Dr. Victor Carrion (08:32):

Yes, that's very true. I often think of primary care physicians in the same way that I think about teachers and educators, right? We keep piling things on them to do.

Dr. Laura Roberts (08:46):

Yeah.

Dr. Victor Carrion (08:46):

And we keep saying, "Oh no, the screening is only two minutes," right? Or, "These are only 20 more questions that you have to do." And they have to do their work, right? The teachers have to teach, and the primary docs have to take care of the men medical conditions. I would say that, yes, the workforce is limited. Whenever there are psychiatrists and psychologists and social workers that are available to work in these primary care settings, we really need to Institute that systematically.

Dr. Victor Carrion (09:22):

And where there's not, there are a number of resources that can really be very helpful to primary care workers. For example, The National Traumatic Stress Network. National Child Traumatic Stress Network website has a number of resources that are very helpful. And so does the American Academy of Child and Adolescent Psychiatry. But I wanted to say that doing this work on trauma and doing this work on treatment, really made us think about the limitations that treatment has, right?

Dr. Victor Carrion (10:05):

Because when we get to treatment, it's almost like operating at the end of the spectrum. And then that's what got us to think about the need for prevention and for health promotion. That also has its challenges because in terms of insurance coverage, in terms of Medicaid, in many situations, you have to have a diagnosis. So it is sometimes very challenging to do preventive work and to do health promotion, but we felt that it would be very important to put a book out there on mindfulness. And if it's okay, I'll give you a little bit of the history of how this came about.

Dr. Laura Roberts (10:50):

Yeah. Because it's so clearly follows on your work with traumatic stress. Although I do believe it's valuable for, frankly, everybody, but yeah, tell us about how the mindfulness book then emerged.

Dr. Victor Carrion (11:06):

So what happened was that, so we have our whole team working on trauma, right? For many years. So I became very concerned for the health of my own team because vicarious traumatization is a real thing. And sometimes you can start getting symptoms of post-traumatic stress if all you see is trauma, right? And so I brought into the team, someone who had a PhD, John Rettger, on mindfulness and yoga, he was a yoga instructor.

Dr. Victor Carrion (11:45):

And we started doing it with the team. And I really saw radical changes in terms of the effectiveness of my team, how they were feeling, the improvements they felt they were getting from it. So we decided to pilot it at schools, we brought yoga and mindfulness to a classroom in East Palo Alto, a seventh grade classroom. And we did it for six months, twice a week. At the end of the year, the principal called us because she wanted to know what was going on in that classroom because kids were not coming to her office anymore, being sent by the teacher, and their behavior improved so drastically.

Dr. Victor Carrion (12:35):

So that motivated us then to do a randomized control trial on a yoga and mindfulness intervention that lasted for three years, it was multi-method and has just been completed. And we are looking at the results and the preliminary results are very, very promising, but we also felt that it would be important. And we are happy that the APA press agree to put a text out there on doing mindfulness with children, because sometimes it was challenge. People know that you could do mindfulness with children. And people also didn't know that you could do mindfulness with individuals that had a history of trauma.

Dr. Laura Roberts (13:24):

Wait, so I'm going to unpack this just a little bit. So your work with children, I mean, you're dealing with really young kids and teaching them techniques of mindfulness, right? You talked about the initial work, which was with seventh graders, but I think you've stretched to do this work with kindergartners.

Dr. Victor Carrion (13:49):

Yes. And so we partner with Pure Edge Inc in the developing a curriculum that was incorporated into the physical education class of everyone from kindergarten to eighth grade, these were 3,600 children.

Dr. Laura Roberts (14:08):

Amazing.

Dr. Victor Carrion (14:09):

The research was only on third graders and on fifth graders, but I wish we would have researched those kindergartners, because for them now as third graders, this is not even an intervention. For them, it's like brushing their teeth, thinking positively of something they do. Taking deep breaths is something they teach their siblings and their parents. So they are fantastic.

Dr. Laura Roberts (14:38):

Isn't that wonderful?

Dr. Laura Roberts (14:39):

And it also demonstrates the importance of how the earlier that you intervene, the more the child internalizes those tools into their repertoire.

Dr. Laura Roberts (14:56):

And so then let's talk about the metrics by which you're evaluating the impact in your research. It's not just say academic performance or behavioral issues in the classroom. I think you're tracking a larger set of outcomes.

Dr. Victor Carrion (15:13):

Yes, this is a multi-method assessment. So in a subset of this group, we actually look at their physiology, looking at cortisol, a hormone that gets secreted during stress because our previous research had shown that a potential biological marker for PTSD early in life is to have high levels of cortisol pre-bed time.

Dr. Victor Carrion (15:39):

And this seems to have an impact in how they sleep as well, which is distorted. Most of our stressful events get processed during the night, during deep sleep. And when at baseline we looked at the deep sleep architecture of these children, we saw that it was very limited. And so we did polysomnography, we did brain imaging. We looked at cortisol and alpha-amylase, and we did look at academic and behavior and other issues as well.

Dr. Laura Roberts (16:17):

And longitudinally, is this project able to do longitudinal work?

Dr. Victor Carrion (16:21):

Yes. This was the span for three years, and it ended just right before coronavirus. We just got our last set of academic data from one of the school districts.

Dr. Laura Roberts (16:39):

Well, we'll stay tuned. We'll be very, very interested in all of that.

Dr. Victor Carrion (16:42):

Thank you.

Dr. Laura Roberts (16:42):

So if you could comment... I know you've done several books. For our listeners who are maybe thinking about developing a book or who just simply wonder what goes into writing a book or editing a book. Could you just comment on the process? What was it like, and what was the hardest part? What was the best part? Would you do it all over again?

Dr. Victor Carrion (17:08):

It's a really good experience. It does pay to be organized, and it does to have parts and divide it by sections because at the beginning it can feel kind of very overwhelming, right? When you think about the whole subject, but in mindfulness, for example, we decided to tackle it by looking at several things. For example, by looking specific clinical populations, by looking at settings in which you can do it, by looking at the importance of personal practice, and also by looking at diagnosis.

Dr. Victor Carrion (17:48):

So that gave us a little bit of a better sense on how to approach it. And then within each of those areas, actually look at different contributors and engage them on the enterprise. For example, on part two of mindfulness, in terms of diagnosis, Sam Himelstein did a beautiful job in terms of describing the authenticity, which is important for everyone and in every treatment, but specifically for handling substance abuse.

Dr. Victor Carrion (18:25):

And on part three, which is about specific clinical populations, we really got to see how it is very important to pair mindfulness with trauma interventions when addressing immigrant youth and incarcerated youth. So dividing it was very helpful. Organizing it was very helpful. Sticking to your timelines is very helpful. And giving your contributors the bigger context, right? Not only, "Oh, please write a chapter on this and this," but really inviting them to the process of what their colleagues are to doing and how the whole volume is created to really build some impact in the field.

Dr. Laura Roberts (19:19):

Well, I can see the thoughtfulness in your approach. And just to underscore for our listeners, and I mentioned at the beginning, Victor and his colleagues put together two books in the course of, I don't know, just a little over a year, for us. And I so appreciate all of that. I think what's so special about the work that you all do is, it's disruptive in the best possible sense. It's bringing new interventions and new ways of thinking to our usual work, and it's broadening the repertoire.

Dr. Laura Roberts (19:54):

And I think really, it's kind of an old fashioned word, but kind of empowering to the clinician because you can see how you can make a difference using new tools and new approaches. So I really, really appreciate having both of these books in our portfolio and believe that they've already been met with great reception and I believe that they will really help change practice in our field.

Dr. Victor Carrion (20:19):

Thank you.

Dr. Laura Roberts (20:19):

So thank you for all of that. Yeah. Could you just leave us with a few reflections on how you have changed your everyday practice, your own mindfulness practice, if you wouldn't mind sharing, because the phenomenon of secondary trauma or vicarious trauma is so profound.

Dr. Laura Roberts (20:38):

And I literally have intrusive thoughts of children who I took care of in New Mexico 25 years ago. And we all, as clinicians, carry our patients with us every day, it's part of who we are, as a person who's cared for these individuals. And we worry about them and feel for them and feel things with them. So helping to manage those hard feelings and move forward, I think, is so important. So what can you help us understand about that?

Dr. Victor Carrion (21:15):

Yes. Thank you, Laura. Mindfulness is really about being present without judgment, being present in the moment. And it's not only about the present, but it's about being. It's about being very aware of what you're experiencing. It can be positive, it can be negative, it can be neutral. But the more that you practice, the better you get at it, right? So if you don't play guitar, and I give you a guitar and I tell you, "Please play me a song," you probably wouldn't be able to do that.

Dr. Victor Carrion (21:53):

But if you're interested, and if you practice, and if you are motivated, a year from now, you might be able to. And it is like that. It is an instrument that is a tool that you need to practice. It's important to recognize that it's a real antidote to stress. This is not a fad. This is actually going to stay with us as an antidote to this stressful, anxious lives that we are all having. And what it does is that it does help not rely on avoidance to manage stress, because avoidance is not helpful. In my team, we have a saying that PTSD feeds on avoidance.

Dr. Victor Carrion (22:47):

So what we really try to do is approach, but approach in the right manner, right? So avoidance can be seen in two ways. There's the avoidance of, "I really cannot handle this right now. I'll manage it on the weekend, or when I have resource X," and that's a coping mechanism, right? That's not by avoidance, but to totally pretend that something didn't happen, to totally say, "This will go away on its own," that's not healthy. That's when then trauma and stress can become more complicated.

Dr. Victor Carrion (23:25):

So I personally engage in this physical exercise, anything that really motivates my breathing and my physical movement. And yoga is one of those things that can do that, because you are actually moving your body in a very thoughtful way, and you are breathing in a very thoughtful way. And if you think about it, breath, which is really the anchor of yoga and mindfulness, breath is almost synonymous with being alive, right? Everything that lives the breathes. So it is very important to pay attention to our breath, to breathe deeply. And that helps us being aware of the present moment, and being present.

Dr. Victor Carrion (24:19):

And being present not only for the moment, but being present for others, being present for ourselves, and being present for those that we interact with. That's why I'm really, really recommending everyone on this era of Zoom and Zoom meetings to have what I call the scrub time, which means that an app hour is really 45 minutes. And you need these other 15 minutes to scrub yourself from what you just went through and be really prepared, and be open for the next appointment or next meeting that you have.

Dr. Victor Carrion (25:01):

But the bottom line on this practice is that the more you do it, the better you get at it. Oh, and by the way, so you need to find good resources to be able to do this. And one resource that we have is John Rettger. He actually does have exercises for meditation for yoga, for mindfulness, for breathing that are posted on our website of the Early Life Stress and Resilience Program under resources

Dr. Laura Roberts (25:39):

At Stanford, is that right?

Dr. Victor Carrion (25:41):

At Stanford.

Dr. Laura Roberts (25:41):

Yeah. Good. Well, I can tell you that I always feel better when I talk to you. You're part of my mindfulness practice and I just-

Dr. Victor Carrion (25:50):

Wonderful. Thank you.

Dr. Laura Roberts (25:51):

Yeah. Thank you so much, Victor, for joining us, and thank you for these beautiful, and we look forward to future conversations with you.

Dr. Victor Carrion (25:59):

Okay. Thank you so much.

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Our original music is by Willow Roberts, our executive producer, Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing, John McDuffie Publisher.

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