Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby.

Brendan: And I'm Brendan. And we are your hosts. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center.

Oby: And by NCATS, the National Center for Advancing Translational Sciences.

Brendan: Early life trauma is often misunderstood, mistreated, or overall neglected. Especially in vulnerable populations like military veterans, trauma manifests itself in many ways throughout life. With many experiences influencing the lives of military veterans trauma-informed care is critical to addressing things like traumatic brain injury, early life violence, and post-traumatic stress disorder. At the VA, Anna Etchin, a registered nurse with a PhD in nursing, approaches the care of military veterans with holistic therapies and uses nursing to make care a personal experience.

Now, Dr. Ethin's recent Translational Innovator pilot grant is looking at how these previous life experiences impact veterans in different ways. Dr. Ethin, thank you for joining us. And welcome to ThinkResearch.

Anna Etchin: Thanks so much for having me.

Brendan: So you are a nurse fellow at the Translational Research Center for TBI and stress disorders at the Boston VA, although we were just speaking-- I don't know if that's still-- you said your postdoc just ended. So you're transitioning into a new role now.

Anna Etchin: Correct.

Brendan: So tell us a little bit about that new role that you're in and the Research Center, the Translational Research Center for TBI and stress disorders.

Anna Etchin: Sure. So right now with the Translational Research Center-- or we call TRCs for short. I'm collaborating with all of the researchers there. And I'm working a little bit more remotely with the research that's going on. And my new role is with VA Boston Quality Management, where I am working from a systems level to improve specifically right now policy management, which of course, relates to veterans' health from all aspects.

Brendan: And you also have a clinical background in hospice and palliative care within the VA. Could you tell me-- tell us or the listeners how you became interested in working with veterans?

Anna Etchin: Yes, of course. So truthfully, I got into the VA by chance. I heard of a nurse internship for a summer position that started the summer before my senior year of nursing school. And I was very naive about it. But I applied and quickly realized it was the perfect place for me. And the first unit that I interned on was actually long-term care, which I thought I would hate because I thought as a new nurse, I would want to be in something exciting like the ICU or the ER.

And then, again, almost instantly I realized that long-term care was actually very exciting, especially for curious brain. I really liked how [inaudible] the veterans were and how much we got to see from them and how much they shared with us about their life stories. And in that respect, I got to work a lot with veterans who were nearing and experiencing their end of lives. And the stories that they shared with us and the symptoms they had-- the whole experience that they were going through was just really fascinating and also challenging, which created a-- almost like a perfect storm, so a great area for me to think we should do more.

And as a nurse, I really wanted to improve the care that we could provide to them during that time. And so all of the complex traumas and life experiences that they had really seemed to come down to trouble them even more so at the end of life. And that's really what sparked my whole interest in research and everything else throughout my career.

Brendan: Yeah. And what were some of the things that you saw that you wanted to improve when you started working with veterans?

Anna Etchin: So there were a lot of times when veterans' symptoms and clinical presentations were really vague and confusing. And as nurses, to treat the person became really hard because we didn't-- a lot of the times we didn't know everything. And we didn't know what we didn't know, especially when the person had some kind of cognitive impairment and they weren't really able to communicate their needs and the things that they were thinking or feeling at the time. So it really became a puzzle.

So one of the veterans that I actually-- that just popped into my head, he was nearing end of life. And he was having a lot of challenging symptoms that were vague. So he was in pain. But nothing was really seeming to cause that pain. He just was agitated and aggressive and was declining to have any treatments or care. He couldn't communicate what was going on with him.

And so one evening I came in-- went into his room and I just listened for a while. And I heard him say something that caught my attention. And I thought maybe he was back in some kind of event in his mind from the military or from combat. And I said to him, sir, the mission is complete. It was a success.

You're here. You're safe. You have your family all around you.

And I noticed that he finally looked at me, like looked into my eyes and seemed to really accept where he was and what had happened-- not to say that just miraculously cured anything by me. But he looked at me. And he became present.

Brendan: Right.

Anna Etchin: It was things like that, really, I noticed a lot and marked my whole career.

Brendan: I want to talk about the research that you've done. I mean, I mentioned in the beginning, you're a nurse by training. You also just completed your postdoctoral fellowship. And you have this combination of clinical and research experience focusing on trauma and veterans.

Maybe you just talk a little bit about the types of trauma that veterans experience and how that affects the complexity of what they have to deal with.

Anna Etchin: Sure. So Veterans on a whole do experience more trauma than their civilian counterparts. And part of that is, of course, related to their military experiences. And that includes things that happen both during deployment and outside of deployment. So if they're going through training, a lot of Veterans have various exposures to blasts-- so during training, things like that. During combat, there's a lot about shooting, armed combat, but also the destruction that goes along with combat experiences, so seeing their troop members injured or expired but also the technical enemy that they're going against, as well as civilians that happen to just be there in the crossfire.

So from that, there's a lot of safety concerns. There's health concerns based on the environment that they're in. There's a lot of moral injury that comes from things. So regardless of what you're doing, if it doesn't go along with your moral stance, that could really affect you and affect your soul, which then influences every other part of your health and well-being. On top of that, veterans especially are more likely to have had early life experiences-- so things that happened to them during childhood and adolescence.

So that can further complicate their reaction to all of these military related traumas. And we know that interpersonal early life trauma. So the situations that happened with known people-- so your family members, your friends, neighbors, things like that-- both emotional and physical neglect and abuse and/or sexual abuse. Those things really can influence a person as they continue throughout their life. It could predispose them to future traumatic events and also worsen their reactions to those future traumatic events.

Brendan: The pre-military trauma that you mentioned-- I thought when we spoke previously, I thought it was really interesting that veterans or people that go into the military tend to have more trauma in their life than-- before they enlist than a civilian. Do you have any sense-- is there a cause and effect relationship there? Does early life trauma predispose somebody to want to enlist in the military? Or is there just-- is it a demographic issue?

I just think that's really interesting. And what-- I don't know if you have thoughts about kind of that relationship.

Anna Etchin: So I'm not-- I can't say concretely. But there's definitely an association between it. So we know that veterans who are a disadvantaged group may be more likely to join the military. But also then again, veterans who are in privileged groups of society, they also join. So the reason why people join is obviously very person specific and varies across.

But there are larger numbers veterans from groups that have had various adverse experiences throughout their lives. I don't know that we can speak to exactly why. But some of the things that we hear is that maybe the military is an escape. Or it could also be a way for them to benefit in the world.

So they're giving back to their country. They're doing something that they feel honorable for. It could help them to develop a career.

Brendan: Right.

Anna Etchin: Things like that.

Brendan: Yeah, it's an opportunity. And it's-- I think you would consider military as being a fairly high status kind of endeavor. And it's a respected position in society. So maybe there's an attraction there.

Anna Etchin: Definitely.

Brendan: Yeah. So we talked a little bit about the ways that trauma can impact veterans. And one of the things that you're focused on and we've talked about previously was trauma-informed care. So maybe you could just describe that a little bit. What is trauma informed care?

Anna Etchin: Yes, definitely. So I like to compare this to universal precaution, which for any health care provider, it's wearing gloves to protect oneself and their patients from bloodborne pathogens. So no matter what, no matter who the person is, no matter what you know about them, even if that they don't have any kind of pathogen. And you yourself, you will still wear gloves in case there's a chance for blood contamination.

Similarly, trauma-informed care assumes that a person may have experienced trauma at some point in their lives. So you're protecting that person during the care that you provide to them. You're protecting them and doing maybe extra things to make sure that you don't hurt then based on the care. All right?

So we know that most people have had at least one trauma in their lives, and veterans more so. And for nurses, we are not specifically trained in trauma-informed care and related practices. But, of course-- within mental health [inaudible] more likely. But nurses spend the most time with patients overall.

And so I believe it really only makes sense for all nurses, regardless of their specialty, to be equipped in delivering trauma-informed care. So from my nursing experiences, there's a lot of veterans who had very complex trauma histories. And oftentimes, their behaviors were, quote unquote, "disruptive" or unmanageable, et cetera.

And a lot of the time, if you just sat there and listened to them and asked them the right questions, you could figure out, well, the way that the staff or provider or whatever the person or situation was, that was triggering something inside of them. And so their behaviors were actually based on the traumas that they had experienced in their lives. So if nurses could be equipped to deliver this trauma-informed care, maybe we could help avoid a lot of the problematic behaviors that end up hurting the veterans' health.

Brendan: Yeah. And you mentioned that this is something that's done a lot more in psychiatry but not necessarily in-- I don't know, a long-term care or something like that. And I-- especially with what we've been talking about the-- just the burden of trauma in veterans. It sounds like that would be a very beneficial thing to incorporate into the standard practice across VA and even beyond that in just-- you said most people have had at least one trauma.

And it's probably-- I think everybody can agree with that. So can you talk a little bit about how that pre-military trauma-- how that affects people and what you've found in your research.

Anna Etchin: So it definitely varies based on the outcome that you're looking at. So my dissertation focused on reintegration challenges-- so the experiences that veterans were having as they're coming back to their civilian roles and responsibilities. And in that, I looked at deployment combat, and deployment safety concern as well as various clinical and behavioral correlates of reintegration challenges-- so things like pain, sleep, alcohol use, post-traumatic stress disorder, and depression.

And early life trauma, especially the interpersonal kind, has a differential effect on reintegration challenges for veterans. So I found that among this group of Veterans from the Translational Research Center for Traumatic Brain Injuries and Stress Disorders-- that Veterans with early life trauma were having worse reintegration challenges. And they had stronger effects after experiencing deployment safety concerns.

And their clinical presentation was worse if they've had early life trauma. And then similarly, one of the recent studies that I completed was looking at the outcome of veteran anger, especially in relation to deployment trauma and, again, other various clinical and behavioral correlates. And we had hypothesized that post-traumatic stress disorder would be the strongest predictor of anger. And in fact, depression was the strongest predictor.

However, among veterans with a history of interpersonal early life trauma, there were more and more severe clinical symptoms that were associated with anger, which we were expecting. But veterans who did not have early life trauma had stronger depressive and post-traumatic stress disorder symptoms but not other symptoms. So it suggests that early life trauma predisposes you to a variety of conditions and impairments that could then influence certain outcomes. So those outcomes, of course, range. There's a lot of research out there that has looked at early life trauma and correlates with-- and it correlates with various outcomes.

But most of that work is siloed. And the types of trauma could be very narrow as well as the outcomes. So part of the work that we're doing in the lab with TRCs is looking at this cumulative trauma burden, like you mentioned, and looking at various outcomes. So we know that trauma is pervasive. It's not going to just influence one aspect of a person's life.

And it's important to understand that it influences conditions as well as behaviors very differently. And the more that we know, the better that clinicians and providers can predict what to work on with the veteran and what to consider if they're having challenges.

Brendan: So kind of having more of a complete picture of the person as you're treating them rather than thinking about just, like you said, condition and behavior. Yeah, seems to make a lot of sense.

Anna Etchin: Right. And that goes along with the idea of holistic care, which is central to nursing, which focuses on the idea that a person is made up of mind, body, and soul. So nurses don't just treat condition or an impairment, a disease. We're treating the person. And they are complex beings.

Their whole picture is going to be complex. And everything is interconnected.

Brendan: Yeah. We talked about sort of the ways that trauma-informed care could benefit veterans and people at large. What are-- I guess what are some things that you've learned working with veterans that you would like to see adopted or transferred to care for the general public.

Anna Etchin: That's a very good question. There is a lot. But I would say some of the most important from this trauma-informed care perspective would be that if a veteran or a civilian patient is displaying some kind of behavior that's not ideal-- so it's either hurtful to them, their health, somebody else, or the provider, to first consider why.

What may have happened to that person that would lead them to demonstrate this type of behavior. And whether it turns out to be true or not, I'm not sure is totally relevant. it's having enough empathy for the person to assume there may have been something that happened and that is why this behavior is happening right now. I think that could really help all providers be able to deliver more person-centered care and to be empathetic and compassionate to the person.

However, of course, that also introduces the problem of compassion fatigue, which a lot of providers experience. But I think that could help everyone to slow down, take a breath, and look at the person from a bigger picture.

Brendan: Yeah. That's great. I mean, I think that that's something that we could all use outside of health care and education and, I don't know, just daily life dealing with people.

Anna Etchin: Interestingly, I told my cousin this, who has a little bit of road rage. Every time a person around her is driving away that she does not agree with-- they may be driving erratically or aggressively-- I would suggest to her, think about why the person might be driving that way. So could they have had a really bad day? They just found out horrible news about their loved one. Or they're rushing to see a loved one or something.

Whether or not that's true, we may never know, of course. But it helps you to calm down and, again, to take that step back so that you can see what's important and what's not.

Brendan: Well, Anna Etchin, Dr. Etchin, thank you very much for joining us. And it was a real pleasure to have this conversation with you.

Anna Etchin: Thanks so much. This was great.

Brendan: Thank you for listening. If you've enjoyed this podcast, please rate us on iTunes. And help us spread the word about the amazing research taking place across the Harvard community.

Oby: To learn more about the guests on this episode, visit our website, catalyst.harvard.edu/thinkresearch.