Our Healthcare Heroes Are Human: Rebecca Hoffmann

Lisa Belisle: Hello, I am Dr. Lisa Belisle and you are listening to or watching Radio Maine. Today I have with me in the studio Rebecca Hoffmann, who is the director of the MaineHealth Center for Trauma Resiliency and Innovation, and also an assistant clinical professor of psychiatry at Tufts University School of Medicine. Thank you for being here today.

Rebecca Hoffmann: Of course.

Lisa Belisle: I'm going to think that your professional trajectory has probably been pretty busy from the beginning. You've been doing this work for a while, but I'm guessing that things have ramped up quite a bit with Covid, and then we've had some recent incidents in Lewiston that have been pretty tragic, so it's been busy for you for a while. How are you doing as a person?

Rebecca Hoffmann: I am invigorated by this part of the work. We do a lot of planning in this kind of work for events that we hope will never happen, but I'm invigorated when I can truly help. So this has been horrible and tragic and a lot of work, but also incredibly invigorating to see people getting help.

Lisa Belisle: I like this idea that you're combining clinical innovation and training and you put it together with behavioral health, because I think there are a lot of old models and a lot of misperceptions that are kind of firmly rooted in the past. So tell me about the innovation. How are we thinking differently about the emotional, behavioral, mental impact on the person?

Rebecca Hoffmann: Sure. The mental health or behavioral health world has often been a little behind the medical world in terms of, I don't want to say valuing innovation, but really holding it as an important part of the work we do. There's a lot of the idea of treatment as usual, which is what someone's always done as a clinician, but there are all these types of treatment and models and research that has shown what works and what doesn't work, and it really takes often grant funds or foundation dollars to bring those practices to an area such as Maine. When I first started my position, which has evolved, 15 years ago, it was really about bringing those practices that we know work to Maine. At that point it was primarily focused on children exposed to trauma and violence. The work was just about infusing the behavioral health community with training in the practices that we know work with children exposed to violence and trauma. There's people we trained 15 years ago that are seeing kids now after Lewiston. So the impact has been really a long-term shift in Maine and how we do this work.

Lisa Belisle: In the health system I work with, we did something related to pediatric behavioral health. We did a presentation, a panel, and we brought in clinicians who were talking about some pretty serious things, depression, anxiety, suicide in children, and I was really interested to hear that we now are doing cognitive behavioral therapy. We're now doing a lot more with family counseling. Are there other examples of things that you've brought to Maine that you think have been particularly beneficial?

Rebecca Hoffmann: Absolutely. The first thing I'll say is that cognitive behavioral therapy has been around a long time and it's still the base of a lot of what we do. One of the treatment models that my team and I brought to Maine was trauma-focused cognitive behavioral therapy. It's a hybrid model that combines cognitive behavioral therapy, CBT, with some exposure components that we know help children reduce symptoms related to their trauma. So again, it's grounded in CBT. There are a couple other types of models in particular that are a little bit different, but speak to what you talked about. One that I feel really excited about is a peritraumatic intervention, so it's done in the immediate aftermath of a traumatic event. The focus is really prevention of PTSD, anxiety, depression, all those things you're mentioning. It's really the first real preventative intervention in kids exposed to trauma. It's brief, it's six to eight sessions, and it's been shown to reduce the likelihood of a child developing PTSD. That's exciting, because kids will often think when they have these types of mental health issues that they're going to be in therapy forever, and that's just not the case. They can heal quickly and have the skills or the tools in their toolbox to handle difficult times in the future.

Lisa Belisle: That's really important, because I know in clinical practice when I have people who have come in who have not had interventions like that and have not been able to access preventive work, which is usually the case, but even sometimes not work that is done after the fact, it really impacts them as adults. They have a difficult time functioning at their job. Sometimes there are physical impacts, they can't sleep. Obviously they develop diagnoses, but then there becomes this intergenerational trauma that occurs. So then you're talking about when they have children, it impacts their children and then sometimes it can impact the grandchildren. So you're not just talking about impacting an individual, you're talking about potentially impacting an entire family system.

Rebecca Hoffmann: I absolutely agree. I think the beauty of some of these interventions is that if you are helping a parent with supporting one child, you're also helping that parent support the other children in the family. Some of these interventions are really much broader than, let's say, a child that has been impacted by something. They impact the whole system, but then they also teach those children tools to function better when they become parents themselves. There's research about the intergenerational transmission of trauma, which is incredibly fascinating, that children and grandchildren of Holocaust survivors, for example, actually have more of a likelihood to develop anxiety or PTSD just based on their genes. It's the field of epigenetics. But what we really try to focus on is, what are someone's tools in their toolbox? So if somebody comes into a difficult situation as an adult and they don't have tools in their toolbox, or they didn't learn them as children, they're going to go to what they learned or what's potentially easiest. That's why you often see substance use after trauma. The use of substances can numb someone from those very painful and difficult feelings they have, and it's an easily accessible tool, but not one that we would consider a healthy coping skill or a healthy tool. So when an adult comes in, in a lot of pain, the goal is the same as it would be for a child, to give them more tools in their toolbox for healthy coping.

Lisa Belisle: I like the way that you're describing it. It's not as blame-based. Oftentimes, I think traditionally when people come in, particularly as adults, maybe not children, there seems to be a tendency to label people with a diagnosis that sometimes puts the onus back on them, like, because you did something, you now are having a substance use disorder problem with alcohol, let's just say. And what you're saying is maybe these people didn't have adequate resources, so maybe they were exposed to something, and maybe if they had had the resources they needed, then they wouldn't have needed to turn to alcohol. I think that puts a lot more hope into the conversation and also makes it possible to invest in more of a growth mindset about people's capacity to change.

Rebecca Hoffmann: Absolutely. I think when we look at an individual, the way I like to say it is, instead of asking what's wrong with them, we ask what happened to them. That allows us to consider the whole system that they grew up in, that they inherited, the community they live in and how supported they've been. Have they faced microaggressions like racism every day that have slowly cut down their coping skills? Instead of looking at what's wrong with them, we say what happened in their life that made this so hard for them, or is making this so difficult for them, and what can we help them with to counteract that impact.

Lisa Belisle: You grew up outside of Bangor and went away, got an education, came back. What was it about your family situation, your school education in the Bangor area? What caused you to move in the direction of doing this work?

Rebecca Hoffmann: I always had something in me. I sort of call it this pocket of pain, where I felt like I was drawn to people's pain and wanted to heal it. I sort of wear it right there on my sleeve, and I've found the other people in my community that have that same desire to ease other people's pain. That's really what drove me into the work. I grew up in a rural community and I love the culture of Maine. I love that individualistic culture, but the culture that helps our neighbors. There wasn't a lot of drive for status or things. There was a lot of drive for family experiences and simple pleasures. So that's what brought me back to Maine. I grew up in a blended family, and so helping children and helping families become the best they can be was really close to my heart.

Lisa Belisle: I'm glad you brought that up, because I think even having a blended family, or coming from a family going through a divorce, there's still a stigma around that. I think for a child to understand that any family setting can be loving and supporting and nurturing, and really you're talking about a different group of individuals who can learn to be together and coexist, that a family really can be anything. It doesn't have to be what we have called nuclear in the past. There are a lot of people who have blended families, so we kind of need to get the word out there that actually this can be done well.

Rebecca Hoffmann: Absolutely. What I often say is that I'm grateful that I come from a blended family, because it taught me so much about what you're talking about, about what makes a family, and it isn't necessarily blood, it's love and connection. My blended family, which was six children who were brought up to not think of each other as half or step siblings, but we were each other's sisters and brothers, really taught me that, as you said, anything can be a family. And bringing it back to the issues of what kids have experienced in the pandemic and in our recent tragedy in Lewiston, research really shows that all kids need is one caring adult in their life. If they have one caring adult who really pays attention to them, shows them that they're valued, that buffers the impact of the stressors they may experience. And anybody can be that caring adult. It can be a bus driver, clergy, a grandmother, a mentor, it can be anybody. That really, I hope, tells the community when they want to help, that they can be that one caring adult for a child and they will buffer the impact of what that child is experiencing.

Lisa Belisle: So let's say I am the caring adult, but I'm not blood related to someone, and I happen to be a clinician, but let's say I'm not. What are some tools that I could use? What are some approaches I could take to be supportive of a child that has had a traumatic impact, maybe related to the Lewiston incident or maybe related to the pandemic or maybe something completely different? What types of things do you suggest could be helpful?

Rebecca Hoffmann: Some things that can be helpful are really showing that child that they're, quote, normal, that they're not damaged from what they've experienced. A lot of kids think that after they go through trauma that that's their whole life. We like to show them that that's just a chapter in their book of life, and they have so many other chapters that they've experienced or that they will experience. So showing that child hope, showing that child joy and fun and levity, is so important. It doesn't need to be a clinical intervention of sorts. It can be playing basketball and asking them how they're doing and really caring about them and letting them know that you're a safe place to come to. If they're experiencing difficulty, if they know they have supports, then that's going to help, again, buffer some of the difficult things they've been through.

Lisa Belisle: That's a really good point. I think we all, even as adults, like to have the sense that somebody cares about us as a human. I personally like to have a moment of levity in a situation. I think that's important, to laugh and to acknowledge that we aren't necessarily our stories, and the story can have a really significant impact, and obviously validate that for a child or for a fellow human being. But you're right, life is long, hopefully, for some people. So one question that I have for you is, how do we help clinicians who have been trained in an older model to understand that there are new ways of approaching this? I know you work specifically with behavioral health clinicians, but you also have a Tufts affiliation. So what are some things that you're doing now to help, say, your family nurse practitioners understand that there are different ways of going about this?

Rebecca Hoffmann: So we do a lot of work with the medical community to help them understand their role. What we have found in behavioral health is that those seeking, let's say, traditional mental health services are kind of the tip of the iceberg. And there's all these people, kids, families, adults, whatever it may be, sort of under the surface, that may need supports, but they might not need that traditional hour of therapy a week or whatever it might be. There's all these interventions that others can do that can help someone with difficult times, or even with mental health issues. Those people are often medical professionals, because what we want to do is find where people are already going and teach those people how to help someone. Many, many people have a primary care practitioner or a family nurse practitioner, someone in their life that's medical, who can be that voice of skill building. So for clinicians to first off be comfortable talking about behavioral health or talking about emotional pain, to be able to ask someone how they're doing and be comfortable with someone saying, I'm not okay. Really teaching medical professionals or others to be okay with asking those questions that we hear so often. I don't want to ask the question because I don't know what to do if they say, yes, I'm struggling. So providing tools, resources, places to refer are part of the ways that we help people feel comfortable with asking those questions. Oftentimes when you ask someone the question, how are you doing? And they say, I'm not okay, that's a healing intervention in and of itself, because someone's listened to them and cared. It comes back to caring and connection. So we really work to provide a toolkit for other professionals to feel like they have the skill set to be able to ask those questions and respond.

Lisa Belisle: I'm going to ask a question that I think is something that I've pondered quite a bit in my own life, and that is, as the mother of originally three children, but now six children in a blended family, when these traumatic events occur in the community, I feel personally impacted, but I feel this brooding impulse. I want to bring the chicks back under my wings. And I know that you similarly have school-aged children, so I know how I have processed all of this and the outreach that I've done with my family. How have you processed the recent events in Lewiston and some of the things that went on longer term over Covid?

Rebecca Hoffmann: That's a great question. So first off, I think this coming really on the heels of Covid is difficult, because what Covid taught us is the importance of connection and really the damage of isolation. We are beings that are born to connect. We need connection in our lives as human beings. When people don't feel connected is when they start to falter. We saw that with Covid, when people lived alone and didn't have a lot of connections, it was really negatively impactful to them. On the heels of this, I feel like what I learned was how important connection is, and when my chicks are suffering, to bring them close, just like you said, and to connect and really connect. That is what heals over and over again, is connection. So when this all occurred and was unraveling around us, I think just the bringing of the chicks into the nest and finding ways to connect is really important. It was important to ask them how they were doing and really listen, instead of talking about the events, talking about how they were doing with processing the events. And then again, finding those times for joy and levity are so important. Kids, depending on the developmental age, they don't understand that this is an event that will have a beginning, a middle, and an end. This heaviness that we're all feeling is so profound and so sad, but we need to have light in the midst of that darkness. So really finding ways to feel joy with them and show them that it's okay to feel joy in the midst of the sadness that we're experiencing with what happened.

Lisa Belisle: I think what you're describing is so interesting to me, because my children are all older, they're adults. We connected the way that we normally do, digitally. And that felt right. My sisters and brothers have school-aged children, and trunk or treat was canceled because of the shelter in place orders. But what was nice was, by the time Halloween rolled around, my nieces and nephews were actually able to go out in the neighborhood and wear their costumes and connect with their classmates and the aunts and the uncles. And that was really important. It didn't negate all the terrible things that had happened a few days later, and it didn't take away the fact that they had lost trunk or treat, but they still got to just be normal kids, which I think you can hold both things at once. Some people will say, well, you have to cancel Halloween, it's all so sad. But the kids don't. What are they going to do? They're just going to sit at home and play Legos. They need that. They need the things that kind of normalize their lives.

Rebecca Hoffmann: Right, exactly. And for kids, there are certain things that help them recover from stressful events. One of the biggest things is normalcy and routines. So balancing out what feels right in terms of honoring the gravity of the situation with maintaining normalcy for our kids, it's a hard line to fall on, but it's really important. I think the other thing that was so important about how Halloween was, again, that it allowed kids to connect with each other and have fun and joy. It doesn't take away from the experiences that happen, but it showed them that, again, this is a chapter in the book of their lives and other people's lives. And there will be other chapters after that. And again, depending on developmental age, some kids don't realize that. They think this could be the way it is all the time, and we want to show them that there will be other phases and there will be joy again.

Lisa Belisle: Well, I really appreciate your taking the time out of your very busy schedule to come in and talk to me today. Rebecca, it was wonderful to talk with you. I'm Dr. Lisa Belisle, and today I've been speaking with Rebecca Hoffmann, who is the director of the MaineHealth Center for Trauma Resiliency and Innovation, and who is also an assistant clinical professor of psychiatry at Tufts University School of Medicine. Thank you for being here today.

Rebecca Hoffmann: Thank you for inviting me.