Barbara Barnes Keynote Session
Black Butterfly Theorem: From Childhood Trauma to a Transcendent Healthful Self
Presenter: Michele Harper, MD, emergency room physician, writer, and speaker
Reported by: Joyce Fried, BA, FSACME
Michele Harper, MD, is a phenomenal physician-leader who has detailed, in exquisite writing, the troubling and destructive gap many patients face in accessing equitable, humanistic care and the challenges healthcare professionals of color face in the current culture of medicine. She is the New York Times bestselling author of The Beauty in Breaking, a poignant memoir of her path of self-healing and the lessons she learned as a daughter, a woman, and a physician. She is an emergency room physician with more than a decade of experience at various institutions, including as chief resident at Lincoln Hospital in the South Bronx and in the emergency department at the Veterans Affairs Medical Center in Philadelphia. She is a graduate of Harvard University.
Dr. Harper began the Barbara Barnes keynote, entitled Black Butterfly Theorem: From Childhood Trauma to a Transcendent Healthful Self, by stating, “I am very familiar with the effects of trauma—both the immediate and the long-term impacts. I not only have knowledge of this professionally, but also personally, because I grew up in an abusive home with a father who was a batterer.” She continued by explaining that it is important to understand trauma not only because it is at the core of one’s own healing but also because of its importance in shaping interpersonal and systems growth.
To demonstrate her lessons on trauma-informed care and adverse childhood experiences, Dr. Harper weaved into her presentation her own story, as well as the stories of two patients, Sofia, a 13-year-old-girl with anxiety, and Jayden, a 14-year-old African American boy, believed to be suicidal. She described how, before her father lost everything, her family lived in an affluent neighborhood in Washington, D.C., with a manicured lawn, where they donned designer clothes and had smartly coiffed hair. She was taught that “even if the inside of your house is a smoldering fire you don’t tell anyone.” She described how no one ever asked her if she was ok and thus she learned that her pain was to be expected and if she was going to find a way out of it, she would have to find it for herself. And so she submerged herself in pretend tea parties and when alone she thought about the song Black Butterfly by Denice Williams where she fantasized that in her pain she could soar and show others that it was possible to survive.
According to Dr. Harper, adverse childhood experiences include: (1) abuse (physical, emotional, sexual); (2) household challenges (substance abuse, mental illness, witnessing a family member being mistreated, parental separation); and (3) neglect.
She referenced a study conducted by Kaiser in the 1990s in which they surveyed 17,000 patients and found that more than 60% of respondents had at least one adverse childhood experience.
Dr. Harper told Sofia’s story and how she encountered Sofia as a patient in the emergency department. Sofia’s mother sat in a chair, nervous and expectant. Her mother explained that she had to come to the ED because there were no available therapist appointments for weeks and she felt Sofia needed help now. She described how Sofia, an excellent student, had begun shutting down, skipping school. Dr. Harper inquired whether Sofia and her mother were safe at home and was told that yes it was just Sofia and her mother at home. Dr. Harper asked if she could speak alone with Sofia and explained to Sofia that their conversation would be confidential except if topics were raised regarding her safety in which case other individuals would be involved. Sofia told Dr. Harper that no one was abusing her now. She felt safe at school and she loves school. However, she is feeling sad and lonely and has never been the same since her uncle came to visit for an extended period and sexually abused her. When she confided in her mother, her mother got angry, denying that it happened and telling her “I never want to hear you speak of this again.” Dr. Harper apologized to Sofia for what this man did and what her mother did by her distrust and denial. Dr. Harper told Sofia that she (Dr. Harper) must speak with her mother. Sofia agreed. Dr. Harper told her mother what Sofia disclosed and her mother broke into tears. Her mother apologized to Sofia for not believing her and disclosed she was assaulted when she was young and could not face the fact that her daughter was having the same experience. They agreed to go to counseling together and Sofia smiled. When Dr. Harper asked Sofia what she might like to be when she grew up, Sofia said either a psychiatrist or a pediatrician.
Dr. Harper then addressed social determinants of health which include: economic stability, neighborhood and physical environment, education, food (hunger, access to health options), community and social context, and health care system. She explained that early adversity has lasting impacts. However, disrupting these cycles yields positive outcomes.
In rich countries, health and social problems are closely related to inequality. A wealthy person in the U.S. is more likely to report financial barriers to care than a low-income person in almost every other rich nation surveyed.
During one of her emergency department shifts, Dr. Harper notices the pediatric psychiatric team circling the nurses station. They bring in a complicated and tragic patient, Jayden, a 14-year-old suicidal black male in blue psychiatric scrubs. Although tall, he is just a child. He tells her he said the wrong thing in his outpatient appointment with his psychiatrist. He told her he didn’t want to live anymore. Actually, he meant to say he doesn’t want to feel the pain. His mother died the previous month. His therapist reprimanded him for not taking his medication and diagnosed him as bipolar. She did not understand that Jayden did not want to take pills because his mother was addicted to drugs his entire life and succumbed several weeks before to her addiction. Jayden lives with his grandmother who is frustrated with him because when he was little he yelled. Yet, on this day, he was more cogent than his caregivers. He was brought to the ED while waiting for inpatient placement in the psychiatric ward. In his small room in the ED there were no windows, no TV, no fresh air, and no sunlight. A technician sits and watches him. With no intervention he will be in this cell for days or weeks paying the price for every adult who has failed him—his family, his psychiatrist, society.
When her shift ended, Dr. Harper signed out his case and went home but thought about it all night. The next day when she returned for her afternoon shift he was still there. He was sleeping. His grandmother was sleeping on a stretcher on the other side. Notes showed he was well and calm, not medicated, and cooperative. Dr. Harper asked to speak with the ER director about the case and told her in her opinion more harm than good was being done for this child. The director stated Jayden is manipulative. Dr. Harper countered that he is bright and insightful beyond his years. The director asked Dr. Harper what she recommended. Dr. Harper said he needs a mentor, preferably a man of color and a psychiatrist who is educated in trauma-informed care. What he did not need was a white psychiatrist who does not listen to him and tells him he is the problem. Dr. Harper then spoke to Jayden’s grandmother and then to the ER social worker about outpatient care and mentoring. Finally, she circled back to his psychiatrist and asked her, “Has Jayden ever been violent or dangerous? Has he tried to hurt anyone or himself? Has he been hospitalized where they had to transfer him to an inpatient unit?” The answer to all three questions was no. She then asked the psychiatrist to reassess him which she did and agreed he could go home and to school. Jayden was elated. What does Jayden want to be when he grows up? A sports coach or a mechanic. The psychiatrist said “This is his last chance. If he makes one more mistake, I am kicking him out of the program.”
Dr. Harper then posed the question, how do we ensure that Sofia lives to become a pediatrician, that Jayden gets a chance, and that she (Dr. Harper) thrives so that she could be here today?
With regard to solutions, Dr. Harper subscribes to two principles: (1) radical honesty to acknowledge the truth of our life experiences, the historical facts of our nation, the social realities and how we process it all; and (2) personal integrity from this space of honesty. She believes that the customary wellness tips that everyone gives are correct--working on ourselves, healing and learning to grow, asking for help, accepting help whether it’s a kind gesture from a stranger or from trained professionals who she believes are good for everyone at some point in their lives. On her list of wellness practices are: (1i) movement practice—walking, running, tai chi, yoga, swimming for physical fitness and to get the energy flowing and to get us integrated into our bodies again; (2) mindfulness practices to connect to our breath, to the present moment, and as a reminder that we can be safe in the present; (3) nutritious anti-inflammatory diets; (4) meaningful engagement; (5) hobbies; and (6) life work. She cautioned that there will be times in our lives when we need to walk the path alone. Sometimes our warrior training can make us grounded in faith. Faith will remind us that we are connected to something larger than ourselves.
On a larger level she feels we need to make big decisions as a nation. These are complex social matters not just individual dilemmas. Higher performing nations have universal healthcare, strong primary care systems, and social support systems (affordable housing, paid parental leave, quality affordable education).
Dr. Harper circled back to the Black Butterfly lesson: “We can survive, we can soar. And the reward in doing so is not just our own personal success but that we have the opportunity to aid in the health and joy of others. When we make these choices we can have trauma-informed care.” She described trauma-informed care as: (1) safety; (2) trustworthiness and transparency; (3) peer support; (4) collaboration and mutuality; (5) empowerment voice and choice; and (6) cultural, historical, and gender issues.
Dr. Harper likes the Robert Wood Johnson Foundation definition of well-being: “…well-being includes people’s physical, mental, and social health, and the opportunities they have to create meaningful futures. It considers basic needs, like food, housing, education, employment, and income. It includes social and emotional needs, like sense of purpose, safety, belonging and social connection, and life satisfaction. And it is tightly linked with the well-being of our communities, our environment, and our planet.”
Returning to the topic of adverse childhood experiences, Dr. Harper reiterated that that kind of trauma is quiet, often silent. She ended by saying: “It is my hope that in having this discussion today, it will help us disrupt some of that silencing, that we become increasingly comfortable with facing the difficult realities that can feel unspeakable because in doing this work we facilitate doing better and being better for ourselves and for each other.”