Episode 4: Trauma-informed care strengthens community resilience in Orange County

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Denny Spinner: 
This is Denny Spinner from the Indiana University Center for Rural Engagement, and welcome to Our Indiana: Stories from Rural Hoosiers, recording today from the Court Street Commons in Paoli, Indiana. We are here with Doctor Brandy Terrell from the Southern Indiana Community Healthcare Center and Doctor John Keesler from the IU School of Social Work. Welcome Brandy and John, and thank you for being here with us today. 
 
Both: 
Thank you. 
 
Denny Spinner: 
Thank you. We have quite a story to tell here, a collaboration that began, if I remember back, back in the 2018 area is when this all started going. Tell us what brought you together. What was the issue that surfaced and how this work and the collaboration began. 
 
Brandy Terrell: 
Glad to, because I think that it is, like you said, an amazing story. So we began the kind of awareness on Adverse Childhood Experiences several years before we were able to put a lot of frameworks and groundwork together. So I was in my masters program when I was first introduced to Adverse Childhood Experiences. And it was kind of like a light bulb moment at that point of, oh, this explains so much.  
 
So then fast forward a few years, and community mental health centers were, at the time, doing Systems of Care. It was kind of a new thing with the Systems of Care program, and one of our Systems of Care coordinators became involved with trauma-informed care frameworks, and then, how does that relate to Adverse Childhood Experiences? So we started to just kind of marginally look at, what does that mean in those two things together?  
 
Fast forward again to about 2018 when our CEO Nancy Radcliff and her sister Ramona Osborne were introduced to Adverse Childhood Experience research, and they brought that back to Southern Indiana Community Healthcare, or SICHC. And when they introduced the work to Doctor Yolanda Yoder, she became very interested in the ACEs framework regarding pregnant women.  
 
So she started to do her own research within our clinics and ask the standard Felitti and Anda 10-question survey about ACEs to our pregnant moms. And what she found there was that 30% of our pregnant moms were reporting an adversity rating of four or more. That's about double the national average. From there, we started to ask questions about, if this is happening with our pregnant moms, what's happening with our children? 
 
And at that point, healthcare providers in our community and school staff decided to start having some conversations. And we, again, were able to identify that 30% of our 7th through 12th graders also were identifying an adverse childhood experience score of four or more. 
 
Denny Spinner: 
And these are the schools here in Orange County?  
 
Brandy Terrell: 
They are, all three of our schools. They really took the opportunity to say, you know, this is important. And we need to know so that we can know exactly what to do about it—not just to ask the question, but to do something, because we're the ones who are going to solve our own problems. Anecdotally, we knew that these things were happening. But you also have to have a clear kind of data point as well.  
 
So that's how Adverse Childhood Experiences and trauma-informed care frameworks really started here in Orange County. 
 
Denny Spinner: 
And then how did the connection happen with your work, John? How did how did you become involved with it, experience it, come to collaborate with them? 
 
John Keesler: 
Well, Ramona Osborne, for those folks that knew her, was a force to be reckoned with. She was a go-getter, and she did not let anything hold her back. My memory is a little bit foggy, but I do remember her just reaching out to me and saying, you know, we're interested in looking more at Adverse Childhood Experiences and trauma-informed care. We know that this is in your area of work, so what might we do with this? And again, when you met with Ramona, you left with a task whether or not you wanted that. 
 
Brandy Terrell: 
Yes, you did.  
 
John Keesler:  
She had a way of getting things done. And so I had a meeting with her and some social work interns and a social worker. And she had said, you know, we began collecting this data around Adverse Childhood Experiences in some of our schools. And I stopped her there. And I said we can take this bigger than just the schools in Orange County. I said you have a story here to tell. And I said we can do an article and get a national or international platform for you to share your story.  
 
Because this was really one of the first times that folks had gone to youth to ask them about their own level of adversity, keeping in mind that oftentimes it's by proxy, asking parents about their children. And this was the first time that we began asking kids. And what we know is that self-report sometimes produces different results than proxy reports. So going to the source and asking them. And doing it safely.  
 
And so there was a lot of hesitation—there has been a lot of hesitation—about asking kids about their adverse experiences or their trauma. But what they showed here in Orange County is that it could be done safely, and it could be done meaningfully. And the saying is is once you see it, you can't unsee it. So the data provided concrete evidence of higher levels of adversity. Now what can we do about it?  
 
But before we go on in this conversation, I think it's important to back the bus up a little bit and talk a little bit for those that may not know what ACEs are. 
 
Denny Spinner: 
Yeah, I was going to say, give us a background. We've used the term. What does that mean? 
 
John Keesler: 
So, back in 1998, the first study of Adverse Childhood Experiences was published by doctors Felitti and Anda from California. They had done a study amongst about 16,000 people or so in their clinic, and they really wanted to know why their patients weren't getting better. And they were able to identify ten types of adversity that were really predictors of poorer health outcomes later in life. And then those ten types of adversity are across two domains—household dysfunction and abuse/neglect.  
 
So household dysfunction included divorce or parental separation, mental illness or suicide, substance use, domestic violence, and incarceration. With abuse and neglect, it was physical abuse, psychological abuse, sexual abuse, as well as physical neglect—so not having your basic needs met—and emotional neglect, feeling unloved.  
 
And with an ACE score, it is a count of the types of adversity you've experienced, not necessarily the number of times that they've occurred. And so, for example, say I came from a household where my parents were divorced, and there was domestic violence. I would have an ACE score of 2. If I had parental separation, divorce, domestic violence, and substance use, I'd have an ACE score of 3.  
 
And what we know is that there's a dose-response effect. So, as your ACE score increases, the risk of poor outcomes increases as well. Again, it's important to recognize that this is really at a population level. At the individual level, so many different things can be factored in, including things like resilience, genetics. And so that can sort of buffer the effects of adversity.  
 
But so much of what has been going on here in in Orange County through Thrive and SICHC as well as Team OC is really about how do we prevent adverse experiences, but how do we also bolster resilience for those that have already experienced adversity?  
 
Denny Spinner:  
Right. When you talked about going to the students to have these questions asked, there had to be a level of trust built before that happened. We talk about what was done here, and when we talked before as we were getting ready, said, you know, lessons learned. As others might address this issue in their communities, it seems to me it begins with that level of trust. And how did you build that level of trust within your own community, people that you knew? It's sometimes harder when you see people every day to establish that. So tell us a little bit about how that trust was established and enabled you to really surface the issue and then started addressing it.  
 
Brandy Terrell:  
Yes, so it's a great question. Really, I think that there was multiple, multiple things, kind of a larger concept of how to build trust and relationship, and also that we've been kind of doing that work. This particular kind of movement came out of the healthcare agency, which is one of the largest healthcare agencies in our little community. We already had, at the time, 40-plus years of community-based work.  
 
So the clinic, of course—SICHC clinic is kind of what everybody calls it—they were already doing a lot of that really good community work. That's in their philosophy. It's not just a medical facility. It's not just a mental health facility or a substance treatment facility. It is a community entity, number one. So a lot of the groundwork was kind of there.  
 
And then I was involved in it, actually, in the very beginning, through Youth First, which is an Evansville-based organization that puts social workers into schools. And two of our three schools had Youth First social workers, and I was one of those in the Orleans school system. So in the Orleans school system and in the French Lick Springs Valley School System, my counterpart there, we then worked with SICHC with the blessing of Youth First to be able to say, if we're going to do this, what does it look like, and how can it be as safe as possible? How can we inform everybody, and what's the best pathway?  

 
So we were already kind of embedded in the community doing community work, doing school work. This was at the very beginning of organizing Thrive Orange County. It was a grassroots kind of effort, so everything started all at the same time, and we just had a lot of people who understood how to take opportunity and run with it. So we were able to rally the school boards in Orange County to let us figure out what is going on so that we can actually do something about it. And they were on board. They got along really well with each other and really put kids' needs first, and they still do.  
 
So we had a lot of traction in that relationship-building, which you have to have. And we had a lot of people who were working here in this community that said, hey, it's okay. And then on a practical level, we did so much outreach and transparency work. So we were talking about what we were going to do in the newspapers. We were holding open meetings. We were sending letters home to schools. We were sending the text reminders to parents that, hey, this is what we're doing. And we tried to be as transparent as possible. And it all came together because I think it's just—it's the way we're supposed to operate in communities.  
 
Denny Spinner:  

Yeah. Another term that we threw out here was "trauma-informed." A community becomes trauma-informed. Tell us what that means. What does it mean for a community to become trauma-informed?  
 
John Keesler:  

This is a great segue, I think, because so much of what Brandy was talking about—this trust, cultural humility—these are part of being trauma-informed. Depending on the model that you ascribe to, there's different models for trauma-informed care, but certainly approaching folks from a standpoint of cultural humility is important to recognize their expertise and their own lived experience is part of that. The other part is trust. Trust is huge.  
 
Brandy talked about the relationship between the clinic and the schools as well as different folks to build that relationship. And my perspective is complementary in that, as a university faculty member, it was really important for me to demonstrate that I was trustworthy. That I wasn't going to come into a community, take what I needed, and leave. And there was reciprocity there. I remember coming down to the clinic, meeting with folks, talking to them. And that required that I made the effort. But simultaneously, Ramona and Terry came to campus, and we did a lunch in the Tudor Room. And so there was this back and forth.  
 
So what is trauma-informed care? Trauma-informed care is really a systems-level approach that recognizes and responds to trauma. And it is not—you know, we talked about ACEs, which were, really, before the age of 18, but trauma occurs across the lifespan. It changes people. It's not the event per se, but it's the person's experience of the event that changes them. It changes them physically, psychologically, emotionally, spiritually. And trauma-informed care really is about recognizing that harm but also beginning to restore the things that trauma has destroyed.  
 
The one model I ascribe to is by Felitti and Harris, and it has five basic principles. So safety—talking about physical safety as well as psychological or emotional safety—choice, collaboration, empowerment, and trustworthiness. And oftentimes, these are the things that are destroyed by trauma. We know that trauma can be related to natural disasters, and that can be significant. We see a lot of that going on in our global community. But what we know at the population level is that trauma between two humans is oftentimes more salient. We're social creatures. We need that sense of connection. We need that ability to relate to others because so much of our survival is interconnected.  
 
So trauma-informed care, again, is about recognizing the harm that's been done. Whether or not we know somebody's experienced trauma, because of the high prevalence of it, we assume. And when we assume that harm could potentially have been done, we can't do further harm by offering people safe environments, giving them a sense of agency through collaboration and choice, and elevating them, and praising them, giving them the resources and skills that they need to be independent, contributing members of society, but also as connected members of society.  
 
Denny Spinner:  

So as Thrive Orange County came about—and this is just an element of that—tell us a little bit more about Thrive Orange County and its mission and how this kind of fits with that. 
 
Brandy Terrell:  

Yeah, sure. So Thrive Orange County is really not an entity of itself. We are under our clinic, so we are what I would call the enabling services, so the community part of SICHC. People go, oh, Thrive is its own thing. No, it's not. We are literally a community branch of SICHC, and there's reasons for that.  
 
So one of the things that we feel makes this work is the fact that we do have a strong community-oriented agency kind of being the anchor for us. They believe that community health is just as important as the individual health or the medical side, and it's wanting to know what is going on that is bringing people into our clinic with things that could be prevented. And then, is there something on a community level?  
 
So, really, Thrive was born out of necessity and out of a lot of community-focused individuals saying, we know there's something going on. Now we kind of have the proof of that, and now we have to do something with it. So we have to look at it through a prevention lens but also an intervention lens. And what we know about these types of adversities is we need those protective factors. We need as many opportunities for our youth and our adults to come in contact with stable, caring adults—other community members, programs, resources.  
 
So then we started to kind of look at the social determinants of health. From that larger umbrella, there are things such as, you know, economics, educational attainment, housing, food insecurities, and I'm sure I'm missing a few. But the reality is all of those things affect how well a community operates. And we know that the healthier our community is, the healthier our children are going to be. And they're going to grow up and be healthier adults.  
 
So part of Thrive is just getting as many organizations and regular community members on board and being able to understand. So that education piece rolls around all the time, understanding kind of what's happening, what our story is, where we're going, but then also, what can we do about it? And utilizing as many resources as possible in order to actually, you know, move the needle a little bit.  
 
Denny Spinner:  

One of those resources we wanted to speak about as well is that Thrive Orange County received an IU health grant to support your work. Tell us a little bit about that work and how that has added to the effort. 
 
Brandy Terrell:  

Oh. Goodness. Well, it did more than probably add to the effort. Again, you know, this is difficult work, and it's not work where you can get an immediate financial gain. It is something that you have to understand is the long game. And it's expensive. It just is. So part of the community capacity grant, it really allowed us to focus on the Thrive mission and being able to take that message out. But it also did an amazing thing, which was to support Safe Haven, which is one of our amazing substance intervention prevention and intervention programs here, which has just been incredible.  
 
And then it, thirdly, anchored Team OC youth mentoring, which was the very first program that our community said they wanted us to work on. So our strategic planning with our community—there was over 80 people there and from all areas of our community. And they decided that mentoring was it. Because if we can start linking up at-risk youth—now it's turned into all youth—but at-risk youth at the time with stable, caring, loving adults, we just might be able to cycle break.  
 
And so the capacity grant did that. It allowed for secure funding for over two years to really start working on these programs and working on Team OC youth mentoring. And right now, I think they're at 54 mentor-mentee right now. It's amazing.  
 
Denny Spinner:  

Wow, yeah. As we talked about what we wanted to tell this story, which— the story is phenomenal—but also takeaways to other communities who might be struggling with these types of issues. I know, John, the Trauma-Informed Care Certificate is something that has become a part of this as well. That's a tool. Tell us a little bit about that, how communities who want to kind of make an assessment of where they are—this is something that's available, right?  
 
John Keesler:  

So, yes, through funding from the Center for Rural Engagement and the Lilly Foundation, we were able to create an interdisciplinary, online, self-paced certificate around trauma-informed care. And what this provides is a foundational understanding to folks. It's intended to be at the community level, so we want to reach all people. It provides a four-hour basic curriculum around "What is trauma?". Let's talk about Adverse Childhood Experiences. Let's get an understanding of trauma-informed care, what's the evidence behind it, and even sharing some of the story of the clinic here and Thrive.  
 
And we have, at this point, four submodules that dive a little bit deeper into trauma and trauma-informed care with specialized populations. So that's children and youth, people with disabilities, veterans, as well as justice-involved folks. And so we've built it in such a way that there is potential to expand to new areas, to refine it. In fact, we're on our second edition or second iteration of the certificate. We've made it auto-scored, so you get your certificate pretty quickly as soon as you finish the training. But again, this provides a foundation, and it's free. 
 
You know, yes, personnel can cost, but we want to make sure that folks get the information that's needed.  

And there's more than 20 people that have contributed to the training both locally and at the state level as well as across the United States. So we we hope that folks utilize it. The last I checked, it was over 6,000 people who have leveraged that training. And it provides, again, a nice foundation for folks to grow. I want to come back to one of the things, though, that's really instrumental with doing the work in rural communities.  
 
Oftentimes, outsiders think, "Rural communities? Well, they don't have a lot of resources." And that's true. Rural communities can lack resources. But the one thing that they have is sense of community, sense of pride, and also generosity. As an outsider, I mean, I live in rural Indiana. I'm in my ninth year. But one of the things that stands out to me is the tremendous generosity of folks. They are willing to give and willing to do the work. Sometimes, they just need the invitation. Sometimes, they just need the framework and the training.  
 
And I think so much of what SICHC and Thrive and Team OC has done is created that. Created an opportunity and a space for people to give back and to make a difference. Because I really think that it's there. Sometimes, they just need some motivation, some additional support. But I think, intrinsically, in rural communities, the desire to help people is definitely there.  
 
Denny Spinner:  

There's a lot of buzzwords when you talk about life in rural Indiana and rural places, and one of those words that seem to come up is "quality of place," as people are looking for that place to live or come back to after they may go to higher education or whatever they may be. And you hear a lot of talk about what "quality of place" is. This is quality of place. What your work here is about—a quality of place in Orange County that is a struggle, or a challenge, but you're not afraid to take on that challenge.  
 
Brandy Terrell:  

Yeah, I think that that's absolutely right. And I think that, too, you know, the thing is, it's not really even Thrive Orange County. It is our community. 

 
Denny Spinner:  

Right. 

 
Brandy Terrell:  

Thrive Orange County wouldn't be anything without the people who do the work, right? And the agencies, and the workforce, and the health clinics. The thing that I think helps us the most is, we are very intentional in our community organizing, in creating pathways for people and organizations to be their best. And that's impressive. So it isn't just about one entity or agency. It is about us kind of working together and utilizing those very limited resources for the common good. And that does take having a few folks that—that's what they do. That's their job. They're loyal to the community as opposed to a particular, you know, agency or company or entity. They're loyal to the broader picture. And I think that that's why we've been able to be as successful as we have, although we have a lot of work to do. I mean, we're literally in the beginnings of this work. 2018 wasn't very long ago. So we just continue the message and continue getting people to work together.  

 
John Keesler:  

I just want to jump in there for a quick second. Here, we again see the evidence of another principle of trauma-informed care being implemented in the work to create a trauma-informed community. And that's really collaboration. Working together. I think that's huge. You know, I'm not sure I answered your original question, or, you know, we can come back to it. It's about, how do we do this in other communities? 

 
Denny Spinner:  

Right, that's where we were going. So yeah. And one of the things we talked about before we started was that this is an open book. Anybody who wants to know more about what you're doing, please reach out to you.  

Brandy Terrell:  

Oh, yes. 

 
Denny Spinner: 

Go ahead, John. 

 
John Keesler:  

Yeah, there's a few things that really stand out as to why this is working here. From the get-go, there was leadership. There was a vision to do something. And there's an anchor to all the work, and that's the clinic, really. We know from other guides and frameworks that are out there and resources that leadership is critical, and that you have to have an investment. That investment can be time, money, resources, etcetera.  
 
And there have been folks dedicated to doing the work. And yes, so much of the work is done by volunteers, but there's also paid positions. You need those paid positions to create continuity in the work, between the volunteers doing things, in between coalitions and committees, meetings. Because without that, change is very hard. You need that constant reinforcement and the same messaging.  
 
And really, what the folks have done is gone out. It's not an expectation that you come to me, but it's that we go out, that we leverage our resources, our relationships. And Brandy will say, you know, sometimes it's that coffee klatch session. Sometimes it's going to that church. It's going to that school. Being visible, being present, and inviting people into that collaboration.  
 

So leadership, investment, and commitment. Brandy says it was back in 2018. It's fairly young. We know that as people and organizations and communities engage in the change process, it's very fragile early on. It's very easy to fall back to baseline, to doing what's comfortable. And what's comfortable may not always be best.  

 
Brandy Terrell:  

And I think I'd like to add a few concrete things. If someone were, hey, you know, I'd really like to try something like this in our community, I would challenge you to say you probably already are. It's just getting the message together. I think that having the right folks with the right type of, I guess we call it "soft skills," to be able to really relate to community and to people—I think that's important. We have to have the right leaders in the right place.  
 
And also, those leaders may not be the one to deliver the message. It very well could be somebody else, and we have to know that. We have to understand the landscape. And I think you understand it better if you're from it, or you live in it, or you've raised your kids in it, something of that nature. But also, some of the things when we started, we really wanted to have the goal of meeting people where they are.  
 
So where are people? We narrowed that down, really, to a few places. So school is clearly one. As much work as we can do with schools, we're going to cover a wide variety of folks in Orange County. Faith-based because our faith-based communities are so vital. So if we also can partner with our faith-based community, we're gathering even a larger group of folks. And then our workforce. People are somewhere working, right?  
 
So if we have those three, and then we tie in our healthcare—because at some point, everybody needs healthcare or is in the healthcare office at some point. So if we take those four groups, we can nearly touch everybody at some point. So that was our tangible kind of goal. If there's anything to take away from this, it's to go where people are and just do the work. Get up every day and do the work. Even the small work. Even the work that is tedious and not grand. Do it anyway.  

 
Denny Spinner:  

Well, John and Brandy, I appreciate your time today. This is a great story to tell and a great story to hear. And hopefully, those listening to us today are inspired by the work that's being done here. Congratulations on the great work done so far, and good luck. I hope we can continue to support what's going on here in Orange County and across rural sections of our state. Thank you so much for being here with us today, and we appreciate your time and your comments.  

 
Brandy Terrell:  

Thank you very much.  

 
John Keesler:  

Thank you.  

 
Denny Spinner:  

Thank you all for listening to us today on Our Indiana: Stories from Rural Hoosiers. I'm Denny Spinner, and we'll talk to you again next time. 

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