Damaged: Childhood Trauma, Adult Illness, and the Need for a Health Care Revolution – Interview with author Dr. Robert Maunder

What I have learned from treating people like Isaac is that our health care systems often go wrong when dealing with adults who are sick because of trauma. Instead of supporting our patients’ strengths and helping them recover, we contribute to their damage. By explicitly identifying circumstances in which our system increases health risks when it could be helping instead, I hope we can open windows of opportunity for change.

Dr. Robert Maunder and Dr. Jonathan Hunter. Authors: Damaged: Childhood Trauma, Adult Illness, and the Need for a Health Care Revolution

A few years ago while scrolling on Twitter, an article published on Medium caught my attention. Intrigued by the title The Damage I Am, I clicked to read. The post was the story of an interaction between a patient named Isaac, a man with a significant childhood trauma history and Crohn’s disease, and his psychiatrist, Dr. Robert (Bob) Maunder. Reading on, I learned there were two writers: Dr. Maunder and his colleague, psychiatrist Dr. Jonathan (Jon) Hunter. The post explained the weekly segments were part of a book Bob and Jon were hoping to get published.

But what really grabbed me – more than the subject matter of childhood trauma – was the way the stories of Bob, Jon and Isaac were told. Interconnected at the meeting place of the medical system, chronic illness, and childhood adversity, the struggles of these ‘characters’ wove in and out, each person grappling with the impact of childhood trauma in their own way. 

I followed the doctors on Medium and Twitter and began to share their posts. Personally, I had just started writing about my perspective as the partner of someone with complex trauma so I really did not expect any further interaction from them. To my surprise, Bob started to engage with some of my posts and we eventually met in person. In summer 2020, I received an email from Bob asking if I would like to write a section of the above book about my perspective as a partner. Of course, I said yes and you can find my contribution in the last chapter.

My connection to this project is not the main reason I invited Bob to do this interview or why I am a huge fan of Bob and Jon’s work. The real reason is because I believe in the message. I believe it when Bob and Jon talk about the conversation not being an ‘us vs them’ dialogue about childhood adversity. I believe it because of my own experiences as a partner accompanying my husband through the medical and mental health system and a writer in this space. Mostly I believe it because my eyes are wide open to the prevalence and impact of childhood adversity on all of us.

Isaac’s experience has much to teach us. If you have not had his experiences, you know someone who has. Childhood adversity that is severe enough to be harmful throughout life affects over sixty million American adults and about nine million Canadian adults. 

Dr. Robert Maunder and Dr. Jonathan Hunter

A couple of things before we dive into the interview. If you read the book, you will learn that while the narrator of the book is Bob, Jon is an equal contributor in every aspect. The other character is Isaac, who urged Bob many times to tell the story. I suspect, Isaac too, believed in the power of storytelling to create change.

Secondly, this book is not a comfortable read nor should it be. However, please be aware that there are descriptions of physical, sexual, and emotional abuse. There is addiction and medical trauma too. Please take care of yourself.

Finally, this interview is a glimpse into this book and the work of Bob and Jon. My hope is it might be enough for you to consider buying it or at the very least, to prompt you to think about the prevalence of childhood trauma amongst adults in our society . Even more, I hope by reading, each of us can contribute to changing the public conversation around childhood trauma and the need for a health care revolution.

Let’s begin. Here is Dr Robert Maunder, co-author Damaged.

The Interview

Heather Tuba: You and I have talked about how the audience for this book is for everyone not just medical practitioners. Why is this so important?

It’s very important to us that this is a book for everyone. If we, as a society, are going to change public perception of childhood adversity, everyone has a part in that change.

Dr. Robert Maunder

Dr. Robert Maunder: It’s very important to us that this is a book for everyone. We wrote it that way and kept a general reader in mind throughout – so the audience is not just medical people and it is not just people with lived experience of trauma – but everyone.

The reason, to be frank, is that we want to change the world, as grand as that sounds. If we, as a society, are going to change public perception of childhood adversity, everyone has a part in that change.

Could you give readers a sense of the timeline of the book and what finally prompted you and Jon to write it?

First of all, as we write in the book, Jon and I have time set aside to talk every week. We have been doing that for many years, so it is a continuous and meandering conversation. It makes it hard to locate the beginning of any particular idea or project.

Another timeline is how we came to realize how common childhood trauma was in our patients, who are all people who have both mental health challenges and physical illness. It is different for each of us, but for me, that took a surprisingly long time – several years of practicing psychiatry. And then a few more years before I came to the conclusion that dealing with the consequences of that trauma was a core part of my work as a psychiatrist.

Then there is the timeline as writers. We published our first book, Love, Fear and Health in 2015. That was about relationships and health as well although not focused specifically on trauma. This was a book about how we all come to have different patterns of close relationship and how that affects our health.

While Love, Fear and Health is accessible to general readers, the intended audience was our colleagues. After that book, we wanted to write more specifically about the consequences of childhood adversity and we wanted to write a book for everyone.

Damaged evolved through writing and re-writing over a few years, probably four or five years. It was not easy to find a publisher because, I think, it was a hard topic for publishers to see as marketable. But AEVO UTP didn’t hesitate. Our editor, Natalie Fingerhut, immediately saw the importance of the topic and helped us to highlight the story of relationships in the book as its central theme.

This book is unique because of the way the stories of relationships weave in and out. The story moves between different scenes in the sense of it being Isaac’s story, your experiences and the subsequent discussions with Jon, followed by lessons for readers. Why was it important to have all of these storylines in the book?

Jon and I have been teaching and writing about the importance of relationships in medicine for many years. And we have a close relationship ourselves, as friends and colleagues, which includes this long conversation. And we both practice psychotherapy, which of course is deeply relational.

You can’t get anywhere in providing health care without first attending to the quality of your relationship with a patient. That may be our core message.

Dr. Robert Maunder

It took a while in the writing and the re-writing to realize that weaving these relationships into the story, or stories, of Damaged, would illustrate our point. That allowed us to show how relationships matter, rather than just saying that they do.

It seems like the relationship between you and Jon is a protective factor. I think anyone who supports someone who is suffering from the impact of childhood adversity needs others to support them. How has having this relationship helped you both as persons and professionals?

I don’t think you can do this work alone. We don’t just have each other, of course. We have our families and other colleagues and friends. But one way or another, you need to be able to find support and solace somewhere to keep yourself whole. 

From a technical perspective, doing therapy with people who have experienced trauma often induces strong feelings in the therapist. It can lead you to leap to conclusions that are not correct. It helps to be able to speak out loud about some of the experience as a kind of correction to that.

There is a place in the book where Jon and I are talking about challenges that arise at the boundary between therapeutic relationships and relationships in the real world, and Jon is saying something that he has figured out and that sounds sensible, and then he realizes as he hears himself say it that “I am full of shit” – that what he has described is not really how he practices.

So, yes, Jon and my relationship is emotionally protective and it improves that quality of our work.

The book emphasizes awareness of ACEs vs having a patient do the questionnaire. How does an awareness of adversity help all people to respond to someone differently?

The Adverse Childhood Experience questionnaire is a really useful research tool but was never intended to provide an understanding of individuals’ experiences. However, it has also turned out to be a valuable public awareness tool – although I don’t know if that was the intent at first.

In healthcare relationships, however, the information that my ACE score is 1 or 3 or 7 or whatever is not nearly as important as the knowledge that I am working with a professional who is open to hearing about my experience and wants to understand how it affects my health currently.

Dr. Robert Maunder

It is that relationship that gives value to the information summarized in the ACE score, as far as healthcare goes.

For example, as a doctor, it is helpful to know that I am talking to someone with an ACE score of four, say. But is is much more helpful to know that I am talking to someone who is afraid of needles and has trouble trusting an older, male physician, for example. You can’t get there without a conversation. And the conversation is what allows a person to know they are with someone that it is worth trying to trust. It is not just about the information.

Naturally, I’m talking about health care relationships because that is what I know best. Something similar applies to other relationships, but not all of them–the ones where trust and sharing matter.

On the other hand, the ACE score from the questionnaire can be a really useful way to start a conversation. I know people who have been very surprised to find that they have a high score because they thought all these experiences that they had to be ‘normal.’ Things like ‘it was a different time then,’ and ideas like that. And then they go and talk to their partner and say, “Do you know I have an ACE score of 5?” The partner asks, “Oh, what does that mean?”

And suddenly they are having a new, different kind of conversation than they’ve had before.

You write about the barriers people with childhood adversity face when interacting with the medical system, especially with communication. How does childhood adversity potentially interfere with storytelling?

Trouble telling personal stories is one of the consequences of adversity that ‘hides in plain sight.’ With very few exceptions, getting medical treatment starts with telling your story.

The truth is, even when a patient comes with a ‘simple’ problem, the story can be complex. There is the historical part about your past. For example, maybe you’ve had something like this before. There is the narrative part about how it started and how it’s progressed. This telling involves timeline, events, and often other people, so the story has characters. There is the part about what makes the trouble and what makes it worse. This part is often sorted out through questions and responses with a health care provider, which makes the story interactive.

All of this is a complex social and cognitive task taking place when you feel unwell and it may feel like the stakes are high.

Of all the ways that childhood adversity makes people sick and then makes it hard for them to get better, perhaps the least recognized is that early adversity plays havoc with storytelling skills.

Dr. Robert Maunder and Dr. Jonathan Hunter. Damaged.

It turns out that people with early unresolved trauma have a lot of trouble with this task. Their telling of their own medical story is often hard to understand and the interactive part often doesn’t go well. They get called ‘poor historians’ in medical settings. Health care is busy so the professional who is taking the history may decide to make an educated guess about what is going on rather than seeking clarification about confusing parts of the story. It sets up care that is less effective.

It is not just a coincidence that early trauma is linked to this trouble, which is called incoherent narrative.

Early trauma is relational. It is in the interactions that occur hundreds of times while our brains are developing that we learn how to tell stories: how to engage our audience, how to summarize, how to to explain ourselves. So people who have experienced serious early adversity are also less likely to have experienced the kind of relationships that support the development of storytelling skills — at least for this kind of high stakes, personal story.

How can practitioners help patients tell better stories and what can people do to help themselves?

There are things that people can do about this. First of all, practitioners need to realize what is going on so they can try to help. Patients can compensate for the trouble by bringing a supportive person with them to the appointment, and by writing out the main points they want to get across in advance, for example.

Thank you, Bob for being here and to you and Jon for your ongoing work and advocacy beyond the publication of Damaged. Do you have a final quote to leave with us?

Yes, there is a line from the dust cover of the book.

The way we care for those who suffer most reveals who we are as a society.

Dr. Robert Maunder and Dr. Jonathan Hunter

Damaged: Childhood Trauma, Adult Illness, and the Need for a Health Care Revolution is available at major booksellers and University of Toronto press.

About the authors

Dr. Jonathan Hunter is a Professor in the Department of Psychiatry at the University of Toronto and holds the Pencer Family Chair in Applied General Psychiatry at Sinai Health. He is Head of Consultation-Liaison Psychiatry at Sinai Health, and the Psychosocial Team at the Marvelle Koffler Breast Center. His clinical practice centers on the psychiatric and psychotherapeutic care of cancer patients, and other people with serious medical and surgical illnesses. His research interests include group psychotherapy in women at high risk for breast cancer, the role of early life experience and attachment in adaptation to disease, and the importance of mentalizing and therapeutic alliance in treatment.

Dr. Robert Maunder is a Professor in the Department of Psychiatry at the University of Toronto and holds the Chair in Health and Behaviour at Sinai Health. His research has focussed on how close relationships influence health, and on the compassionate support of resilience in healthcare workers. Clinically, he provides psychiatric care for people with chronic physical illnesses.

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