September 26, 2023

Christina Bethell | Relational Systems of Health Care

Thomas is joined by internationally recognized change agent and Professor at Johns Hopkins University, Christina Bethell. They discuss her research and work to transform children’s healthcare systems and promote relational well-being for families and communities. Christina has created what she calls the Positive Childhood Experiences Scale, a measurement of beneficial relational experiences that can help to offset the effects of Adverse Childhood Experiences, or ACEs. She and Thomas explore how medical health providers, therapists, and families can improve their relational attunement and build lasting connections that build pathways to healing.

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“Parents, teachers, providers – we don’t have to be perfect, but we do have to be intentional.“

- Christina Bethell

Guest Information

Christina Bethell

Dr. Christina Bethell is an internationally recognized change agent and Professor at Johns Hopkins University, working to promote a just and thriving society by restoring our relational and social roots of well-being. Advancing a “We Are the Medicine” framework, Christina’s research and publications have sparked an international focus on promoting Positive Childhood Experiences to prevent and heal childhood, community, and intergenerational trauma and the syndemic of Adverse Childhood Experiences we face today.

Notes & Resources

Key points from this episode include:

  • The National Academies of Science Committee and how it’s working to create what Christina terms “relational systems of care”
  • How all health and well-being is co-produced and relies on the establishment of a trusting relationship
  • The need to build training for connection, attunement, and mindfulness into medical education
  • Creating “personalized connected encounters” that foster a sense of safety in children and allow them to work through trauma
  • The “Engagement and Action Framework,” a scalable model of creating healthy engagement and relation between parents and children and providing resources to areas in need

Episode Transcript

Thomas Hübl: Welcome to the Point of Relation. My name is Thomas Hübl, and I’m sitting here with Christina Bethell. So much welcome. Very warm welcome, Christina!

Christina Bethell: Thank you for having me. 

Thomas Hübl: We have a long-term friendship. We have known each other for a long time. And we had many of these conversations already. I know every time I walk away first it’s nourishing that we meet and our friendship gets deeper. And so I am simply amazed by the science data you come up with relational health. And I know you’ve worked a lot on Adverse Childhood Experiences (ACEs) and Positive and Adverse Childhood Experiences (PACEs) and so many so many parts that really resonate deeply with me. And so we share a lot of passion together. So I’m really excited that we have this conversation here on my podcast. 

Christina Bethell: I remember meeting you and thinking, Oh my goodness, here’s somebody who I can talk to, who I can relate to, and we’re talking about the marketplace, which is so much of what my journey is and is bringing it into very concrete forms in the world. 

Thomas Hübl: That’s right. You know, and many of the listeners know, we explore a lot of how to heal collective trauma, how to create relational health, how to have attuned relationships that help us to flourish. Maybe you can speak a little bit to what you are working on that you would consider your leading edge at the moment? So what’s new for you or what’s exciting for you? 

Christina Bethell: Well, one thing that’s exciting is the sort of accumulation of studies and mindsets and cultural shifts that are allowing us to really have a very explicit conversation about relational health as a solution. And so we’ve been talking about toxic stress and trauma. And we worked with the American Academy of Pediatrics and my colleague Andy Gardner, who you spoke with, who read the policy statement, shifting the dialog from toxic stress as the problem to relational health as the solution. And of course, you run into the toxic stress and the trauma, but inside the container of the intention to create and attune safe space for that, which then ends up being the healing force. So we get to talk about it, and now we’re bringing it in at a national level as well. 

So we’d already gotten some play with Congress and senators, and now there’s lots of funding streams. So all of a sudden there’s a lot happening. But it’s very important that we not forget what we’re trying to actually do is create a very safe, stable, nurturing relationship with ourselves, with each other, with life. And that’s actually something we’re built for. But we often go offline and we have to build skills. And so a lot of what you talk about, the embodiment of the capacity to connect, to be seen and to see is a deep learning. So it’s definitely really exciting right now, working on a National Academies of Science Committee on improving child and youth well-being through children’s health care system transformation. And the centerpiece of all of it is addressing, you know, what we’re talking about. Relationships are like the first principle. 

And also that flourishing well-being isn’t the absence of illness. It’s the living of the living and relating self. So life involves difficulty and adversity, and we are the descendants of people who got through some of that horrible adversity that we’re built for that. And how do we focus on building that capacity so that we can turn toward the trauma and not just retraumatized? There I’m in a thought because there’s so many other things that I wanted to mention that there’s actually a National Academy of Sciences Committee that’s coming out with a big report to help guide the nation here. And there’s things going on globally, too, with this work that I can talk about more of that in a minute, very exciting. 

Thomas Hübl: And so maybe you can talk a little bit more about what’s going on globally, I think that’s because we need to. 

Christina Bethell: So I think you probably know that a few years ago we created something called the Positive Childhood Experiences Scale. You know, what I’ve always noticed is that there’s similar levels of adverse childhood experiences and very different outcomes depending on other factors. What we’ve had to show population based, even though you and I know it’s true you still have to study it and show it to get action or attention anywhere is that the quality of the relationships between parents and children, teachers and children, and communities really impact and are the major things that are leading to whether children do better or not better, given similar levels of adversity and that it goes into adulthood. 

So similar to ACEs playing out, getting under your skin, and playing out over your life – positive experiences do too. Except for there’s this paradox where when we look at what is a positive childhood experience, it’s how we’re met when things are hard. So it’s not like it’s divorced from adversity, but it’s how we are with each other and whether we feel safe to talk about our feelings and create a sense of support for one another that are extremely effective all the way through to adulthood, just like  ACEs are. So it’s a dual continuum. It’s not like you only have positive if you don’t have negative or you only have, you know, they’re not like that. They’re operating similarly. So we should always be encouraged.What we noticed after the paper came out is that it was being taken up all over the world. Like, you know, you can look at that like where it actually is. I think it’s in every country except not so much in Russia, but everywhere else. And in particular, like in Africa, they’re making posters of these positive childhood experiences in communities and in Mexico, Spain and Italy. We’ve been talking to the Scottish Parliament about instead of focusing on getting rid of ACEs focused on promoting capacity for relational health, and you run into ACEs, but if you go straight at it without a sense of safety and a safety container and a sense of healing, you are whole already, you know, it’s not like there’s something wrong with you that it doesn’t really seem to work. So it’s very exciting. And for some reason that really resonated with people that they felt like they weren’t powerless. But the things that the positive experiences point to is building that capacity to connect in the attuned way, the felt sense way like my body and my brain and your brain and body don’t lie to each other. And we’re built for that. And that’s really what I think people are resonating with is that and of course, there’s a lot of very intricate issues like what is the anatomy of an authentic connection and what do you do when somebody loses the desire to connect? You know, how do you work with teams who are shut down already? A lot of things like that, but it has definitely been a part of both policy and public health strategy now in the globe, which is really great. 

Thomas Hübl: It’s amazing and it’s also very helpful. 

Christina Bethell: But I’m not a part of it, like they just send it to me. They’re like, “Okay, we’re posting these, thank you for your work.” And I’m like, Oh, great. So it’s being taken up organically.

Thomas Hübl: Mm hmm. And so tell me because maybe many of the listeners would say, yes, that intellectually makes a lot of sense. But, you know, when we get triggered, when we already shut down, when we’re already distant. How does being in communities create relational health? What are the things that really work, the to do’s and the not to do’s we improve and upgrade relational health in communities? 

Christina Bethell: Yeah. I mean, obviously you’re the master here and that but the first thing I would say is to be aware of what’s happening and bring to the present what is absent or we tend to like to push away. That’s where the life comes in is to be aware in groups and in communities about sort of the felt sense of the coherence of the relational field. And that can be trained and people know it, definitely do these polls in groups about these things and they know where things are at. And it’s when we tell the truth often, that we get the life force to come up. And then that ends up being like a positive experience, but it’s through the portal of being authentic about what’s challenging. And so the vulnerability is really needed. 

And so of course, all the processing from theory comes into play and many of the community based healing strategies are all about creating that capacity to feel and not miss an opportunity to maintain that coherence. Even if you think you’re going backwards and wasting time, like in a meeting, if you override the fact that people have shut down because something happened or what have you, you’re not actually moving forward. You’re doing something, but you’re not necessarily moving with that group coherent possibility for what might emerge creatively. And so I think those are skills that are really important. 

How do you apply them in a work context or a policy context or in a room with a patient? You know, because we often think these kind of things only happen inside of intimate relationships, but we need really many of the connections that people talk about when we’ve done the research on positive childhood experiences and a sense of belonging and how you got through a hard time and somebody will say, well, you know, I was really down. And then I walked into this 7-Eleven and the clerk looked at me like I existed, and I realized no one had ever really seen me. Or maybe I never really showed myself to anyone because I hadn’t gotten that broken open. And then all of a sudden something happened. Good for them. So I think we all like the bus driver, the delivery person, the grocery clerk, everybody has a superpower. And in our studies, it’s not always what happens in the family, it’s the school and the community and things like that. 

Thomas Hübl: It’s also very empowering because it says it’s not only about professionals, it’s about everybody’s kind of a collective competence that we can acquire that we are all part of, and that’s beautiful. 

So we spoke about patience. Maybe we can speak a little bit about childhood health care and health care in general. I mean, the health care system is a lot of stress. It’s full of stress and toxic stress. People get sick, people get suicidal, people go to drug abuse. And a lot has to do with the systemic stress being exposed to trauma, to difficult life circumstances, to disease all the time. So how would you say we can transform our health care system into a much more resilient and supportive network? ]

Christina Bethell: Yeah, I can speak to that a little bit. So I mentioned the National Academies of Science Committee that is working on a proposal for children and youth in the healthcare system to create well-being in the context of this mental stress and high rates of mental health problems and things like that, and the nickname we have for it is “creating relational systems of care.”

 And so if we think that I, as a provider, a professional, I’m here to help you, with stress and toxic stress and mental health issues. And the only way to help you is to partner with you because it’s co-produced. It’s not like I can just give you something, pin you down and give you a drug and somehow that you’re going to get better. 

All health and well-being is co-produced – so the glue is the relationship and the trusting relationship that you can’t hide from. So who we are as professionals and how we engage makes such a difference.

In the study they’re really clear that when youth or children feel they’re close or cared about, then it opens the door for being able to, first of all, share that something in part and to create that pathway of awareness that there’s something deeper that’s true about us that isn’t just the trauma. That’s where the positive pieces come in to build a sense of meaning and purpose and will to stay engaged and related and reach out for help. And so I think that in health care, creating these what I call personalized connected encounters is what we’re trying to do. And that’s what the AP is trying to do. 

So part of that, though, is not using the visit time to collect data and checkboxes and be disease oriented, but really get that information through using digital health apps, which we create to help safely engage youth in self-reflection, picking what they care about. And then when they’re met in a clinical setting, you’re responding to what they’ve said they are interested in. So the engagement is there, and then you pull the thread of what they’re interested in, no matter what it is. And then I think all roads lead around that eventually that creates the relational trust pathway to then go deeper into what the opportunity might be to meet that youth into a place of their own healing. 

So that attunement of the provider to that process is going to vary a lot because not everybody, but still, I think if you even intend it and you’re on the pathway, it’s like a superpower. It seems to me like parents, teachers, providers – we don’t have to be perfect, but we do have to be intentional. 

Thomas Hübl: Now, two questions coming up. One is about the skill building of health care professionals, because as you said, relating is not just a given, is something that some of us grew up in a way that stays attuned and intact, but for some of us it gets really hurt. So we are less related, even if you’re intentional. So how do we upgrade the skill set and how do we counter a little bit the force in the healthcare system that everything we can make shorter and cheaper is better, right?Because relating needs its time, it needs its resonance. Even if it doesn’t need a lot of time, it needs quality, maybe quality relationships. But still there is something we could say, Oh, why do we if we can collect the data, So let’s make the meeting short. And so how do we counter that movement and say, listen, relationships are one incredibly important element of the healing process? 

Christina Bethell: Well, one thing I can tell you is that it is top of the agenda declared by almost every healthcare body at this point. Now, whether it’s being operationalized or not, I think that’s where we have to really be persistent. But at least stated that this is what needs to happen. 

Basically we have a term called relational health workers. So that every patient, every person, every young person or family has somebody that they can go deeper with. And it may not be the doctor. It may be a family specialist. But that relationship is the key. And so that’s one good thing. 

I know in our work with pediatricians and doing well visits, which are like 15 of them in the first few years of life. And they’re meant to promote relational health. Their top goal is to promote family connections, healthy attachment and dealing with all that. I don’t think we’re going to try to shrink the time, but we can optimize it by not using it to do administrative tasks and then to grow it, and often this is where research comes in badly. Like we have to actually show that when we extend the visit that over time – they don’t all have to be that long. But if you don’t create a base. Or a foundation. Especially in the beginning of trust and connection, which can take time. It’ll take different amounts of time with different people, then we don’t get the benefits. And so that’s part of where the research pieces come in, is to show it badly. I mean, you think not? But it’s showing that when we can really engage patients, when there’s a sense of trust and being heard and all of those things, it goes better. 

So then the question is, how do we build those skills? And I think the biggest challenge is people who think they have those skills because they’re thinking transactionally they’re like, I did the thing I was supposed to do, I checked the boxes, I related. And to really have a lived experience I think is probably the most important thing. If we could replicate what you do in hundreds of millions of places where people have the lived experience of they because it’s natural to feel when I’m actually connected and when I am not. And once you feel the difference through roleplaying, through the triad work that you do, then I think it just sparks something and awakens something because that becomes your bar with your patients or with those you’re caring for. And then you start to realize that you want to go from fixing to connecting. That if you’re not connected, there’s not a lot happening now. I’m not saying if you have a broken leg and it’s an emergency. But even in that context, it’s not like you go offline in your capacity to connect because there’s something urgent in front of you. And we have all these myths. You know that if it’s urgent and really important, I don’t have time for connection. 

Thomas Hübl: Exactly. 

Christina Bethell: You know, connection is that thing that’s a luxury. But we actually have the capacity to bring attunement into all situations in a microscopic way. It’s really that sort of microscopic attunement. That also mirrors what’s happening in our body, right? Like our cells are dividing and combining. And it’s almost like the more intimate we are with our own bodies and processes, then we can start to move with that, which I think brings with them to a place to connect, if that makes any sense. We call it “biobehavioral synchrony.” There’s all these science words, but it’s basically attunement. 

And I do think breaking it down so that it’s really clear. Like I talk about the anatomy of the connection and what it actually feels like in you and the other and how you can see it and how you can hold it, even if it seems like the other isn’t connecting. You know, there’s all these really important scenarios where I think a lot of providers think, “Well, I did what I could, I said the words, and it’s up to them now” instead of staying connected. So we try to get this included in things like ACGME requirements for training. So there’s deep training in medical school, in social work and mental health to really build these relational skills. And some medical goals are really going with that. Some aren’t, but it’s moving its way up into the accrediting organization, the training organization, and then also into performance measurement. 

I know that sounds crazy, but how do you measure whether there was a sense of safety, trust and connection? So that’s part of what this national report’s going to do, is talk about what are the measures, what are the training? What do we need to do with how we finance so that we don’t put doctors in a position to have to just do more and more patients fast so they actually can spend more time with one person and less with another, but still get paid. You know, we don’t put the financial incentives in a place where there’s all this moral injury because I can’t be with you because I feel like I’m on a hamster wheel. We have to fix the system. 

Thomas Hübl: Exactly. That’s also one of the parts of my question is how do we create that financial base that can really flourish and that we don’t need to be in this hamster wheel, that we can actually take the time, if it’s needed, will be different from patient to patient. 

Christina Bethell: The more we base that on outcomes and experience and not on the time spent, but the good thing that happens and so outcomes based measurement is a key thing because, you know, I used to always say if you can get somebody healthy by having them stand on their head, good for you. It may be different, but you know, when we get away from the mechanistic measurements and into outcomes that can free people out so the financing has been a big part of my career, it’s what we call “free your brilliance.” So that the incentives are aligned with our capacity to be co-creative and do what’s needed for each person rather than, you know, the hamster wheel. 

Thomas Hübl: Two things I want to pick up on. One is that you said when it’s urgent, there’s no time for it. And that especially when it’s urgent, I saw this when I worked as a paramedic many years ago. Especially when people are in this deep shock and when people are in this kind of life threatening phase, like somebody being there, even if it’s just a few minutes and being attuned while people get treatment, I think is a very important skill to have. And that especially if you work with emergencies, to be there and be present with the person really helps and I’m sure you’ve got data that it decreases the PTSD afterwards.

Christina Bethell: It does. Actually, The Harvard Mastery of Stress study started in 1951, and they looked at some freshmen. And they did it in a 35-year follow-up that happened. They asked them about their experiences of being cared about by their family and others. And then they randomized them and they basically followed up. Those that did not report feeling that, having those experiences, which often happened in the middle of stress, it’s like that positivity paradox that the most positive experience is how I was met when I was in a crisis. That is what lodges also in babies’ attachment, when I have a stumble, and then you’re there for me after, like, the attachment molecules go great there. So it’s in the falling down that we learn to walk, right? And so basically, they found that 87% that didn’t have those embodied memories of care, which we know is especially when things are hard – 87% had pretty serious health problems 35 years later, but 25% for those that had both parents and felt like they were supported and cared about. 

Just from 1951 to 1986 and the study reported in the early 90s, but it’s well-regarded and there’s other studies like that too that we think as a human and the “inter-relational pharmacy” not the pharmacy pharmacy, that it’s not important. I think that people don’t realize how important they are in that way. So anyway, I wanted to make sure I share that with you. But can you go further because I want to follow your questions. 

Thomas Hübl: No, this was perfect because it also shows people can look this up and can see the studies. So I think the data is as important. 

And then I want to say, that has a big impact on how people heal, how people deal with the trauma later. I was going to ask you also about how we can train because we all know that when one is hurt, traumatized. It’s very hard for one to be related. Let’s say trauma is not so much less in the health care system. So when we say how do we create training programs on a larger scale, maybe there is already a lot happening. So how do healthcare professionals or people that work in mental health resources, social workers can train those skills so that we create a resilient network? And maybe in pediatrics, how can we create a physician, child parent, or healthcare workers, child parent network so that those relational ecosystems start to become the help? You know, health is an ecosystem we could fix. So you can speak a little bit to that. 

Christina Bethell: Yeah. I mean, so if you’re going to be a surgeon, you’re supervised by all these other surgeons and they give you feedback and they watch you do the surgery and all these things, we need something similar for creating that container of care and attunement. That, of course, can mean fostering it in the people who are training. Of course, the organizations and I’m in an organization, a big university, I mean, I think we talk about it, but is it built into the structures and how things are done and the time that’s given? So I think we really do have to get it growing, getting to a point where we really have you know, there’s a sea of continuing medical education requirements and that when we started making pain management a required training like you couldn’t get your recertification or licensing renewed unless you did at least a certain amount of hours around pain management. 

And of course, mindfulness started getting in on pain management and it created a whole opportunity for bringing some of these things in because pain is actually very affected by mindfulness practice and yoga and also healthy relationships. So I think we need to keep getting it in as a required training. 

And sometimes – I think most of the time, and it certainly was true with me, even though since I was a child, I was attuned to the inner connection and all these things. There was some part of me that didn’t really attune as much to the relational part because it wasn’t really obvious to me that there was another that could actually be a part of my attunement, because it was kind of me and me at the moment for a while in my childhood. It’s like an awareness that happens in your body through practice and then all of a sudden you feel it differently. I think we do need that deep dive. So having it be part of the environment of the training program with deep dive opportunities that really takes the time for a person to in mindfulness practice seven days straight at the beginning, just do it deeply and then we learn it. So I do think that’s where we’re headed and it’s more and more. 

But one of the questions I’ve always had with you is how do we scale so that we don’t just pass it off as learning how to have difficult conversations because there’s still from the head and they’re transactional. You know, but that’s building that in, again, the training expectations, performance measures with opportunities is really what came. 

Thomas Hübl: I think nowadays at least I have great experiences with those online spaces. We’re very attuned and can train a lot of attunement skills online, even if at first people might need to kind of open their minds to that. But I think there’s a lot that can be done in order to scale the training that not everybody needs to be in-person. You know, there’s a good mix. But I think there is a great opportunity also in the reach of online medium. And so okay, So that’s it for the health care system. 

I’m sure you have a lot of data about how different communities are more traumatized so that that relational fabric might be more hurt and there may be more side effects. So how do we bring this into communities that really need it? And maybe also the financial means is not so high. So how can we, all of us, be part of taking responsibility for bringing it to the places that really need it and how can we support it?

Christina Bethell: Yeah, well, this is really where my heart is. I just got done doing a lot of work with Mississippi, which was the high need, low income state in the country with the highest rates of all problems you can imagine. And Congress dedicated $17 and a half million for them to create a framework that could be scaled nationally as a model to really address what you’re talking about. And so I help facilitate the creation of what we call the “Engagement and Action framework,” which is a hologram of we’re trying to create healthy engagement and relation with children and their parents, which relies on the parents and their community and the community and the larger structures and the policies that flow down and impact that and the disparities in resources between some communities and another. And then the rates of school readiness or school engagement or high school graduation or crime or just really mirrored right up the way. So basically, the frameworks that are being used to transform systems across sectors between healthcare, school, social work, businesses, juvenile justice and all of that are framed in terms of creating connections among them where they start to model and move out of their affairs. 

So that’s where we started, is how can I get these agency people to realize that if they empower this one, that doesn’t mean they’re getting something taken away and then stay the course with the importance of creating the relational basis, which you can see there’s a lot of variation in how communities do with similar levels of diversity based on a lot of factors that don’t require legislative change. 

However, we need policies like there wasn’t postpartum depression coverage in Mississippi. Well, there is now. And that was a big deal to get that passed. That was a lot of advocacy and data bringing and really educating legislators. And so to optimize capacities without having to change all the uber structures and policies is possible while we work on those structures and policies. That’s where I think we have the biggest challenge. But I have a theory that we want to deal with poverty and racism and all these things that can do it the right way to change the structures we do need policy change. 

And yet the people in a position to do policy change are already advantaged in a way privileged. And so I feel like it’s really important to work with building the awareness and capacity for attunement and care in those populations and starting from early childhood so that we can become the people that, as an instinct, want to care for one another which I think is what the studies that have been done on putting kids on an island and they don’t try to kill each other, they end up wanting to support and love each other. And that I think we are built for that. 

So it’s very hard. I have to say I’m going to Arkansas tomorrow and Tennessee and a lot of these southern states that have policies that can kind of make you gasp, but they’re real places and there’s a lot they can do without policy change that really builds on the relationships they have and then creating strong advocacy that combines data with advocacy to really push the policy changes. 

I can share a lot more with you about the framework, but it’s very intricate. What are the roles and responsibilities of all the sectors, but the simple rules if you’re aware of complex systems change are based on simple rules, like you can’t actually follow somebody around and tell them what to do every minute. They have to have an internalized sense of how we do things around here. 

In this framework, one of the simple rules is that everyone owns their power as a leader. No matter where you are, everyone has power within and between themselves and each other to heal, to support, to be a healing presence with every child and family they come in contact with. And through any door, it doesn’t matter where you are like we talked about, it can really be early education, healthcare or, you know, in a community center. 

Through every door and that we make sure that when we’re working with people, there’s no broken link. So we don’t just let people leave our present without bridging to another, which means we’re related to that other group. And then, finally, to get feedback loops. So we do mindfulness and we reflect, we get feedback. And so having a practice of: How it’s going? How is it going? And so that’s where some of the data and reflective processes come in. 

So there’s these simple rules that can help organize everybody from different parts of the community around what we’re up to. And then it can be churches that are leading or it can be the school that’s leading and everyone is a part of it. I know this sounds vague because it’s hard to talk about this in detail in a short call, but the idea that there’s a framework for systems change statewide that’s being scaled nationally called “Engagement in Action,” that is what’s centered is the engagement which is defined relationally. And in many of the ways that you talk about it.

Thomas Hübl: To me it doesn’t sound vague at all. I know it’s much more complex than what you can share in such a short time, but it gives us a bit of a feeling. I also like that everybody’s a leader. It is empowerment. Everybody’s being invited into relational work, so this all sounds very concrete to me, not vague at all and very healthy. I think when I listen to you, I get a feeling of this sounds good and it feels, yeah, but it feels organic and right. 

Christina Bethell: It’s really exciting because, you know, our health systems in America are held accountable based on something called the high-reliability organization (HRO) model, the Joint Commission. And if you’re going to open the door for a clinic or a lab or anything, you have to be accredited. So they use the high reliability organization’s model, which is really the study of how systems optimize performance. And the core skill is what’s called collective mindfulness. That’s it. 

And so how do we collectively become situationally aware of what’s happening? How do we basically be more curious and afraid than to get feedback, to be aware in a moment by moment way, about how things are going? So the different expertise is one of them, and I think that’s one of the most important things, if we respect each other. 

In surgery centers, sometimes it’s literally the person cleaning the floors that notices the problems that if they didn’t find them, would lead to a problem in the surgery. And so just to really create these a lot more in place, if you will, but we need to back it up with training and financial alignment and in many ways activating people like the public, patients, family to be aware of their own power and possibilities. 

Because I think that when we look at our data, which took decades as you know, to create these measures and get them into surveys in a population way so we can even study it, but we ask about family resilience and whether families are feeling hopeful, whether they feel they have any story to draw on, whether they turn to each other when they’re having problems, to work out their problems, or do they isolate and whether they reach out to others. And less than half of children in the country right now live in homes where families report those things. And this is on a survey where it’s a positive report, like they’re going to say it’s true. The positivity bias is less than half, probably worse than that. 

And so what we also then know is if those families are working with professionals that really listen to them, and they feel they can trust – their resilience, the family resilience, sense of hope, strength, possibility to get help goes up, which is a straight shot to the resilience of the child and the sense of the child feeling safe, which is a straight shot to school readiness and school engagement and relational health when they’re an adult, which is what the whole trajectory of our research has shown is it lasts all the way through life whereas an adult you are more likely to have social emotional connection, way less depression. If, as a child you have these positive experiences that are relational, that depend on the family, that also depends on how they’re met by the professionals in the community with that family. 

Thomas Hübl: That’s amazing. That’s amazing. 

Christina Bethell: Yeah and that’s the line where we’re drawing. So I think it’s been drawn to. Then my question is, okay, what do we do now? Continuing to translate it into concrete things that for me, an interest is really going deep with what you’re talking about, which is how do we really operationalize the training?

Thomas Hübl: Exactly. And I have one more question that relates to the training, because as we both know, when I look at the systemic trauma in an organization, society, wherever – it’s inverse, the information. So it’s kind of it’s the unconsciousness, the non rising of data, information of perception. So every system because you said before collective mindfulness, which I think is very powerful and essential and at the same time, how do we support systems to become aware of what the system doesn’t see? Because every system has its own unconscious dimension that it can perceive. And I’m wondering how we systemically work on individual and collective opening so that the collective dimension of shared unconscious spaces can grow. Any thoughts you have about this? 

Christina Bethell: We have a lot of models on quality improvement. And the core of it is to drive out fear. You can’t improve if you’re too afraid. That if you notice something that might not be working, you’re going to get in trouble. So one thing is to create a culture of curiosity and where we all know we have strengths and weaknesses and it’s okay to talk about what’s not working without being threatened for a job, which I think is still a huge issue. Often when people have problems, there’s a systemic factor, right? So if I’m struggling, there’s a larger university structure I’m in and societal structure I’m in that may be impacting that. 

So the first to drive out fear and to just always assume that we need each other in these reflections and ways of purposeful reflection and measurement to give feedback. So in some of our work, it seems really simple. But we were working on maternal depression screening and the importance of that, and it wasn’t happening at all. When we started our work, we interviewed lots of doctors and we couldn’t get acceptance to do this as a routine thing because doctors thought, well, I know when a mom is depressed, so I only screen the people that I’m pretty sure are. So we did a study and we looked independently at maternal depression rates. And then we looked at whether they were screened or not, and it was a 50/50 chance that the providers felt who they needed to screen. And when they saw that data, it was actually working in Kaiser Permanente at the time. They just changed overnight. They were like, Oh my God, I am blind. I thought I could see and this data showed me that it was like flipping a coin whether I was right. And so this is the interplay of the culture, creating a safety and almost like an excited curiosity, what I call take on transparency, to be more curious and afraid to get feedback. And then there’s always someone who’s doing better than me and somebody who’s doing worse, and I can teach them and they can teach me. And so creating a culture of continuous presencing of what happens, knowing that it’s there, I think is really key. 

But it is actually already built into the good models of quality improvement, but the system has to match it. So the payments and if something doesn’t go right and then it’s tended to, it can’t always be a process of being reprimanded but supported. And I think that’s often what’s missing across the board. But it is really happening in a lot of places. I just don’t think it’s fast enough. But that’s my issue in life. I have to let go of the speed at which things happen. You know what I mean? And how it works. But I think there’s a need to drive out fear, make it a safe place to make things present that are absent and measurement really does help. 

Thomas Hübl: Yeah, that sounds great. Like how you describe how the data showed that we need to do something new. 

Christina Bethell: We have a tool that’s an online tool you can just send to your patients every now and then where they give you feedback, but it’s blinded. And then after 25 completed, you get the aggregate report as a provider. And so you get to stay in touch with your own patients and they love it. They’re like, Oh, okay, I got that look at that. Actually it went better than I thought. This is something. And then there’s a whole motivation when you know it’s your patients. It’s not some like inanimate administrative data record, but you’re actually giving communities, patients and families a chance to share with you. And it turns out that that’s very energizing for providers to get information from their families. So we make it really easy for them to do that and safe because they control it and it’s still confidential. Those are just example strategies we can use.

 Thomas Hübl: Yeah, that sounds amazing. Also to improve the systemic intelligence flows. 

Christina Bethell: Exactly. I mean, it’s like your app, you know, I mean, we need these kinds of things to create a sense of group knowledge. 

Thomas Hübl: So Christina every time we talk time flies by, but it’s amazing. I was so much with you, and it’s so interesting, I resonate with so many things you’re saying, and I think we are so much on the wavelength here. Maybe just to finish, is there anything that you would like our listeners to take away from this, any kind of summary or things that you think are important?

Christina Bethell: I think one thing is that there’s a lot of good happening, but we really need people to be activated. I feel like some people are kind of dropping out of the structures of our society because they seem just too much. But we make a difference and getting activated and making truth, it makes a difference, especially if we can combine it with science and data that combines integration. It really does help and change the world. And to be helpful because there’s pockets of possibility like your pocket project everywhere, and to just work to be that in whatever way and then inspire everyone else. 

Because I think we just really have to be at the watch of, the level of hopelessness that can otherwise arise when we start to see the trauma bubble up to the top like it is right now. But most of your listeners already know that. 

Thomas Hübl: And still it’s good to hear it over and over.. People get your enthusiasm and your motivation.

Christina Bethell: And to support each other because I have to tell you, it’s very hard out there and I can’t lift the people that I’m working with directly without that support. So we really need each other.

Thomas Hübl: That’s why I love it that you’re here. And I feel we are working together somehow. It’s lovely. So thank you very much, Christina. I think this is a very rich one. Maybe we can do part two soon, it would be lovely. 

Christina Bethell: Another update.

Thomas Hübl: Another update, yeah. Thank you and bless your work. 

I love that you’re doing this, it supports very much what we all do. 

Christina Bethell: Thank you! You support me in every way.

Thomas Hübl: Thank you.