Self-Care Margaret Samuels, LCSW Center for Child and Family Health Duke University Department of Psychiatry 5 th Annual Nebraska Behavioral Health Conference.

Self-CareSelf-Care

Margaret Samuels, LCSWMargaret Samuels, LCSWCenter for Child and Family Center for Child and Family

HealthHealth

Duke University Department of Duke University Department of PsychiatryPsychiatry

5th Annual Nebraska Behavioral Health Conference.

Self-Care for the CaregiverSelf-Care for the Caregiver Multiple Role of the Staff:Multiple Role of the Staff: Compassion fatigueCompassion fatigue Effects of working with victims Effects of working with victims

exposed to traumatic events, violence, exposed to traumatic events, violence, disasters, war, humanitarian crisis, disasters, war, humanitarian crisis, loss of loved ones, communityloss of loved ones, community

Secondary traumatic stress; Vicarious Secondary traumatic stress; Vicarious trauma; Indirect trauma trauma; Indirect trauma

Stress Management and RelaxationStress Management and Relaxation SAFETY!!!!!!!!!!!!!SAFETY!!!!!!!!!!!!!

ChallengesChallenges

Emotional drain from empathizing Emotional drain from empathizing Difficult client population Difficult client population Long hours with few resources Long hours with few resources Ambiguous success Ambiguous success Unreciprocated giving and Unreciprocated giving and

attentiveness attentiveness Failure to live up to one's own Failure to live up to one's own

expectations expectations Professional isolationProfessional isolation

Compassion StressCompassion Stress Compassion stress is seen as a Compassion stress is seen as a

naturalnatural outcome of knowing about outcome of knowing about trauma experienced by a client, trauma experienced by a client, friend, or family member, rather than friend, or family member, rather than a pathological process. It can be of a pathological process. It can be of sudden onset, and the symptoms sudden onset, and the symptoms include:include:

Helplessness Helplessness Confusion Confusion Isolation Isolation

Compassion FatigueCompassion Fatigue

Considered a more severe example Considered a more severe example of cumulative compassion stress. It of cumulative compassion stress. It is a defined as "a state of exhaustion is a defined as "a state of exhaustion and dysfunction, biologically, and dysfunction, biologically, physiologically, and emotionally, as a physiologically, and emotionally, as a result of prolonged exposure to result of prolonged exposure to compassion stresscompassion stress

Posttraumatic Stress Posttraumatic Stress Disorder (PTSD)Disorder (PTSD) Re-experiencingRe-experiencing

Awake/AsleepAwake/Asleep Biopsychological Distress Biopsychological Distress Secondary RemindersSecondary Reminders

Avoidance/NumbingAvoidance/Numbing Emotional NumbingEmotional Numbing Social DetachmentSocial Detachment Memory LossMemory Loss

HyperarousalHyperarousal AnxietyAnxiety IrritabilityIrritability InsomniaInsomnia Poor ConcentrationPoor Concentration HypervigilanceHypervigilance

Vicarious TraumaVicarious Trauma

Vicarious Trauma: Normal Vicarious Trauma: Normal cognitive or emotional changes cognitive or emotional changes when working with trauma when working with trauma survivorssurvivors

o Becoming judgmental of others Becoming judgmental of others o Having a reduced sense of connection Having a reduced sense of connection

with loved ones and colleagues with loved ones and colleagues o Becoming cynical or angry and losing Becoming cynical or angry and losing

hope or a sense of meaning hope or a sense of meaning o Rescue fantasies, becoming over involvedRescue fantasies, becoming over involvedo Heightened protectiveness/decreased Heightened protectiveness/decreased

sense of the safety of loved ones sense of the safety of loved ones o Avoiding work and social contactAvoiding work and social contact

Secondary Traumatic StressSecondary Traumatic Stress

Secondary trauma: Symptoms of Secondary trauma: Symptoms of PTSD that mirror those PTSD that mirror those experienced by clientsexperienced by clientso Hyper-arousal (heightened reactivity -- Hyper-arousal (heightened reactivity --

startle, heart rate, pulse) startle, heart rate, pulse) o Intrusive symptoms Intrusive symptoms o Avoidance or emotional "numbing" Avoidance or emotional "numbing" o Anxiety Anxiety o DepressionDepression

Who and When is at greatest Who and When is at greatest risk?risk?

Exposure to life threatening danger Exposure to life threatening danger or physical harm (especially to or physical harm (especially to children) children)

Exposure to gruesome death, bodily Exposure to gruesome death, bodily injury, or dead or maimed bodies injury, or dead or maimed bodies

Extreme environmental or human Extreme environmental or human violence or destruction violence or destruction

Loss of home, valued possessions, Loss of home, valued possessions, neighborhood, or community neighborhood, or community

Loss of communication with or Loss of communication with or support from close relations support from close relations

Who and When is at Who and When is at Greatest Risk?Greatest Risk?

Intense emotional demands (such as Intense emotional demands (such as searching for possibly dying survivors or searching for possibly dying survivors or interacting with bereaved family members) interacting with bereaved family members)

Extreme fatigue, weather exposure, hunger, Extreme fatigue, weather exposure, hunger, or sleep deprivation or sleep deprivation

Extended exposure to danger, loss, Extended exposure to danger, loss, emotional/physical strain emotional/physical strain

Exposure to toxic contamination (such as gas Exposure to toxic contamination (such as gas or fumes, chemicals, radioactivity) or fumes, chemicals, radioactivity)

Exposure to other traumas Exposure to other traumas Chronic medical illnessChronic medical illness

Where do we want to be?Where do we want to be? Relationship with meaning and Relationship with meaning and

hope hope Ability to get one's Ability to get one's

psychological needs met psychological needs met Intelligence Intelligence Willpower Willpower Sense of humor Sense of humor Ability to protect oneself Ability to protect oneself Memory/Imagery Memory/Imagery

What is important?What is important? Existential sense of connection to others Existential sense of connection to others Self-capacities, including: Self-capacities, including: The enduring ability to maintain a steady The enduring ability to maintain a steady

sense of selfsense of self Tolerance for a range of emotional Tolerance for a range of emotional

reactions in one's self and othersreactions in one's self and others A sense of inner connection to othersA sense of inner connection to others A sense of self as viable, worth loving, A sense of self as viable, worth loving,

deservingdeserving A sense of self that is groundedA sense of self that is grounded

Managing Providers in DisastersManaging Providers in Disasters Mandated rotation:Mandated rotation:Move providers from the most highly exposed Move providers from the most highly exposed

assignments to varied levels of exposureassignments to varied levels of exposure Enforced Support:Enforced Support:

SupervisionSupervision Case conferencesCase conferences Appreciating staff contributionsAppreciating staff contributions Peer partners and peer consultationPeer partners and peer consultation

Monitor providers who meet certain high risk Monitor providers who meet certain high risk criteria (use of standardized measures)criteria (use of standardized measures)

Conduct trainings on stress management Conduct trainings on stress management practices practices

Personal PreparationPersonal Preparation Limit daily numbers of most severe cases Limit daily numbers of most severe cases Utilize buddy system to share distressing Utilize buddy system to share distressing

emotional responses emotional responses Use benefit time—vacations, personal Use benefit time—vacations, personal

time time Access supervision routinely Access supervision routinely Practice stress management exercises Practice stress management exercises

during relief work shiftsduring relief work shifts Stay aware of limitations and needs Stay aware of limitations and needs

BeforeBefore Personal preparation Personal preparation Stress and strain monitoring Stress and strain monitoring Relaxation, recreation, intimacy Relaxation, recreation, intimacy Managing personal resources Managing personal resources Planning for family/home safety Planning for family/home safety Team and organizational preparation Team and organizational preparation Using standardized measures to assess stress levelsUsing standardized measures to assess stress levels Defining roles and rehearsing team interventions Defining roles and rehearsing team interventions Insuring a coordinated organizational plan for disaster Insuring a coordinated organizational plan for disaster

response response Educate coworkers and management Educate coworkers and management Bring items necessary to survive in disaster areaBring items necessary to survive in disaster area Bring materials to use when not doing relief work (Ipod; Bring materials to use when not doing relief work (Ipod;

Books: portable DVD/CD players, magazines, etc.)Books: portable DVD/CD players, magazines, etc.)

DuringDuring

Make every effort to:Make every effort to: Self-monitor and pace your effortsSelf-monitor and pace your efforts Maintain your boundariesMaintain your boundaries Regularly check-ins with colleagues, family, Regularly check-ins with colleagues, family,

and friendsand friends Work with partners or in teamsWork with partners or in teams Take brief relaxation/stress management Take brief relaxation/stress management

breaksbreaks Use regular peer consultation and supervision Use regular peer consultation and supervision Take time-out for basic bodily care and Take time-out for basic bodily care and

refreshment refreshment Accept that you cannot change everythingAccept that you cannot change everything Try to be flexible, patient, and tolerantTry to be flexible, patient, and tolerant

DuringDuring Make every effort to avoid engaging in:Make every effort to avoid engaging in:

Working too long by yourself without checking inWorking too long by yourself without checking in Working “round the clock” with few breaksWorking “round the clock” with few breaks Feeling like you are not doing enoughFeeling like you are not doing enough Excessive intake of sweets and caffeineExcessive intake of sweets and caffeine

Common obstacles to self-care:Common obstacles to self-care: ““It would be selfish to take time to rest.”It would be selfish to take time to rest.” ““Others are working around the clock, so should I.”Others are working around the clock, so should I.” ““The needs of survivors are more important than the The needs of survivors are more important than the

needs of helpers.”needs of helpers.” ““I can contribute the most by working all the time.”I can contribute the most by working all the time.” ““Only I can get the job done.”Only I can get the job done.”

AfterAfter Expect a readjustment period upon returning Expect a readjustment period upon returning

homehome Schedule time for a vacation or gradual Schedule time for a vacation or gradual

reintegration into your normal life reintegration into your normal life Make personal reintegration a priority for a whileMake personal reintegration a priority for a while Make every effort to engage in rejuvenation Make every effort to engage in rejuvenation

activitiesactivities Find things that you enjoy or make you laughFind things that you enjoy or make you laugh Discuss situation with coworkers and Discuss situation with coworkers and

management management Participate in formal help if extreme stress Participate in formal help if extreme stress

persists persists Ask help in parenting, if you feel irritable or have Ask help in parenting, if you feel irritable or have

difficulties adjusting difficulties adjusting

AfterAfter Prepare for worldview changes that may Prepare for worldview changes that may

not be mirrored by others in your lifenot be mirrored by others in your life Increase experiences that have spiritual or Increase experiences that have spiritual or

philosophical meaning to youphilosophical meaning to you Shift Frame from Helper Shift Frame from Helper

Practice receiving from othersPractice receiving from others Try at times not to be in charge or the “expert”Try at times not to be in charge or the “expert” Let go what you can’t controlLet go what you can’t control Know the world won’t fall apart without youKnow the world won’t fall apart without you

Make meaning of the workMake meaning of the work

AfterAfter Make every effort to avoidMake every effort to avoid::

Excessive use of substancesExcessive use of substances Making any big life changes immediately Making any big life changes immediately

after returning from relief workafter returning from relief work Negatively assessing your contribution to Negatively assessing your contribution to

relief workrelief work Worrying about readjustingWorrying about readjusting Obstacles to better self-care:Obstacles to better self-care:

o Keeping too busyKeeping too busyo Making helping other more importantMaking helping other more importanto Sharing constantly about experiences and telling Sharing constantly about experiences and telling

graphic “war stories” with those not familiar with relief graphic “war stories” with those not familiar with relief workwork

Managing Stress:Managing Stress: Connection with coworkers Connection with coworkers Take a breaks Take a breaks Defuse briefly whenever you experience Defuse briefly whenever you experience

troubling incidents and after each work troubling incidents and after each work shift. shift.

Talk about events as they ariseTalk about events as they arise Don't take anger too personally - it's often Don't take anger too personally - it's often

an expression of frustration, guilt, or worry. an expression of frustration, guilt, or worry. Mood swings will diminish with time. Mood swings will diminish with time. Don't overwhelm children or your families Don't overwhelm children or your families

with your experiences with your experiences Other forms of expression such as journal Other forms of expression such as journal

writing, hobbies, and exercise are writing, hobbies, and exercise are recommended.recommended.

Compassion SatisfactionCompassion SatisfactionWork that brings meaning into your life, increased sense Work that brings meaning into your life, increased sense

of purpose and strength, and heightened their sense of purpose and strength, and heightened their sense of connection with others. Often these individuals took of connection with others. Often these individuals took breaks, sought assistance or mentoring, or increased breaks, sought assistance or mentoring, or increased self-care when they began to see signs of negative self-care when they began to see signs of negative effects. These professionals were able to resume their effects. These professionals were able to resume their work and/or feel decreased stress and an overall work and/or feel decreased stress and an overall gratitude for this work with time. gratitude for this work with time.

Sense of strength Sense of strength Self-knowledge Self-knowledge Confidence Confidence Sense of meaning Sense of meaning Spiritual connection Spiritual connection Respect for human resiliencyRespect for human resiliency

ReferencesReferences Dunning, C. 1990. Mental health sequelae in disaster workers: Prevention and Dunning, C. 1990. Mental health sequelae in disaster workers: Prevention and

intervention. intervention. International Journal of Mental HealthInternational Journal of Mental Health, 19, 91-103., 19, 91-103. Hass, A. 1995. Survivor guilt in Holocaust survivors and their children. In J. Lemberger Hass, A. 1995. Survivor guilt in Holocaust survivors and their children. In J. Lemberger

(Ed.). (Ed.). A global perspective on working with Holocaust survivors and the 2nd generation.A global perspective on working with Holocaust survivors and the 2nd generation. (pp. 163-183).(pp. 163-183).

Keough, ME, Samuels, M., Keough, ME, Samuels, M., The Kosovo Family Support Project: Offering Psychosocial The Kosovo Family Support Project: Offering Psychosocial Support for Families with Missing PersonsSupport for Families with Missing Persons Volume 49, Number 4 587-594. Volume 49, Number 4 587-594.

Keough. ME, Kahn, S., 2000. Keough. ME, Kahn, S., 2000. Physicians for Human Rights Ante Mortem Database Physicians for Human Rights Ante Mortem Database Protocol Manual. Protocol Manual. . December 1997; revised April 2000.. December 1997; revised April 2000.

Keough, ME, Simmons, T., Samuels, M. 2004. Missing Persons in post-conflict settings: Keough, ME, Simmons, T., Samuels, M. 2004. Missing Persons in post-conflict settings: best practices for integrating psychosocial and scientific approaches. best practices for integrating psychosocial and scientific approaches. The Journal of the The Journal of the Royal Society for the Promotion of HealthRoyal Society for the Promotion of Health. 124(6): 271-275.. 124(6): 271-275.

Herman, J. 1992. Herman, J. 1992. Trauma and RecoveryTrauma and Recovery: : The Aftermath of Violence-from Domestic Abuse The Aftermath of Violence-from Domestic Abuse to Political Terrorto Political Terror. NY, NY Basic Books.. NY, NY Basic Books.

National Center for PTSD. 2001 ENational Center for PTSD. 2001 Effects of Traumatic Stress in a Disaster Situationffects of Traumatic Stress in a Disaster Situation. A . A National Center for PTSD Fact Sheet. National Center for PTSD Fact Sheet.

Physicians for Human Rights, 1999. Physicians for Human Rights, 1999. War Crimes in Kosovo, A Population based War Crimes in Kosovo, A Population based assessment of Human Rights Violations against Kosovo Albaniansassessment of Human Rights Violations against Kosovo Albanians, Boston; A report by , Boston; A report by Physicians for Human Rights in conjunction with Program on Forced Migration and Physicians for Human Rights in conjunction with Program on Forced Migration and Health, Center for Population and Family Health, The Joseph L. mailman School of Health, Center for Population and Family Health, The Joseph L. mailman School of Public Health, Columbia UniversityPublic Health, Columbia University

Roberts, A., ‘Crisis Intervention Handbook, Oxford University Press, 2005Roberts, A., ‘Crisis Intervention Handbook, Oxford University Press, 2005 Dziegielewski, S., Sumner, K., “An Examination of the U.S. Response to Bioterrorism: Dziegielewski, S., Sumner, K., “An Examination of the U.S. Response to Bioterrorism:

Handling the threat and Aftermath Through Crisis Intervention” pgs 262-278Handling the threat and Aftermath Through Crisis Intervention” pgs 262-278 Kaul, R., Welzant, V., “Disaster Mental Health: A Discussion of Best Practices as applied Kaul, R., Welzant, V., “Disaster Mental Health: A Discussion of Best Practices as applied

after the Pentagon Attack” pgs 200-220 after the Pentagon Attack” pgs 200-220 Regehr, C., “Crisis support for families of emergency responders” pgs 246-261Regehr, C., “Crisis support for families of emergency responders” pgs 246-261 Stover, E. and Shigekane, R. 2002. The missing in the aftermath of war: when do the Stover, E. and Shigekane, R. 2002. The missing in the aftermath of war: when do the

needs of victims’ families and international war crimes tribunals clash? needs of victims’ families and international war crimes tribunals clash? International International Review of the Red Cross.Review of the Red Cross. 848: 845-865. 848: 845-865.

Stover, E., Haglund, WD. Samuels, M., 2003, Exhumation of Mass Graves in Iraq: Stover, E., Haglund, WD. Samuels, M., 2003, Exhumation of Mass Graves in Iraq: Consideration for Forensic Investigations, Humanitarian Needs and the Demands of Consideration for Forensic Investigations, Humanitarian Needs and the Demands of Justice. Justice. JAMA JAMA 8/6/03 290(5) 663-666.8/6/03 290(5) 663-666.

UN Press Briefing by War Crimes Tribunal Prosecutors, 11/10/99UN Press Briefing by War Crimes Tribunal Prosecutors, 11/10/99

References:References: National Center for PTSD websiteNational Center for PTSD website Somnier, F. and Genefke, I. K. (1986). Psychotherapy for victims of Somnier, F. and Genefke, I. K. (1986). Psychotherapy for victims of

torture. torture. British Journal of Psychiatry.British Journal of Psychiatry. 149149, 323-329., 323-329. Ochberg, F. M. (Ed.). (1988). Ochberg, F. M. (Ed.). (1988). Posttraumatic therapy and victims of Posttraumatic therapy and victims of

violence.violence. New York, Brunner/Mazel. New York, Brunner/Mazel. Van der Kolk, B. (1989). Trauma spectrum disorders: Treatment and Van der Kolk, B. (1989). Trauma spectrum disorders: Treatment and

research. Paper presented at the Center For Victims of Torture. Third research. Paper presented at the Center For Victims of Torture. Third Annual Conference. Minneapolis.Annual Conference. Minneapolis. Basoglu, M. (1993). Behavioral and cognitive approach in the treatment Basoglu, M. (1993). Behavioral and cognitive approach in the treatment of torture-related psychological problems. In Basoglu, M. (Ed.). of torture-related psychological problems. In Basoglu, M. (Ed.). Torture Torture and its consequences: Current treatment approaches. and its consequences: Current treatment approaches. Cambridge, Cambridge, Cambridge University Press, 402-424.Cambridge University Press, 402-424.

Langer, L. (1991). Langer, L. (1991). Holocaust testimonies: The ruins of memory.Holocaust testimonies: The ruins of memory. New New Haven and London, Yale University Press. p21.Haven and London, Yale University Press. p21.

Dowdall, T. Torture and the helping professions in South Africa. (1991). In Dowdall, T. Torture and the helping professions in South Africa. (1991). In Basoglu, M. (Ed.). Basoglu, M. (Ed.). Torture and its consequences: Current treatment Torture and its consequences: Current treatment approaches.approaches. Cambridge, Cambridge University Press, 452-471. Cambridge, Cambridge University Press, 452-471.

Kozaric-Kovacic, D., Folnegovic-Smalc, V., and Skrinjaric, J. (1993). Kozaric-Kovacic, D., Folnegovic-Smalc, V., and Skrinjaric, J. (1993). Systematic raping of women in Coratia and Bosnia and Herzegovina: a Systematic raping of women in Coratia and Bosnia and Herzegovina: a preliminary psychiatric report. preliminary psychiatric report. Croatian Medical Journal, Croatian Medical Journal, 43, 1, 86-88.43, 1, 86-88.

Chester, B. (1990). Because mercy has a human heart: centers for victims Chester, B. (1990). Because mercy has a human heart: centers for victims of torture. In Suedfeld, P. (Ed.). of torture. In Suedfeld, P. (Ed.). Psychology and torture. Psychology and torture. New York, New York, Hemisphere Publishing Corporation, 165- 184.Hemisphere Publishing Corporation, 165- 184.

Teter, H., and Arcellana, N. Teter, H., and Arcellana, N. Where There Is No Therapist: A Mental Where There Is No Therapist: A Mental Health Manual For Oppressed Communities. Health Manual For Oppressed Communities. Coalition to Aid Refugee Coalition to Aid Refugee Survivors of Torture and War Trauma. San Francisco (in process).Survivors of Torture and War Trauma. San Francisco (in process).

Lira, E., Becker, D., and Castillo, M.I. (1988). Psychotherapy with victims Lira, E., Becker, D., and Castillo, M.I. (1988). Psychotherapy with victims of political repression in Chile: A therapeutic and political challenge. of political repression in Chile: A therapeutic and political challenge. Paper presented at the meeting of the Latin American Institute of Mental Paper presented at the meeting of the Latin American Institute of Mental Health and Human Rights. Santiago, Chile Health and Human Rights. Santiago, Chile