The Bowles Chapel Lecture for 2014

Advancing Healing After Community Violence: Victims, Families, and Health

Professionals

Charles R. Figley

Bowles Chapel Lectures 2014 8:00 – Noon,

Memorial-Hermann Medical System, Houston

Need v  Advancing healing after community violence –

in our medical patients, their families, and the professionals who care for them.

v  Let us be part of a movement to be focus more attention on compassion in health and mental health care

v  One that involves a spirit of love, wisdom, and competence by being informed about trauma and resilience.

Agenda v  Session One: Violence and the patient, family,

community, and practitioners

Brief Break

v  Session Two: Promoting resilience in traumatized patients and their families

Brief Break

v  Session Three: Promoting resilience in the compassionate practitioner

VIEWER ADVISORY -- considering violent and traumatic material

v  Secondary trauma is experiencing the fear and horror second-hand, like second-hand smoke,

v  The second hand trauma and second hand smoke are potentially harmful and need to be managed

Lecture One: Violence and the patient, family,

community and practitioners v  Some Terms and Models

v  Violence-related Trauma causes and consequences

v  The physical, emotional, and spiritual needs of patients and their families

Part A: Conceptual Overview

v The factors, variables, models, and other tools to help view the traumatized and understand how traumatized people behave – individually as a patient, collectively in a group, community – resulting from violence.

The Fundamental Questions of the Traumatized

1. What happened to me? a. What happened to us?

b. What happened to my people?

2. Why did it happen?

The Fundamental Questions of the Traumatized

3. Why did I act like I did, at the time?

4. Why have I acted like I have, since then?

5. What will happen if it

happens again?

What is violence? v  The World Health Organization defines violence as the  intentional    v  use  of  physical  force  or  power  (threatened  or  actual)    v  against  oneself,  another  person,  or  against  a  group  or  community,  that  caused  v  injury,    v  death,    v  psychological  harm,    v Maltreatment  or    v  deprivation  

WHO Typology of Violence

Types  of  violence  (WHO,  2002) v Self-Directed Violence Types

v Suicidal behavior (i.e. attempts, outcry)

v  Self-abuse. (e.g., self-mutilation)

Collective Violence types v  I will not be focusing on collective violence, though

the impact of any violence is largely the same.

v  Social collective violence (e.g., lynching, rioting, vigilantism, and terrorism) and associate with social control

v  Political collective violence (e.g., motives are to control daily living through force or threat of force or law)

v Economic collective violence (e.g., motives are to control the money so important in daily living)

Interpersonal Violence

v Violence within a Family and Intimate Partnership

v Violence within a Community between unrelated individuals

Both have significantly more importance to trauma dosage and recovery.

Nature of Violence

v  Physical Nature – traumatic reality of the potential for being harmed or killed;

v  kinesthetic experiences of body-based fear;

v Conditioned dislike for the perpetrator and anything associated with the trauma

Sexual Nature of Violence

v  – Traumatic reality potential for physical and emotional harm;

v  affects sexual functioning and satisfaction;

v  In addition to negative attitudes toward perpetrator and associated factors

Psychological Nature of Violence

v  Traumatic reality potential for lasting v  bonding because of the personal nature of the

violation. v  Cue to the traumatic memory (i.e., persons, places,

or things) that are linked to the traumatic experience that often fades in time

v  Connections trigger a fear response and associated efforts to cope to gain a strong since of safety.

v  But there can often be post-traumatic growth and resilience

Psychological Nature of Traumatic Stress Reactions to Violence

v Connections trigger a fear response and associated efforts to cope to gain a strong since of safety.

v But there can often be post-traumatic growth and resilience

What is Trauma v  Trauma is defined as a sudden, potentially

deadly experience, often leaving lasting, troubling memories

v  It’s both a cause and a consequences – in both the short and long-term

v  Causes of Trauma: those events – both internal and external – that significantly elevates stress reaction baseline.

Violence-related Trauma causes and consequences

v  Traumatic Stress Reactions: Phase I Pre-injury (prior knowledge and expectations;

v  Phase II the Traumatic Stress Injury (shattering of meaning)

v  Phase III the Initial Recovery (initial meaning)

v  Phase IV the Long-term Reactions and Recovery (new meaning)

Retraumatization v Defined as reliving a trauma and experiencing similar traumatic stress reactions again, though usually to a lesser degree. v  During retraumatization, the memories associated with the trauma are reawakened.

Retraumatization v Most survivors are able to work through their traumatic experiences, return to their regular activities, and enjoy their lives. v But some do not and require attention to enable the patient to activate their resilience promotion strategies: Grounding, self talk, stress management.

How are we doing? Need for Counter-balancing v  “Every class I teach ends with a counterbalancing

exercise. Sometimes we sing. Sometimes we dance. It depends on the room and trainees. But everything I try to make them smile. That’s the indicator of counterbalancing.”

v  --Kathleen Regan Figley

v  Options: laughing (audience jokes), smiling while, standing up and making a fool of yourself;

v  singing – “. . . when you’re smiling, when you’re smiling, the whole world smiles with you.”

Safe Place Visualization (SPV)

v You can imagine it right now.

v You can shut your eyes and block out the sounds and the thoughts from here.

v  Shut your eyes and imagine yourself sitting in this safe place and taking in everything and letting everything else go.

After the break: v Shifting from the experience of

trauma to healing from trauma

v After the break we will address what can best be done for

v our patients and their families

v to enable them to heal from traumatic events

BREAK – 1 (9:20-9:50AM)

Lecture Two: Promoting Resilience in Traumatized

Patients and their Families v  Purpose: This lecture will focus on what is

critically important in order for trauma survivors (e.g., from community violence) to recover from violence and other frightening experiences; bolstering their trauma resilience.

Promoting Resilience in traumatized Patients and their Families

v What is promoting trauma resilience?

v What is a traumatized patient?

v What is a traumatized patient family?

What is promoting trauma resilience in medical settings?

v  If trauma resilience is “. . . recovering from the impacts of trauma quickly and completely in the five Resilience Capabilities areas of functioning,”

v  How best to promote the five capabilities among the patients and their families?

v  They will be discussed in the final lecture.

Helping the patient’s family help

v Helping the patient through the family to

v  (a) reduce the additional sources of traumatic stress (e.g. case work with an assigned agency)

v  (b) avoid re-traumatization (e.g., be prepare;, keep the patient safe and informed);

Helping the traumatized patient

v  (c) establishing a safe and reliable environment, and;

v (d) help families help the other family members troubled by trauma.

v (e) provide trauma-informed care.

What is a traumatized patient family?

v  Family self identified as supporters of the traumatized patient

v  Members are dealing with both primary and the secondary trauma in their lives and the interpersonal disruptions in family care, protection, and stability.

v  The symptoms are primarily chronic stress reactions associated with traumatic memories that are often cued by other family members.

What is Trauma-Informed Care?

v  An  approach  to  engaging  people  with  histories  of  trauma  –  including  patients  with  major  mental  illness  –  v   in  a  way  that  recognizes  the  presence  of    v  trauma  symptoms  and    v  acknowledges  the  role  that  trauma  has  played  in  their  lives.      

What is Trauma-Informed Care?

v Trauma-informed human service programs

v Include every part of its organization, management, and service delivery system

v Services represent at least a basic understanding of how trauma affects the life of an individual seeking services.  

What is Trauma-informed Care for communities, families, and organizations?

v Based on an understanding of the vulnerabilities or triggers of trauma survivors v  that traditional service delivery approaches may exacerbate, v  so that these services and programs can be more supportive and avoid re-traumatization.  

What is Trauma-Informed Care?

v  Referral  services  for  mental  health,  substance  abuse,  housing,  vocational  or  employment  support,  domestic  violence,    victim  assistance,  and  peer  support.  v  Trauma-­‐informed  care  involves  NOT  asking  "What's  wrong  with  you?"    v  But  rather  asks,  "What  has  happened  to  you?  And  How  can  we  help?  

Retraumatization may lead to treatment

v Some people, however, experience retraumatization and could benefit from recognizing and learning how to manage their symptoms or seeking additional help, as needed. v  This is especially true for family members

Retraumatization symptoms

v Nightmares and flashbacks, v Re-experience many of the initial negative thoughts, feelings, and behaviors experienced during the trauma, long after the event is over. v  Often associated with a lack of safety and the fear that something bad is about to happen

Retraumatization Triggering Events

v  A triggering event is something that immediately reminds you, your family, or your community of a fear that was experienced during the original trauma.

v  These events can include anniversary time frames, news stories of similar incidents, similar disasters or threats of disaster, and sometimes even experiences that seem unrelated.

Retraumatization Symptoms v  Often relived it in any or all of the following five ways:  1.  Negative thoughts and actions that are associated

with fear or other emotions experienced during the actual trauma (e.g., appearing and acting fearful and anxious).  

2.  Physical symptoms such as sleep problems, significant changes in weight, physical pain for no apparent reason, and feeling tired and having little energy.  

Retraumatization Symptoms (cont.)

3.  Social withdrawal and isolation or an excessive feeling of neediness -- might result in substance misuse.  

4.  Spiritual disconnection is a challenge to your faith confidence -- a sense that your spiritual expectations were not met, -- a loss of connection to a higher power, and -- less relief from prayers and other spiritual activities that were previously effective in reducing your stress.  

Retraumatization Symptoms (cont.)

5.  Emotional symptoms such as -- not being able to control your emotions while in public, -- not being able to calm yourself down, and a decrease in your sense of security and love.  

Managing Retraumatization

v Once there is recognition a patient is experiencing retraumatization v Ask about the original traumatization to determine the connection v  Normalize the impact of the original trauma  v Understand how and why the event happened.  

Managing Retraumatization (cont.)

v Appreciate ways to prevent the impact by knowing what helps and what does not

v Educate patient and family about retraumatization

v Refer patient to a skilled trauma practitioner to desensitize the patient’s trauma memories.

Managing Retraumatization (cont.)

v Develop effective coping skills (e.g., stress management, self-care, social support).  

v Refer patient to a skilled trauma practitioner to desensitize the patient’s trauma memories and eliminate the retraumatization symptoms.

Trauma Resilience and Protective Factors

v  Resilience is the degree to which a person or group of people effectively cope with a traumatic event without experiencing retraumatization.

v  Protective factors can also be considered “signs of resilience” and can help you prevent retraumatization from occurring in the first place.

Trauma Resilience and Protective Factors

The factors found to be especially important in preventing retraumatization include:  1. Feeling connected to others such as being

involved in satisfying, personal, and supportive relationships;  

2. A sense of safety and security such as social support from friends and family that is reliable.

Another example is being able take measures to quickly feel safe and secure; having effective stress management skills is another.

Trauma Resilience and Protective Factors

3.  Good coping skills, such as, being effective at managing stress, and generally viewing adversity as a series of challenges that can be met with hard work and the help of others.  

4.  Ensuring that your support system is easily accessible and made up of people who know, accept, and seek to support you.  

5.  Living in a community with resources geared towards resilience rather than only medical and mental illness.  

What are Trauma-informed Interventions?

v  Trauma-specific interventions are designed specifically to address the consequences of trauma in the individual and to facilitate healing. Treatment programs generally recognize the following:  •  The survivor's need to be respected,

informed, connected, and hopeful regarding their own recovery  

What are Trauma-informed Interventions?

•  The interrelation between trauma and symptoms of trauma (e.g., substance abuse, eating disorders, depression, and anxiety)  

•  The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers  

Example:  Trea,ng  Trauma,zed  Families

v  The model (Figley & Kiser, 2013) is intended for use by social workers and others working with families with chronic challenges.

v  The model guides the collection and discussion of key data to determine the family clients’ resilience (i.e., adaptation to trauma).

v  The model helps determine where the family fits on a spectrum of adaptation.

Conclusion v  Violence is fundamentally traumatic.

v  Traumatized patients and their families, irrespective of the presenting problem, requires due diligence to avoid re-traumatization and include referral to an evidence-based treatment program for both the traumatized patients and their families.

v  In the final section we will focus on the caregiver’s secondary traumatization and promoting resilience.

Counter-balance Exercise

Break (11:45-11:00)

Lecture 3 Promoting Resilience in the Compassionate Healer

v  Objectives: Identify the secondary affects upon the medical and mental health professionals who work with the traumatized, including those affected by violence and especially the innocent.

v  Clarify what is needed in order to promote resilience in the health professional who works with the traumatized and those affected by violence.

Violence Impact on Trauma Workers (see 17 min video)

v  Identify the symptoms of secondary trauma as it affects trauma workers

v  Listen to the Norwegian psychologist who worked with traumatized children

v  Listen for what these trauma workers, including healers here in hospitals, need to build up their resilience

v  Available at http://www.giftfromwithin.org/html/When-Helping-Hurts-Sustaining-Trauma-Workers.html#4

Lecture 3 Promoting Resilience in the Compassionate

Healer

v What is promoting resilience?

v Who are compassionate healers?

v How are resilience levels among healers determined?

Lecture 3 Promoting Resilience in the Compassionate Healer

v Who are compassionate healers?

v  Those who display compassion as professionals working in the health professions – physicians, nurses, administration personnel who also work with patients and their families.

Resilience Level of Functioning Spectrum

v Most professionals operate at the top resilience levels of functioning (Levels 1 or 2)

v But those who are functioning at Level 3 or below require attention that is often not provided

Spectrum-specified Services Knowing the level of functioning will

v Help quickly determine who needs help that stimulate trauma resilience.

v Help promote thriving in both the traumatized and the worker

v  Table 1 is a guide to determining where we are on the spectrum of resilience functioning

Resilience Capabilities

The capacity to utilize critical protective factors of trauma resilience in five domains.

See Figure 2.

Figure 1. Capabilities Contributing to Resilience

Resilience Physically

capable (measured by level of energy due

to sleep, health)

Psychologically capable (measured by level of enthusiasm,

intellectual capability, morale, spiritual

support)

Interpersonally capable (measured by level of social support

and cohesion with group)

Technically capable (measured by

standard productivity, client satisfaction, and

competence scales)

Personally Capable (measured by

the self care plan and following; other measures

of self regulation competencies)

Five trauma resilience capabilities

1.   Physically capable (measured by level of energy due to sleep, nutrition, health)

2.   Psychologically capable (measured by level of enthusiasm, intellectual capability, morale, spiritual support)

3.   Interpersonally capable (measured by level of social support and cohesion with group)

4.   Technically capable (measured by standard productivity, client satisfaction, and competence scales)

5.   Self (Care) Regulation capable (measured by the existence of an EB self care plan and following it)

Spectrum Resilience Levels Determined by the 5 Capabilities

Level 5 Level 4 Level 3 Level 2 Level 1

Highly Resilient

Resilient Challenged Resilience

Supported Resilience

Failed Resilience

Exceptional role model

Good functioning

Acceptable functioning

Unacceptable functioning

Dysfunctional

No challenges in capabilities

Challenged in 1 of the 5 capabilities

Challenged in 2 of the 5 capabilities

Challenged in 3 of the 5 capabilities

Failing in 1 or more capabilities

Action: Train and coach others on the team

Action: Maintain

Action: Provide coaching and peer support

Action: Implement Explicit plan immediately

Action: Immediate behavioral health services

Level 5 - Highly Resilient

v No challenges in the five capabilities

v Train and coach others on the team

v Important to determine how best to recruit and retain highly resilient workers

Level 4 - Resilient v Good functioning

v Challenged in 1 provider capability element (e.g., lowered physical capabilities perhaps due to lack of sleep or health challenges)

Level 3 – Challenged Resilience

v Challenged in 2 functions (e.g., lowered psychological capability as measured by level of enthusiasm, morale, spiritual support and lowered interpersonally capable as measured by level of social support and cohesion with group)

v Supervisor should provide coaching and peer support

Level 2 – Supported Resilience

v  Unacceptable functioning with clear message of concern to the survivor/worker and specific requirements for improvement associated with specific help in making the improvements

v  Challenged in 3 or 4 functions (e.g., Self Care Regulation)

v  Explicit plan implemented for addressing resilience promotion

Level 1 – Failed Resilience

v  Failing in 1 or more capabilities

v  (e.g., significant reduction in the worker’s Technical capabilities as measured by standard productivity and competence, client satisfaction, and supervisor reports competence scales)

v  but most often there are 2-3 capability reductions.

v  Action: Immediate behavioral health services

Building Resilience -- Assessment

v  Self capabilities to identify strengths and weaknesses

v Mutual Support System Inventory

v Work-based support

v Friends of the same gender

v Love relationships

Building Resilience – Self Care Plan Development

v Limiting the stressors v Both at home and at work

v Building stress management capabilities v Monitoring and reducing stress

during the day v Able to go to sleep and stay

asleep

Building Resilience – Self Care Plan Development v Review all capabilities and

determine where you are on the chart

v Eliminating unhealthy habits

v Eating, drinking, with moderation

Building Resilience – Self Care Plan Development

v Building in joy and a program for increasing it

Special Note to Physicians and Nurses

v  Sir William Osler spoken to young doctors in 1889

v  A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the uncertainty which pertains not alone to our science and art, but to the very hopes and fears which make us [human]

Conclusions

v  The traumatized deserve our best technical and personal care;

v  they must learn to bolster their own resources;

v  to take the lessons of being traumatized and surviving;

v  To answer the five questions and plan their lives accordingly.

Conclusions (cont.)

v Community violence workers sometime wonder how they are functioning, concerned about the symptoms they are experiencing;

v Now there is a way of assessment and investigating capability inadequacies to guide worker training and preparation, including doctors.

Conclusions (cont.)

v  Trauma resilience is being well-prepared for future traumas

v  The focus here is on building up worker resilience for better stress management – of both acute and chronic stressors.

v  Trauma resilience capabilities indicators direct trauma resilience development

Conclusions

Trauma Resilience Promotion is the responsibility of all of us for each other.

This is especially the responsibility of leadership.

Final Thought In his foreword to the book, First do no Self Harm: Understanding and Promoting Physician Stress Resilience, the well-established medical educator, John Bligh noted:

The human in the doctor must speak and listen to the human in the patient As doctors, our students will share joy, relief, grief, and despair with their patients and their families; they will experience the elation that comes from helping people, and the aguish that comes from failing to meet their own and others’ expectations.

Questions and Observations

Contacts: 504-862-3473

Slides available: contacting [email protected]