Lessons Learned from Veterans about Trauma, Grief, and Loss:

The Case of the Combat Medic

First Annual General Assembly and the Focus is Palliative Care,

Monday, March 11, 2013 at 4:00 pm.

Charles R. Figley, Ph.D.Tulane University Kurzweg Chair in

Disaster Mental HealthSchool of Social Work

Welcome to New Orleans

Thanks SWH & PCN on behalf of Dean Ron Marks and the Tulane University School of Social Work and Ky Luu, Disaster Resilience Leadership Academy, Tulane University School of Social Work

AcknowledgementsMy Research Team

LtCol Dave Cabrera (deceased)

Joseph Boscarino

Joia Special and Kathy Regan Figley

Jeff Nagy

Purpose of the Presentation

Share the lessons learned about Trauma, Grief, and Loss from studying veterans for more than 30 years

To appreciate combat medics resilience in the face of horror and hardship

Note the lessons useful to us in managing primary and secondary trauma and promoting resilience

Trauma, Grief, and Loss Exposure

Combat medics compared to other combatants are

• exposed to more trauma, grief, and loss but

• more resilient (mental health) despite the additional compassion stress

Other units that risk compassion stress include Mortuary Affairs (formerly Graves Registration) and the Chaplaincy Services

Formulating the Research Question

Dave Cabrera and I decided to figure out

• Why combat medics appear to be so resilient and

• What can learned about why and how best to build resilience

This goal emerged in Heidelberg Germany (September, 2009) while working with the US

Army

Combat Medic Mettle Study

Mixed method: Longitudinal survey with intensive, video interviews with peer nominated combat medics.

Surveyed 848 combat medics in person in 2009 and Internet-based re-survey and 17 interviews in 2010, and 2011 re-survey, and Combat Medic Mettle Scale survey in 2012.

Combat experiences reported

67 percent saw dead bodies or human remains

56 percent saw dead or seriously injured Americans

53 percent saw sick or injured women or children they were unable to help

26 percent shot or directing fire at the enemy, and

6 percent directly responsible for enemy death

Preliminary Findings (Military Medicine, 2013)

• Medics see significantly more combat than most who are deployed

• Yet, less likely to be screened for anxiety disorders, particularly PTSD

Preliminary Findings (Military Medicine, 2013)

• However, they report higher levels of depression compared to non-deployed soldiers

• Consistent with previous research, the more effort to seek mental health services, the greater perceived stigma and barriers to mental health services.

Preliminary Findings (Figley, Cabrera, Pitts, & Chapman, 2011)

• Medic Mettle (resilience) Scale responses linked to survey data to produce 13-item version

• Combat medics adapt to violent death by “dual attention”• focusing on their job, apart from the

emotional reactivity experienced by non-medic soldiers

Preliminary Findings (Figley, Cabrera, Pitts, & Chapman, 2011)

• Medics avoid stress injuries by a set of strategies that include displays of leadership, soldiering, and medical care.

• Thus, combat medics adapt to violent death through effective self regulation that includes focusing on the mechanics of caregivers.

Combat Medic Mettle Study

Recent results yielded a 13-item Combat Medic Mettle (resilience) Scale

Measure will help build a theoretical, process model of resilience to guide theory, research, education, and

intervention to support combat medics and other caregivers such as emergency medical technicians (EMTs)

Combat Stress Injuries Resilience Model

Findings consistent with the Figley & Nash CSI Resilience Model, that

Self regulation is both a trait and state for combat medics

Dual attention required in combat is protective.

 

15TRAIT RESILIENCE FACTORS

Intelligence Trait Resilience (ER-89) Stress Adaptation CompetenceSelf Confidence and Self ConfidenceOCCUPATIONAL HAZARDS

Individual DemandsUnit DemandsEnvironmental DemandsFamily Demands

WORKER STRESS REACTIONS

Biological MarkersPsychological MarkersSocial Relationship MarkersBehavioral MarkersSpiritual Markers

TRSTRESS INJURIES RESILIENCE

Physical Fatigue Injury ResilienceGrief Injury ResilienceBelief Injury ResilienceTrauma Injury Resilience

STATE RESILIENCE (protective) FACTORS

Trust in the UnitTraumatic Unit CohesionContext-based Stress- reducing Competencies

Stress Injuries and Resilience Model (Figley & Nash, 2007)

Trauma-related

Stress Injuries Resilience

Trauma Injury Resilience -- memory management and re-establishing safety

Physical Fatigue Injury Resilience – physical wear and tear

Belief Injury Resilience –moral and ethical challenges

Grief Injury Resilience -- adaptation to loss of person, place, thing

Combat Stress Injuries Resilience Development

• Self regulation

• Unit connection and mutual support

• Mission focus, and

• Post-mission attention to self care and self development

 

Lessons from The Combat Medics Study

• Depression is an active ingredient in compassion fatigue (exhaustion in the service of the suffering) in healers

• where there is harm to an innocent life;

• inability to save everyone, including a buddy;

Lessons from The Combat Medics Study

• The findings suggest that medics who are resilient

(1) Don't fear the stigma of mental health treatment.

(2) Are Approachable

(3) Are Trustworthy

Lessons from Combat Medics

(4) Are Interpersonally skilled

(5) Can sense the needs of others

(6) Are adaptable to situations

(7) Learn to cope with mental and emotional challenges

(8) Focus through the stress and process later

Building Medic Mettle

Step One: Estimating Functioning with the Spectrum of Caregiver Resilience.

Step Two: Action (if needed) by combat buddy/family to acquire proper help.

 

How do we know to refer

for professional

help?

Spectrum of Caregiver Stress Resilience

• Useful for caregivers to determine the effectiveness of their self care plan and for

• Leaders and role models in stress resilience

The Spectrum of Caregiver Resilience

• Helps determine the Level of Resilience from Lowest Level, requiring immediate assistance,

• To the Highest Level of functioning that could involve serving as a peer counselor or a trainer;

• Resilience Functioning is defined by the presence of five capabilities.

Resilience Functions

Resilient

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)

Self (Care) Regulation

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

Spectrum of Caregiver Resilience

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 functioning

Challenged in 1 provider function

Challenged in 2 functions

Challenged in 4-5Functions

Failing in 1 or more functions

Train and Coach others on the team

Maintain Provide Coaching and Peer Support

Explicit Plan Implemented for Resilience

Immediate behavioral health services

ConclusionsStress and stress regulation are

among the biggest challenges in war and combat medics are vulnerable to stress injuries that may lead to mental disorders but can also lead to growth.

First study to confirm medics experience secondary trauma, like other medical health care providers.

ConclusionsThough witnessing

significantly more combat stress, medics scored better in behavioral health measures

Consistent with compassion fatigue theory, combat medics experience higher levels of depression than other soldiers.

Conclusions• Combat medics adapt to violent

death by focusing on their job, apart from the emotional reactivity experienced by non-medic soldiers

• Medics avoid stress injuries by a set of strategies that include displays of • leadership, • soldiering, and • medical care competence.

ConclusionsThus, combat medics with “medic mettle”

• adapt to trauma, violent death, and loss

• through effective self regulation indicated by the Spectrum of Caregiver Resilience

Conclusions (cont.)

Medics and other caregivers’ secondary stress reactions must be closely monitored and given proper positive attention

Caregivers should utilize good self care, practice colleague (buddy) care, and;

Encourage supervisory support for caregivers

Q & A Slides available from:

Tulane University

School of Social Work and the Traumatology Institute by contacting

FIGLEY@TULANE.EDU

Preliminary Findings (Military Medicine, 2013)

• Mental health care should be tailored to the military specialty (e.g., combat medics).

• Medics also experience stigma when seeking mental health services.

• Thus leadership must be more insistent to removing the barriers; to enact change in how services are delivered and received by Service Members rather than changing the minds of others; these include iMedicine technologies to eliminate barriers of transportation, time, and being observed by others.

• Permit trained clinicians to anonymously provide care may result in more Soldiers seeking needed assistance.

• Be guided by the crisis of the current suicide epidemic.

Sample of Combat Medics

Place Deployed -long

Deployed- short

Non- Deployed

Totals

Site 1 252 56 155 463

Site 2 88 0 297 385

Totals 340 56 452 848