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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

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Dr. Figley shares his perspective on developing greater resilience capacity by focusing on building up the five capabilities of resilience; something that can be done before trauma strikes.

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  • 1. Advancing Healing After Community Violence: Victims, Families, and Health Professionals Charles R. FigleyBowles Chapel Lectures 2014 8:00 Noon, Memorial-Hermann Medical System, Houston

2. 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 moreattention on compassion in health and mental health care v One that involves a spirit of love, wisdom, andcompetence by being informed about trauma and resilience. 3. Agenda v Session One: Violence and the patient, family,community, and practitionersBrief Breakv Session Two: Promoting resilience intraumatized patients and their familiesBrief Breakv Session Three: Promoting resilience in thecompassionate practitioner 4. VIEWER ADVISORY -- considering violent and traumatic material v Secondary trauma is experiencing the fearand horror second-hand, like second-hand smoke, v The second hand trauma and second handsmoke are potentially harmful and need to be managed 5. Lecture One: Violence and the patient, family, community and practitioners v Some Terms and Models v Violence-related Trauma causes andconsequencesv The physical, emotional, and spiritualneeds of patients and their families 6. Part A: Conceptual Overview v The factors, variables, models, andother tools to help view the traumatized and understand how traumatized people behave individually as a patient, collectively in a group, community resulting from violence. 7. 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? 8. 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, sincethen? 5. What will happen if ithappens again? 9. What is violence? v The World Health Organization definesviolence as theintentional v useofphysicalforceorpower (threatenedoractual) v againstoneself,anotherperson,or againstagrouporcommunity,thatcaused v injury, v death, v psychologicalharm, v Maltreatmentor v deprivation 10. WHO Typology of Violence 11. Typesofviolence(WHO,2002) vSelf-Directed Violence Types v Suicidal behavior (i.e. attempts,outcry) v Self-abuse. (e.g., self-mutilation) 12. Collective Violence types v I will not be focusing on collective violence, thoughthe impact of any violence is largely the same.v Social collective violence (e.g., lynching, rioting, vigilantism, and terrorism) and associate with social controlv 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) 13. Interpersonal Violence v Violence within a Family andIntimate Partnership v Violence within a Communitybetween unrelated individuals Both have significantly more importance to trauma dosage and recovery. 14. Nature of Violence v Physical Nature traumatic reality of thepotential for being harmed or killed; v kinesthetic experiences of body-basedfear; v Conditioned dislike for the perpetratorand anything associated with the trauma 15. Sexual Nature of Violence v Traumaticreality potential for physical and emotional harm;v affects sexual functioning andsatisfaction; v In addition to negative attitudes towardperpetrator and associated factors 16. Psychological Nature of Violence v Traumatic reality potential for lasting v bonding because of the personal nature of theviolation. v Cue to the traumatic memory (i.e., persons, places, or things) that are linked to the traumatic experience that often fades in timev Connections trigger a fear response and associatedefforts to cope to gain a strong since of safety.v But there can often be post-traumatic growth andresilience 17. Psychological Nature of Traumatic Stress Reactions to Violence v Connections trigger a fear response andassociated efforts to cope to gain a strong since of safety. v But there can often be post-traumaticgrowth and resilience 18. What is Trauma v Trauma is defined as a sudden, potentiallydeadly experience, often leaving lasting, troubling memories v Its both a cause and a consequences in boththe short and long-term v Causes of Trauma: those events bothinternal and external that significantly elevates stress reaction baseline. 19. 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 (initialmeaning)v Phase IV the Long-term Reactions andRecovery (new meaning) 20. Retraumatization v Defined as reliving a trauma andexperiencing similar traumatic stress reactions again, though usually to a lesser degree. v During retraumatization, the memories associated with the trauma are reawakened. 21. Retraumatization v Most survivors are able to workthrough 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. 22. How are we doing? Need for Counter-balancing v Every class I teach ends with a counterbalancingexercise. Sometimes we sing. Sometimes we dance. It depends on the room and trainees. But everything I try to make them smile. Thats the indicator of counterbalancing.v --Kathleen Regan Figleyv Options: laughing (audience jokes), smiling while, standingup and making a fool of yourself;vsinging . . . when youre smiling, when youre smiling, the whole world smiles with you. 23. Safe Place Visualization (SPV) v You can imagine it right now. v You can shut your eyes and block out thesounds and the thoughts from here. v Shut your eyes and imagine yourselfsitting in this safe place and taking in everything and letting everything else go. 24. After the break: v Shifting from the experience oftrauma to healing from trauma v After the break we will address whatcan best be done for v our patients and their families v to enable them to heal fromtraumatic events 25. BREAK 1 (9:20-9:50AM) 26. Lecture Two: Promoting Resilience in Traumatized Patients and their Families v Purpose: This lecture will focus on what iscritically important in order for trauma survivors (e.g., from community violence) to recover from violence and other frightening experiences; bolstering their trauma resilience. 27. Promoting Resilience in traumatized Patients and their Families v What is promoting traumaresilience? v What is a traumatized patient? v What is a traumatized patientfamily? 28. What is promoting trauma resilience in medical settings? v If trauma resilience is . . . recovering fromthe impacts of trauma quickly and completely in the five Resilience Capabilities areas of functioning,v How best to promote the five capabilitiesamong the patients and their families?v They will be discussed in the final lecture. 29. Helping the patients family help v Helping the patient through the family to v (a) reduce the additional sources oftraumatic stress (e.g. case work with an assigned agency) v (b) avoid re-traumatization (e.g., beprepare;, keep the patient safe and informed); 30. Helping the traumatized patient v (c) establishing a safe and reliableenvironment, and; v (d) help families help the otherfamily members troubled by trauma. v (e) provide trauma-informed care. 31. What is a traumatized patient family? v Family self identified as supporters of thetraumatized patientv Members are dealing with both primaryand the secondary trauma in their lives and the interpersonal disruptions in family care, protection, and stability.v The symptoms are primarily chronic stressreactions associated with traumatic memories that are often cued by other family members. 32. What is Trauma-Informed Care? v Anapproachtoengagingpeoplewithhistoriesoftraumaincludingpatients withmajormentalillness v inawaythatrecognizesthepresenceof v traumasymptomsand v acknowledgestherolethattraumahas playedintheirlives. 33. What is Trauma-Informed Care? v Trauma-informed human serviceprograms vInclude every part of its organization,management, and service delivery system vServices represent at least a basic understanding of how trauma affects the life of an individual seeking services. 34. What is Trauma-informed Care for communities, families, and organizations? v Based on an understanding of thevulnerabilities 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 retraumatization. 35. What is Trauma-Informed Care? v Referralservicesformentalhealth,substanceabuse,housing,vocationalor employmentsupport,domesticviolence, victimassistance,andpeersupport. v Trauma-informedcareinvolvesNOT asking"What'swrongwithyou?" v Butratherasks,"Whathashappenedto you?AndHowcanwehelp? 36. Retraumatization may lead to treatment v Some people, however, experienceretraumatization 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 37. Retraumatization symptoms v Nightmares and flashbacks, v Re-experience many of the initialnegative 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 38. Retraumatization Triggering Events v A triggering event is something thatimmediately reminds you, your family, or your community of a fear that was experienced during the original trauma. v These events can include anniversary timeframes, news stories of similar incidents, similar disasters or threats of disaster, and sometimes even experiences that seem unrelated. 39. Retraumatization Symptoms v Often relived it in any or all of the following fiveways: 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. 40. Retraumatization Symptoms (cont.) 3. Social withdrawal and isolation or anexcessive 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. 41. 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. 42. Managing Retraumatization v Once there is recognition a patient isexperiencing 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. 43. Managing Retraumatization (cont.) v Appreciate ways to prevent the impactby 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 patients trauma memories. 44. 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 patients trauma memories and eliminate the retraumatization symptoms. 45. Trauma Resilience and Protective Factors v Resilience is the degree to which a personor group of people effectively cope with a traumatic event without experiencing retraumatization. v Protective factors can also be consideredsigns of resilience and can help you prevent retraumatization from occurring in the first place. 46. 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. 47. Trauma Resilience and Protective Factors 3. Good coping skills, such as, being effective atmanaging 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. 48. What are Trauma-informed Interventions? v Trauma-specic interventions are designedspecically 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 49. 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 50. Example:Trea,ngTrauma,zed Families v The model (Figley & Kiser, 2013) is intended foruse by social workers and others working with families with chronic challenges. v The model guides the collection and discussionof key data to determine the family clients resilience (i.e., adaptation to trauma). v The model helps determine where the family tson a spectrum of adaptation. 51. Conclusion v Violence is fundamentally traumatic. v Traumatized patients and their families, irrespective ofthe presenting problem, requires due diligence to avoid re-traumatization and include referral to an evidencebased treatment program for both the traumatized patients and their families. v In the final section we will focus on the caregiverssecondary traumatization and promoting resilience. 52. Counter-balance Exercise 53. Break (11:45-11:00) 54. Lecture 3 Promoting Resilience in the Compassionate Healer v Objectives: Identify the secondary affects upon themedical 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 resiliencein the health professional who works with the traumatized and those affected by violence. 55. Violence Impact on Trauma Workers (see 17 min video) v Identify the symptoms of secondary trauma as itaffects trauma workersv Listen to the Norwegian psychologist who workedwith traumatized childrenv Listen for what these trauma workers, includinghealers here in hospitals, need to build up their resiliencev Available at http://www.giftfromwithin.org/html/When-Helping-Hurts-Sustaining-TraumaWorkers.html#4 56. Lecture 3 Promoting Resilience in the Compassionate Healer v What is promoting resilience? v Who are compassionate healers? v How are resilience levels among healersdetermined? 57. Lecture 3 Promoting Resilience in the Compassionate Healer v Who are compassionate healers? v Those who display compassion asprofessionals working in the health professions physicians, nurses, administration personnel who also work with patients and their families. 58. Resilience Level of Functioning Spectrum v Most professionals operate at thetop resilience levels of functioning (Levels 1 or 2) v But those who are functioning atLevel 3 or below require attention that is often not provided 59. Spectrum-specified Services Knowing the level of functioning willv Help quickly determine who needs help thatstimulate trauma resilience. v Help promote thriving in both thetraumatized and the worker v Table 1 is a guide to determining where weare on the spectrum of resilience functioning 60. Resilience Capabilities The capacity to utilize critical protective factors of trauma resilience in five domains. See Figure 2. 61. Figure 1. Capabilities Contributing to Resilience Interpersonally Psychologicallycapable (measured by level of social support and cohesion with group)capable (measured by level of enthusiasm, intellectual capability, morale, spiritual support)Physicallycapable (measuredby level of energy due to sleep, health)Technicallycapable (measured by standard productivity, client satisfaction, and competence scales)PersonallyResilienceCapable (measured bythe self care plan and following; other measures of self regulation competencies) 62. Five trauma resilience capabilities 1.Physically capable (measured by level of energy due to sleep,2.Psychologically capable (measured by level of3.Interpersonally capable (measured by level of social4.Technically capable (measured by standard productivity, client5.Self (Care) Regulation capable (measured by thenutrition, health)enthusiasm, intellectual capability, morale, spiritual support)support and cohesion with group)satisfaction, and competence scales)existence of an EB self care plan and following it) 63. Spectrum Resilience Levels Determined by the 5 Capabilities Level 5Level 4Level 3Level 2Level 1Highly ResilientResilientChallenged ResilienceSupported ResilienceFailed ResilienceExceptional role modelGood functioningAcceptable functioningUnacceptable functioningDysfunctionalNo challenges in capabilitiesChallenged in 1 of the 5 capabilitiesChallenged in 2 of the 5 capabilitiesChallenged in 3 of the 5 capabilitiesFailing in 1 or more capabilitiesAction: Provide coaching and peer supportAction: Implement Explicit plan immediatelyAction: Immediate behavioral health servicesAction: Train Action: and coach Maintain others on the team 64. Level 5 - Highly Resilientv No challenges in the five capabilities v Train and coach others on the team v Important to determine how best torecruit and retain highly resilient workers 65. Level 4 - Resilient v Good functioning v Challenged in 1 provider capabilityelement (e.g., lowered physical capabilities perhaps due to lack of sleep or health challenges) 66. Level 3 Challenged Resilience v Challenged in 2 functions (e.g., loweredpsychological 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 andpeer support 67. Level 2 Supported Resilience v Unacceptable functioning with clear message ofconcern to the survivor/worker and specific requirements for improvement associated with specific help in making the improvementsv Challenged in 3 or 4 functions (e.g., Self CareRegulation)v Explicit plan implemented for addressing resiliencepromotion 68. Level 1 Failed Resilience v Failing in 1 or more capabilities v (e.g., significant reduction in the workers Technicalcapabilities 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 69. Building Resilience -Assessment v Self capabilities to identifystrengths and weaknesses v Mutual Support System Inventory vWork-based support vFriends of the same gender vLove relationships 70. Building Resilience Self Care Plan Development v Limiting the stressors vBoth at home and at work v Building stress managementcapabilitiesvMonitoring and reducing stressduring the day vAble to go to sleep and stay asleep 71. Building Resilience Self Care Plan Development vReview all capabilities anddetermine where you are on the chart v Eliminating unhealthy habits vEating, drinking, with moderation 72. Building Resilience Self Care Plan Development v Building in joy and a program forincreasing it 73. Special Note to Physicians and Nursesv Sir William Osler spoken to young doctors in 1889v A distressing feature in the life which you are about toenter, 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] 74. Conclusions v The traumatized deserve our best technicaland personal care; v they must learn to bolster their ownresources; v to take the lessons of being traumatized andsurviving; v To answer the five questions and plan theirlives accordingly. 75. Conclusions (cont.) v Community violence workers sometimewonder how they are functioning, concerned about the symptoms they are experiencing; v Now there is a way of assessment andinvestigating capability inadequacies to guide worker training and preparation, including doctors. 76. Conclusions (cont.) v Trauma resilience is being well-prepared forfuture traumas v The focus here is on building up workerresilience for better stress management of both acute and chronic stressors.v Trauma resilience capabilities indicatorsdirect trauma resilience development 77. Conclusions Trauma Resilience Promotion is the responsibility of all of us for each other. This is especially the responsibility of leadership. 78. 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. 79. Questions and Observations Contacts: 504-862-3473 Slides available: [email protected]