Trauma 101: Basics of Understanding and Helping the Survivors of the Crematory Incident While Not Fo

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Trauma 101Basics of Understanding and Helping
the Survivors of the Crematory Incident(While
Not Forgetting About Ourselves) 

• A Full-Day Workshop
• March 19, 2002 9AM - 5PM
• by
• Dr. Charles R. Figley, Ph.D. and Kathleen Regan
  Figley, MS, MT

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Goal

• Provide a primer on working with survivors in
  shock, anticipating their long-term care, and our
  own

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Objectives Review, Discuss, and Apply the
Following Concepts

• Thanatology
• Traumatology (Traumatic Stress Studies)
• Post-Traumatic Stress Disorder
• Ambiguous Loss
• Traumatology of Grieving

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• Emergency Assessment Strategies
• Crisis Intervention and Referral Strategies
• The Role of Spirituality
• The Role of the Self of the Helper
• Stress Management
• Assessing and Preventing Compassion Fatigue

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 Provided free by the Green Cross Foundation
(www.greencrosos.org)

• Established in 1997
• Provides humanitarian aid (e.g.,the Green Cross
  Project), training and education
• Supports Traumatology (the International Journal)
  and the
• Academy of Traumatology

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Key Concepts
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Thanatology

• The study of grief and bereavement
• Also informs our knowledge of crisis and the
  crisis reaction

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Traumatology

• The study of the immediate and long-term
  psychosocial consequences of highly stressful
  (traumatic) events

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Stress

• Mechanical
• Physiological
• Selye

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Acute Stress

• Stress reactions associated with a crisis state.

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Acute Stress Disorder

• An anxiety disorder
• An acute state

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Trauma

• Dictionary DSM-IV
• Traumatic Stress

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Traumatic Stress

• A nonspecific response of the body to a traumatic
  stimulus.
• Hypertraumatic
• Hypotraumatic

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2.6 Secondary/Systemic Traumatic Stress

• the natural consequent behaviors and emotions
• resulting from knowing about a traumatizing event
  
• experienced by a significant other

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2.7 Post-traumatic Stress Disorder

• An anxiety disorder
• Acute, chronic and delayed

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2.71 DSM-IV Symptom Criteria

• The person has been exposed to a traumatic event
• B. The traumatic event is persistently
  re-experienced

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DSM-IV Criteria continued

• C. Persistent avoidance of stimuli associated
  with the trauma and numbing of general
  responsiveness (not present before the trauma)
• D. Persistent symptoms of increased arousal (not
  present before the trauma)

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DSM-IV Criteria continued

• E. Duration is more than one month.
• F. The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

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2.72 Incidence and Prevalence

• Lifetime Rates
• Current Rates

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Lifetime Rates
35-95 of rape victims 65 of assault victims
(excluding sexual assault) 50 of POWs 39 of
women experiencing aggravated assault 31 of
Vietnam war theater veterans
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Current Rates
84 of battered women seeking help through a
shelter 56 of Dutch resistance fighters from
WWII 31 of severely injured terrorist attack
survivors 25-33 of various types of community
disasters 22-60 of Falkland War veterans from
the UK
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Post-Traumatic Stress Disorder
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Ambiguous Loss
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Traumatology of Grieving
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Emergency Assessment Strategies
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Crisis Intervention and Referral Strategies
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The Role of Spirituality
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The Role of the Self of the Helper
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Stress Management
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Assessing and Preventing Compassion Fatigue
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2.8 Secondary Traumatic Stress Disorder and
Compassion Fatigue

• Syndrome of symptoms
• Nearly identical to PTSD
• Exceptions to PTSD

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2.81 Incidences and Prevalence of STS and STSD

• Recent study in Australia found 27 of
  professionals who work with the traumatized
  experienced extreme distress from this work
• 54.8 were distressed at the time of the survey.
  35.1 were very or extremely emotionally
  drained

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• In another study 17.7 had STSD and 18 just
  below cut off for the diagnosis.
• In a study of rural mental health professionals
  the prevalence rate was 24.1 for STSD and 21.4
  subclinical.

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Oklahoma City Trauma Workers

• In a study of Oklahoma City trauma workers,
• 64.7 exhibited some degree of severity for
  posttraumatic stress disorder, as measured by the
  Frederick Reaction Index.

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•  44.1 of counselors exhibited "caseness"
  (scores at or above the 90th percentile for
  nonpatient norms on the SCL-90-R Global Severity
  Index score or two dimensional T scores greater
  than or equal to a T score of 63).

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•  73.5 of counselors were rated as being at
  moderate risk (23.5), high risk (29.4), or
  extremely high risk (20.6) for compassion
  fatigue, as measured by the Compassion Fatigue
  Self Test for Psychotherapists (Figley, 1995).

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• 76.5 of counselors were rated as being at
  moderate risk (35.3), high risk (26.5), or
  extremely high risk (14.7) for burnout, using
  the same Compassion Fatigue Self Test.

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Northridge Earthquake

• 60.5 of disaster workers from the Northridge
  Earthquake met criteria for PTSD.

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3. Contrasts between STS/STSD/Compassion Fatigue
and Other Concepts
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3.1 Identical Concepts with different names

• Co-victimization
• Secondary victimization
• Vicarious traumatization

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3.11 Countertransference

• From Psychodynamic therapy
• Emotional reaction to client by therapist

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3.12 Burnout

• State of physical, emotional and mental
  exhaustion
• Long term client involvement
• Emotionally demanding situations

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4. BURNOUT

• 4.1 includes but is not limited to Compassion
  Fatigue

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4.2 Physical Symptoms

• 4.21 Fatigue (physical exhaustion)
• 4.22 Sleeping difficulties
• 4.23 Somatic problems

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4.3 Emotional Symptoms

• 4.31 Irritability 4.32 Anxiety 4.33 Depression
  4.34 Guilt 4.35 Sense of helplessness  

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4.4 Behavioral Symptoms

• 4.41 Aggression 4.42 Callousness 4.43 Pessimism
  4.44 Defensiveness 4.45 Cynicism 4.46
  Avoidance of clients 4.47 Substance abuse  

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4.5 Work-Related Symptoms

• 4.51 Quitting the job 4.52 Poor work performance
  4.53 Absenteeism 4.54 Tardiness 4.55
  Constantly seeking avoidance of work 4.56
  Risk-taking  

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4.6 Interpersonal Symptoms

• 4.61 Perfunctory communication 4.62 Inability to
  concentrate 4.63 Social withdrawal 4.64 Lack of
  a sense of humor 4.65 Dehumanization 4.66 Poor
  patient interactions

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5. COMPASSION FATIGUE

• 5.1 DEFINED A state of tension and preoccupation
  with the traumatized patients by re-experiencing
  the traumatic events avoidance/numbing of
  reminders persistent arousal (e.g., anxiety)

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5.2 COMPASSION FATIGUE

• has the following seven characteristics, compared
  to Burnout and Countertransference

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• 5.21 Faster onset of symptoms 5.22 Faster
  recovery from symptoms 5.23 Sense of
  helplessness and confusion 5.24 Sense of
  isolation from supporters

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• 5.25 Symptoms disconnected from real causes 5.26
  Symptoms triggered by other experiences 5.27
  Highly treatable once worker recognizes and acts

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6. Theories of Traumatology Related to Compassion
Fatigue
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6.1 Scientific Method

• Process in which the cycle of creating, testing,
  revising, re-testing, and then reformulating
  theories is repeated over and over again.

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6.2 Scientists posit theories

• the underlying processes that both account for
  and find expression in observed events

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6.3 Theory Construction Process Steps 1-4

• Determine the phenomenon for which the theory is
  to account
• Develop theoretical constructs, identify
  relations, and note connections
• Construct a diagram of the theory
• Test the relationships among variables

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6.4 A theory of the traumatization process

• for example, should suggest the underlying
  mechanisms for people and systems survive and
  thrive when exposed to traumatic events.

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6.5 Three Useful Theoretical Models

• The Recovery Context
• Long Term Stress Reactions
• Stage of Recovery from Traumatic Events

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6.51 The Recovery Context

• Pioneers in traumatology who first studied
  survivors of the Buffalo Creek Dam disaster in
  far eastern Kentucky and went on to study
  developed this model.

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6.52 Long-Term Stress Reactions

• This model (Figley, 1985) suggests that people
  and systems surviving a crisis do the best they
  can under the circumstances and then relive the
  experience after it is over. The purpose Mastery
  of the event

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6.53 Stages of Recovery from Traumatic Events

• This model suggests that there are waves of
  recovery that are dominated by efforts of
  avoidance
• Suggests that adjustment results from matery of
  the the memories and fear responses

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• 7. FACTORS CONTRIBUTING TO COMPASSION STRESS
  MANAGEMENT
• A Model of Compassion Stress and Fatigue
• (see Model below)  

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• 7.1. Empathic Ability is the aptitude for
  noticing the pain of others.
• 7.2. Emotional Contagion is experiencing the
  feelings of the suffer as a function of exposure
  to the sufferer.

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• 7.3. Empathic Concern is the motivation to
  respond to people in need.
• 7.4. Empathic Response is the extent to which
  the helper makes an effort to reduce the
  suffering of the sufferer.
• 7.5. Sense of Achievement is the extent to which
  the helper is satisfied with his or her efforts
  to help the client/sufferer.

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• 7.6. Disengagement is the extent to which the
  helper can distance himself or herself from the
  ongoing misery of the traumatized person.
• 7.7. Compassion Stress is the demand for action
  to relieve the suffering of others

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• 7.8. Prolonged Exposure is the on-going sense of
  responsibility for the care of the suffering,
  over a protracted period of time.
• 7.9. Traumatic Recollections are memories that
  trigger the symptoms of PTSD and associated
  reactions, such as depression and generalized
  anxiety.

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• 7.10. Life Disruption is the unexpected changes
  in schedule, routine, and managing life
  responsibilities that demand attention (e.g.,
  illness, changes in life style, social status, or
  professional or personal responsibilities).
  
   

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8. Implications for Managing and Treating
Compassion Fatigue
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• 8.1 desensitization through reciprocal inhibition
• 8.2 sensitive to the intensity of the trauma
• 8.3 sensitivity to the exposure dosage
• 8.4 mitigating circumstances
• 8.5 careful assessment and diagnosis

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Lets take a Break!
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Part II

• Assessments and Standards of Practice

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Objectives

• Define and discuss the appropriate clinical
  approaches for those working with survivors of
  trauma and who need help in managing their
  distress
• Identify accepted methods of practice in the
  field of traumatology that especially apply to
  professionals
• Conduct informal assessments of colleagues and
  give them directions they need to thrive not
  just survive in working with the traumatized

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Trauma Assessment

• 1.1 Clinical Interviews
• 1.2 Standardized Tests
• Foa or Mississippi (civilian) or IES-Rev.Purdue
  Social Support Scale
• Traumagram

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• 2. Burnout Assessment
• 3. Compassion Fatigue
• Assessment
• 4. Self Care Assessment

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5. Standards of Practice

• 5.1 Treating Primary Traumatization see Academy
  of Traumatology website _at_ www.greencross.org/soc.h
  tml
• 5.2 for treating Professionals
• Assessment with permission
• Diffenentiating between PTSD, Compassion Fatigue,
  Burnout and non-work problems
• Exposure Issues
• Iatrogenic re-traumatization
• Reaching therapeutic levels

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then LUNCH BREAK
Morning QA
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Part III

• Matching Burnout Professionals with Treatment
  Approaches

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Objective

• 5. Identify factors to consider when seeking
  appropriate intervention for professionals
  working with the suffering

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1. Available Desensitization Treatment Approaches

• Non direct exposure
• Client centered Exposure
• Direct exposure

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1.1 Non-Direct Exposure-Based

• Thought Field Therapy (TFT)Journaling
• Visual Kinesthetic Disassociation
  (VKD)HypnosisStress Management

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1.2 Client-centered Exposure-Based

• Traumatic Incident Reduction (TIR)JournalingArt
  TherapyPoetry TherapyMusic and other Creative
  Therapy
• Dance and other Kinesthetic Treatments

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1.3 Direct Exposure-Based

• Cognitive Behavioral Therapy (CBT)Eye Movement
  Desensitization and Reprocessing (EMDR)
• Video Dialogue and other Gestalt Methods

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2. Available Self-Assessment Approaches

• Self Test for Compassion Fatigue
• Life Course Analysis

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3. Intervention Goals that Fit Recovery Waves of
Clients

• First Wave Intervention Debrief worker
• Second Wave Intervention Relax worker
• Third Wave Intervention Square with reality by
  helping the worker
• Fourth Wave Intervention Accommodate to losses

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3.1 First Wave Intervention Debrief worker

• 3.11 stabilize their emotions and behaviors3.12
  lower negative arousal3.13 learn about acute and
  traumatic stress3.14 cope with current and
  future life circumstances

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3.2 Second Wave Intervention Relax worker

• 3.21 continuing to stabilize their emotions and
  behaviors3.22 teaching them how to lower
  negative arousal3.23 learn about acute versus
  chronic traumatic stress3.24 continuing to
  facilitate coping with current and future life
  circumstances

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3.3 Third Wave Intervention Square with reality
by helping the worker

• 3.31 answer the universal "victim" questions
• o What happened to me?
• o Why did it happen and to me?o Why did I act as
  I did?o Why have I acted as I have since then?o
  Will I be able to cope if it happens again?

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•  3.32 to continue to learn how to lower negative
  arousal
• 3.33 cope with current and future life
  circumstances

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3.4 Fourth Wave Intervention Accommodate to
losses

• (in the case of the loss of the beloved)
  Accommodate to the losses (through the
  bereavement process) by helping the client to
  satisfy the "six functions of the mourning
  process (Rando, 1993).

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Sextet Functions

• Recognize
• React
• Re-experience
• Relinquish
• Readjust
• Reinvest

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4. Green Cross Projects Seal of Approval criteria

• No Harm Criterion
• Replication Criterion
• Client Satisfaction Criterion
• Placebo Criterion
• Field Test Criterion

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5. Wave One

• Methods of Choice
• CISD-Modified and Self-Soothing techniques (TFT,
  Self-hypnosis, Visualization, Breath work)

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6. Wave Two

• Methods of Choice
• The above along with EMDR, VKD (Rewind and other
  NLP techniques)

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7. Wave Three

• Methods of Choice
• EMDR, VKD, CBT, TIR supplemented by those noted
  above.

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8. Wave Four

• Methods of Choice Accelerated Trauma Recovery
  (with video rewind) and Wave Three methods.

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5 Minute Stretch Break
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PART IV

• Critical Clinical Issues Interviewing, Self of
  the Therapist, Modulation of Exposure, and Stress
  Management

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Objective 6.

• Identify specific skills and supervision needed
  by clinicians to ensure appropriate intervention
  for survivors of trauma.

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Introduction

• Based on the literature and experiences in
  training and supervising traumatologists and
  graduate students over the last 30 years.
• Four Critical Issues least addressed by the field
  and practicing traumatologists

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2. Issue 1 Effective Interviewing of the
Traumatized

• Going too slowlyGoing too fastThe "silencing
  response"Pleasing the interviewerPleasing the
  client

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3. Issue 2 The Self of the Therapist

• Motivation to work with the traumatizedSurvivorG
  ood at itValued for itCountertransference
  issuesThe Compassion Trap Losing the Self

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4. Issue 3 Modulation of Exposure

• Exposure to the learned fear stimulus is the key
  active ingredient in successful trauma therapy.
• Major contribution of the neoteric treatment
  approaches is the ability to modulate exposure.
• Reciprocal Inhibition makes exposure more
  tolerable if used correctly.
• Modulation should consider what the client can
  handle and ALSO what the therapist can handle.

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5. Issue 4 Stress Management and Compassion
Fatigue Prevention

• Recognition of the stress reactions (self and
  client)
• Confirmation of summarization and immune system
  effects of stress
• In vivo (public) stress management methods
• Private stress management methods

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5.5 COMPASSION TRAP

• 5.51. Trauma Work and Services include
• 5.52. Compassion Requirement
• 5.53 Factors in Survival  

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5.53 Factors in Survival

• Willingness to be Compassionate
• Non-judgmental Acceptance of Compassion Stress
• Awareness of Traps
• Awareness of Own Weaknesses
• Being Prepared  
•  

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6. PREVENTION of Compassion Fatigue

• 6.1 Repair Support Systems at home and at work
  6.2 Setting Boundaries 6.3 Inventory of
  Pleasures and Practice them 6.4 Continue with
  Stress Reduction methods

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Time for a Break!
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PART V Experiential Session in Assessing,
Preventing, Treating, and Managing Compassion
Stress
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Objective 7

• Become more aware of ones own issues and
  vulnerability in working with suffering and
  experiencing helping and being helped.

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Background

• 1.1 A 15 minute Film
• When Helping Hurts
• Sustaining Trauma Workers
• (Gift From Within 800-888-5236)

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2. Who Are You? A Self-Assessment

• 2.1 Complete the Self-Test for Psychotherapists
  and add your scores on burnout, compassion
  fatigue, and satisfaction 2.2 Distinguish
  Between Changing Jobs and Changing Ways Look at
  your Three Subscores and the various combinations

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• 2.21 High Burnout, High Compassion Fatigue, Low
  Satisfaction Change Careers
• 2.22 High Burnout, Low Compassion Fatigue, High
  Satisfaction Change Jobs
• 2.23 Low Burnout, High Compassion Fatigue, High
  Satisfaction Stay and Manage the Emotional Toll
  of the Work
• 2.24 Low Burnout, Low Compassion Fatigue, Low
  Satisfaction Change Clients

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3. Career and Life Review

• 3.1 On a separate piece of paper identify 3.11
  on the left side the major sources of stress
  categories that affect the scores on the
  self-test3.12 on the right side the major stress
  reduction methods (both during and following work)

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• 3.13 on the other side list coping methods that
  remind you daily of your achievements and enhance
  your sense of satisfaction and help you separate
  for your work and clients

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4. Visualization (with music)

• 4.1 Select a safe place4.2 Listen to your
  breathing4.3 Mind wander to a past client you've
  really helped4.4 Mind wander to a
  supervisor/co-worker who really thinks you're
  great

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• 4.5 Mind wander to safe place to ponder
• What do I want out of my life and career from now
  on?
• How can I remind myself to take care of myself
  more to reach those goals?

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• Note Training and certification as a Compassion
  Fatigue Specialistavailable in Tallahassee,
  Florida and elsewhere.
• Call 850-644-1966.
• Or visit the website for the Traumatology
  Institute (see handout) or at www.greencross.org.

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Workshop Summary,Evaluations,andAdjourn
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1. Summary

• 1.1 Work-related problems leading to compassion
  fatigue burnout is common and may result in
  either an intervention or disciplinary interview.
  
• 1.2 The compassion trap is the inability to let
  go of the thoughts, feelings and emotions useful
  in helping another, long after they are useful.

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• 1.3 Compassion trap taps compassion stress that
  can lead to compassion fatigue burnout, a state
  of extreme dissatisfaction with ones work
  characterized by

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• 1.31 excessive distancing from patients
  
• 1.32 impaired competence 1.33 low energy 1.34
  increased irritability/ other signs

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• 1.4 Symptom categories include the physical,
  emotional, behavioral, work-related, and
  interpersonal symptoms
• 1.5 Compassion fatigue burnout is a state of
  tension and preoccupation with the traumatized
  patients by re-experiencing the traumatic events,
  avoidance/numbing of reminders, persistent
  arousal (e.g.. anxiety)

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• 1.6 Preventing it means re-arranging your work
  life, social and your interpersonal life, and
  your own behavior.
• 1.7 Focus on ourselves as much as we focus on our
  clients

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• 1.8 Create a safe haven for compassionate people
  who work with the traumatized
• 1.9 How we will be an instrument for change to
  break the conspiracy of silence about compassion
  fatigue

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• Questions and Answers
• for the Day
• Evaluation of the Workshop
• Adjourn