Introduction to Resilience Training and Post Traumatic Growth

Transcription

1 Introduction to Resilience Training and Post Traumatic Growth Brian R. Davis, MD Associate Professor, Residency Program Director Texas Tech University Health Sciences Center El Paso May 16, 2018

2 Objectives - Describe how empathic engagement challenges cognitive schema and assists in adaptation to traumatic life events. - Outline how organizations can provide individual recognition and treatment for the emotional costs and burdens of surgical work. - Generate agendas for building resilience coping skills and team-based connections that promote post-traumatic growth.

3 The Hero s Journey

4 Incidence of PTSD in Trauma Surgeons -Trauma surgeon national survey- PTSD symptoms were present in 40% (181/453)-15% met diagnostic criteria for PTSD. -PTSD is a disabling psychological condition that occurs in military combat veterans and emergency first responders with a prevalence 10 times that of the general population.

5 Secondary Traumatic Stress (STS) -Factors: 1) how intimately the provider is connected to the traumatic event; 2) provider s perception of how extreme the event was; and 3) the length of time the provider was involved -Warren et al Article Does caring for trauma patients lead to psychological stress in surgeons : 22% of surgeons met diagnostic criteria for PTSD and 65% met exhibited one symptom of STS. Journal of Trauma 2013

6 Signs of PTSD -Insomnia / disrupted sleep cycle. -Irritability / short temper / anger outburst. -Hypersensitivity to noise and surprises. -Social isolation. -Poor frontal cortical function. -Association with drug and alcohol abuse.

7 R0 The Seventh Competency -Resilience training can and should be developed for each specialty to reflect unique stressors. -Dynamic factors such as social network connectivity, rationalizing behavior, and access to family and spiritual support can be measured. -Critical events can be tested to determine recovery periods.

8 Resilience Scales -Resilience refers to how an individual reacts and adapts to a traumatic event. Individuals with greater resilience overcome a traumatic event more successfully than individuals with low resilience. -Connor-Davidson Resilience Scale- measures resilience as a predictor of outcome to treatment with medication or psychotherapy, stress management and resilience building- marker of progress in treatment.

9 AMA Program STEPS Forward -Write down your individual mission statement. -Write down inspiring patient stories. -Consider the legacy you want to leave behind. -Start a gratitude journal. -Find support in groups outside of work. -Find personal meaning outside of work. Claudia Finkelstein, University of Washington

10 Post Traumatic Growth (PTG) -Social network analysis and psychological recovery tools can help individual members cope with grief cycle of shorten the rebound cycle. -Team building and group cohesion are critical to processing negative emotions and survivor guilt. -Debriefing to include psychological stressor role assessment and counseling is important whether after mass casualty or routine deaths in the ER.

11 Cultivating PTG -Evidence indicates that exposure to battlefield trauma may lead to different outcomes than terrorism or traffic accidents. -PTSD affects self-related cognitions and self efficacy more in individualistic cultures. -Collectivistic cultures may adapt more effectively through functional social support which reduces negative consequences of trauma.

12 Cognitive Behavioral Therapy (CBT) -Several studies show equal efficacy to antidepressants and other medication for CBT. -Group facilitators do not require medical training. -High prevalence low cost solution for veterans with PTSD and others recovering from traumatic events.

13 Social Cognitive Theory - Based on triadic reciprocal determinism as interactions between the environment, individual factors, and behavior. - Self-regulation is the key mechanism adaptation. - Functions through internal feedback processes that aim at recalibrating efforts toward desired outcomes especially toward reduction of negative emotional states. -Bandura 1996

14 Self Efficacy Education - Self- efficacy is the perceived ability to manage environmental demands and personal functioning after adverse traumatic experiences. - Practice self- efficacy perception creates adaptation in anticipation of exposure to major trauma and life stressors. - Healthcare workers should be educated about the importance of enhancing specific self-efficacy perceptions and about the role of efficacy beliefs in fostering PTG.

15 Constructivist Self-Development Theory - Individuals construct their realities through development of cognitive structures or schemas that include beliefs, assumptions and expectations. - Trauma challenges individual s schemas and triggrers cognitive processes that can result in no change (assimilation), positive change (positive accommodation) or negative change (negative accommodation).

16 Positive Accommodation -Examples include gaining a new appreciation for spiritual paths, heightened awareness of the individuals good fortune, and a strengthened sense of optimism. -Predictors of post-traumatic growth include higher levels of sense of coherence, empathy, social support and organizational support.

17 Flipping Consciousness - Flipping occurs most frequently in flow states or when in the zone while immersed in high adrenaline activities that shut down the inner critical function of the prefrontal cortex. - Meditation can be a form of negative or lack of sensory flow which can take time and resources to cultivate. - New perspectives and revelations more readily appear when the habitual inner critic is silenced and alternative coping strategies emerge.

18 Controlling the Narrative -Flipping off the shame switch allows new options and alternative stories to arise which reflect passion and courage rather than defeat and failure. - Challenges to schema allow a window for breakthrough behavioral changes in teams and organizations that create adaptive change.

19 Immersion and De-Conditioning -Wake Up-Change Comes from Within

20 Organizational Factors in PTG -Managing and diversifying workload. -Promoting a non-authoritative evaluation style and inclusive work style- team STEPPS. -Debriefing sessions in peer small groups should allow expression of negative emotions.

21 Self-Care Behavior Promotion -Promotion of workplace exercise facilities. -Training in meditation and mind-fullness exercises. -Conscious and intentional effort to engage in pleasurable activities to disconnect and tune-out from thinking about work

22 Political Activism -Outreach and activism can help combat the cynicism and channel the anger that the work triggered. -Public outreach events can promote personal self efficacy and counter perceptions of helplessness. -Public education can be effective to reduce accidents and injury as well as reinforcing the provider s hero narrative.

23 Spirituality -Spiritual practices buffer the negative impact as a coping mechanism that counters isolation and despair. -Provides meaning for the participant s workidentity as part of a faith community is related to lower levels of stress. -Post traumatic growth occurs when events reinforce faith and spiritual beliefs whether from outcomes or peer support.

24 Sense of Safety -View of the world as unsafe may occur following trauma creating a cynical dark view of reality. -Increased awareness of potential personal vulnerability can occur-this can manifest in mistrusting others. -Creates organizational challenge to embrace safe spaces for critical feedback and professional growth.

25 Importance of Organization Recognition -Trauma victim survivor days help reinforce positive outcomes years later. -Organizations should recognize and effects and emotional costs of surgical work to include storytelling and narrative competitions. -Optimism takes perpetual cultivation and is a resilience factor that play an important part in all aspects of post-traumatic growth.

26 Dissipative Structures -The integrity of the self depends on the ability to take neutral or destructive events and turn them into positive changes in belief and behavioral schema. -Unconscious self assurance- implicit belief that one s destiny is in the hands of a higher power. -Focus attention on the world- socially conditioned desires. -Discovery of new solutions- perceive unexpected opportunities.

27 Unconscious Self Assurance -Energy is not bent on dominating the environment as much as finding a way to function within it harmoniously. -Recognition that personal goals may have to be subordinated to a greater entity and that to succeed one may have to play by a different set of rules. -Strong component for organizational psychology to define and shape morale in surgical teams.

28 Focus Attention on the World -An open stance makes it possible for a person to be objective and aware of alternative possibilities and sense union with the surrounding world. -To experience psychic entropy one must concentrate on the internal disorder- the goal is to disrupt the cycle of isolation and shame.

29 Discovery of New Solutions -Transformation requires a person be prepared to perceive unexpected opportunities that present as a result of fracture of the ruts carved by genetic programming and social conditioning. -Training in resilience and post-traumatic growth aims to shorten the span between grief over outcomes and revelations from hidden opportunities that result from breakthroughs when cognitive schema are challenged by trauma.

30 Stress Inoculation Training -Taught for police first responders for live shooter events in schools and other settings. Active component of military training. Historical part of surgical training. -Simulation training with stress induction can demonstrate areas for critical thinking and algorithm modification to adapt to high adrenaline environments.

31 Psychological Drown-Proofing

32 Conclusions - Growth is a habit and mind-set. - Organizational strategies should include education and intervention to prevent complications of burnout. - Insightful creative solutions can come from an open culture that cultivates safety and teamwork over guilt and shaming.