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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
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