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UBC Faculty of Medicine Retreat

Healthy Docs: A toolkit for supporting

resident wellness

Grief and Working With It

November 4th, 2014

Douglas Cave, MSW RSW, PhD, RPsych, MA, AMP, MCFP

Paul Whitehead, PhD, CCC, RPsych

Hilary Pearson, MA, PhD, CCC

Disclosures

We have no disclosures to make regarding

commercial interests.

We do not have any conflict of interests with

regard to this presentation.

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Outline

1. The Centre for Practitioner Renewal

2. Grief and Relationship

3. Self awareness

4. The complexity of grief for HCPs

5. Responding supportively

1. Psychological First Aid

2. ABCD Communication Model

6. Closing

Core Messages

Relationships that are maintained can sustain

The past is always present

Self awareness is a key tool

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Centre for Practitioner Renewal (CPR)

Health care is about living/dying, curing/healing; art/science, mind/heart, skills/knowledge, technology/compassion

Health care is based on a business model of efficiency, the work we do is about relationship—relationship with self, other and Other

Relationship is often sacrificed to action and efficiency

© Centre for Practitioner Renewal

Centre for Practitioner Renewal

How do we sustain health care providers in the work

place?

What is the effect of being in the presence of suffering?

What would be reparative, healing or restore resilience

for health care providers?

“Efficiency Through Relationship”

CanMEDS Roles

Explicit Curriculum includes relationships: Medical Expert

Communicator

Collaborator

Manager

Professional

Scholar

Advocate

Hidden Curriculum discourages disclosure of

vulnerability

Our Experience at CPR

Sustaining Healthcare Providers in the workplace:

Burnout / Compassion Fatigue / Vicarious

Trauma / Moral Distress / Grief / Depression

/ Anxiety

and

“Lateral Stress” among colleagues

© Centre for Practitioner Renewal

Chart Review Data

Referral Reasons Frequencies Examples

L M S Total

Emotional reactions about work 1 7 13 21 Overwhelmed by work after

learning of colleague’s severe

criticisms

Family/ relationship issues 6 1 10 17 Relationship issues related to 20-

year marriage

Misc. 5 4 8 17 Feeling apologetic for living

Stress/ cumulative stress 5 1 9 15 Stress at work from relationship

with colleague

© Centre for Practitioner Renewal

Grief

Grief

Change

Loss

Anger/Rage

Sadness

LethargyIsolation

Uncertainty/Fear

Impact on Relationships

Grief

Grief is wanting more of what one will never get

again.

Grief begets grief (Grief of the past creeps into

the present)

Variable in duration

Differentiation:

Grief (Acute adjustment stage)

Mourning (Long term sadness due to loss)

Simple vs. Complex Grief

Simple grief

Single event, or not complicated by previous/other events

Complex grief

Accumulated over a number of events that were not completely processed

Conscious and unconscious layers of acute loss and sadness that resist processing

Symptoms of ―Complicated Grief‖ (Horowitz, 1997) are similar to Post Traumatic Stress

Vital Importance of Relationships

(self, other and Other)

Emotional self-regulation is learned through

early attachment bonds

Most effective resource for stress management

= social support

Personal sense of meaning, achievement, future

orientation involve core relationships

―Emotional cut-off‖ in response to acute stress

or grief can be deadly

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Responding to Resident Grief

A resident’s grief can result in a loss of his or her sense of identity or competence as a physician

A ―first disclosure‖ is a risk that makes the resident vulnerable to shame/rejection

The way we respond to the other’s vulnerability depends on how well we have processed our own

Self Awareness

To understand ourselves we have to be understood by

another.

To understand another we have to understand ourselves.

Watzlawick, Beavan & Jackson, 1967

Reflection on an Early Loss

Think back to one of your early experiences of loss. This may have been of a person, a pet, loss of connection to home and friends if your family relocated, or loss of a dream.

What happened?

How old were you at the time?

Who was present?

Who comforted you (or did you feel alone)?

What, if anything, would you have wanted to be different?

As you reflect on this event, how does it impact you today?

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Guidelines to Create Safety

C onfidentiality

E qual airtime

N on-judgemental listening

T imeliness

R ight to pass

E ngaged

Emotional Processing for HCPs

Papadatou 2000 – Model of HCPs grieving

process

Stroebe & Schut 2008 – Dual Process Model of

Coping with Bereavement

Whitehead 2012 – The Lived Experience of

Physicians Dealing with Patient Death

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Emotional Processing for HCPs:

Grief Model from Papadatou (2000)

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Physicians Dealing with Patient Death (Whitehead, 2012)

Key Theme: Action versus Presence

Action Mode

Acute situations – Life or Death

Focus on pre-established protocols or pathways

Reduced personal/emotional experience

Presence Mode

Calmer situations – No immediate intervention needed

Focus on mindful awareness of self and other

Greater receptivity to new information/connection

The “Functional Disconnect” Whitehead, 2012

Emotional Disconnect – a part of

Burnout

Compassion Fatigue

Vicarious / Secondary traumatic stress

Functional Disconnect

Functional because of a balancing ―emotional re-connect‖

Allows emotional distance as a tool to remain functional

Disconnect can be generated by focusing on protocols

Reconnect can be generated by focusing on mindfulness

Psychological First Aid

World Health Organization PFA manual:

Look (establish safety)

Listen (empathize, establish relationship)

Link (expand relationships, provide resources)

Psychological First Aid

World Health Organization PFA manual:

Look (establish safety)

Listen (empathize, establish relationship)

Link (expand relationships, provide resources)

Herman (1992) Trauma Recovery Model:

Safety

Remembrance / Mourning

Reconnection

Resident Resilience Committee

Flowchart

Communication Template

A ttend

B ridge

C omment

D evelop Relationship / Plan

Communication Template

Attend

Self: What am I experiencing? What am I aware of

within myself?

Other: What is the other person experiencing?

Context: What is happening around us right now?

Bridge

Ask if it is a good time to talk

Introduce topic / Invite conversation

Communication Template

Comment Deliver message

Check for understanding

Develop Relationship / Plan Acknowledge impact on other person

Establish time-line/follow-up

Commitments:

Self care

Resident support

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Centre for Practitioner Renewal

www.practitionerrenewal.ca

© Centre for Practitioner Renewal