The Bowles Chapel Lecture for 2014

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

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 more

attention on compassion in health and mental
health care
v  One that involves a spirit of love, wisdom, and

competence by being informed about trauma
and resilience.

Agenda
v  Session One: Violence and the patient, family,

community, and practitioners

Brief Break

v  Session Two: Promoting resilience in

traumatized patients and their families

Brief Break

v  Session Three: Promoting resilience in the

compassionate practitioner

VIEWER ADVISORY
-- considering violent and traumatic
material
v  Secondary trauma is experiencing the fear

and horror second-hand, like second-hand
smoke,
v  The second hand trauma and second hand

smoke are potentially harmful and need to be
managed

Lecture One:
Violence and the patient, family,
community and practitioners
v  Some Terms and Models
v  Violence-related Trauma causes and

consequences

v  The physical, emotional, and spiritual

needs of patients and their families

Part A: Conceptual
Overview
v  The factors, variables, models, and

other tools to help view the
traumatized and understand how
traumatized people behave –
individually as a patient, collectively
in a group, community – resulting
from violence.

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?

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, since

then?
5.  What will happen if it

happens again?

What is violence?
v  The World Health Organization defines

violence as the
intentional

v  use
of
physical
force
or
power

(threatened
or
actual)

v  against
oneself,
another
person,
or

against
a
group
or
community,
that
caused

v  injury,

v  death,

v  psychological
harm,

v  Maltreatment
or

v  deprivation

Types
of
violence
(WHO,
2002)
v Self-Directed Violence Types
v  Suicidal behavior (i.e. attempts,

outcry)
v  Self-abuse. (e.g., self-mutilation)

Collective Violence types
v  I will not be focusing on collective violence, though

the impact of any violence is largely the same.

v  Social collective violence (e.g., lynching, rioting,
vigilantism, and terrorism) and associate with social control

v  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)

Interpersonal Violence
v  Violence within a Family and

Intimate Partnership
v  Violence within a Community

between unrelated individuals
Both have significantly more
importance to trauma dosage and
recovery.

Nature of Violence
v  Physical Nature – traumatic reality of the

potential for being harmed or killed;
v  kinesthetic experiences of body-based

fear;
v  Conditioned dislike for the perpetrator

and anything associated with the trauma

Sexual Nature of Violence
v  – Traumatic

reality potential for physical
and emotional harm;

v  affects sexual functioning and

satisfaction;
v  In addition to negative attitudes toward

perpetrator and associated factors

Psychological Nature of Violence
v  Traumatic reality potential for lasting
v  bonding because of the personal nature of the

violation.
v  Cue to the traumatic memory (i.e., persons, places,
or things) that are linked to the traumatic
experience that often fades in time

v  Connections trigger a fear response and associated

efforts to cope to gain a strong since of safety.

v  But there can often be post-traumatic growth and

resilience

Psychological Nature of Traumatic
Stress Reactions to Violence
v  Connections trigger a fear response and

associated efforts to cope to gain a strong
since of safety.
v  But there can often be post-traumatic

growth and resilience

What is Trauma
v  Trauma is defined as a sudden, potentially

deadly experience, often leaving lasting,
troubling memories
v  It’s both a cause and a consequences – in both

the short and long-term
v  Causes of Trauma: those events – both

internal and external – that significantly
elevates stress reaction baseline.

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 (initial

meaning)

v  Phase IV the Long-term Reactions and

Recovery (new meaning)

Retraumatization
v  Defined as reliving a trauma and

experiencing similar traumatic stress
reactions again, though usually to a
lesser degree.
v  During retraumatization, the memories
associated with the trauma are
reawakened.

Retraumatization
v  Most survivors are able to work

through 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.

How are we doing?
Need for Counter-balancing
v  “Every class I teach ends with a counterbalancing

exercise. Sometimes we sing. Sometimes we
dance. It depends on the room and trainees. But
everything I try to make them smile. That’s the
indicator of counterbalancing.”

v  --Kathleen Regan Figley

v  Options: laughing (audience jokes), smiling while, standing

up and making a fool of yourself;

v 

singing – “. . . when you’re smiling, when you’re smiling,
the whole world smiles with you.”

Safe Place Visualization (SPV)
v  You can imagine it right now.
v  You can shut your eyes and block out the

sounds and the thoughts from here.
v  Shut your eyes and imagine yourself

sitting in this safe place and taking in
everything and letting everything else go.

After the break:
v  Shifting from the experience of

trauma to healing from trauma
v  After the break we will address what

can best be done for
v  our patients and their families
v  to enable them to heal from

traumatic events

Lecture Two:
Promoting Resilience in Traumatized
Patients and their Families
v  Purpose: This lecture will focus on what is

critically important in order for trauma
survivors (e.g., from community violence) to
recover from violence and other frightening
experiences; bolstering their trauma resilience.

Promoting Resilience in traumatized
Patients and their Families
v  What is promoting trauma

resilience?
v  What is a traumatized patient?
v  What is a traumatized patient

family?

What is promoting trauma
resilience in medical settings?
v  If trauma resilience is “. . . recovering from

the impacts of trauma quickly and
completely in the five Resilience
Capabilities areas of functioning,”

v  How best to promote the five capabilities

among the patients and their families?

v  They will be discussed in the final lecture.

Helping the patient’s family help
v  Helping the patient through the family to
v  (a) reduce the additional sources of

traumatic stress (e.g. case work with an
assigned agency)
v  (b) avoid re-traumatization (e.g., be

prepare;, keep the patient safe and
informed);

Helping the traumatized patient
v  (c) establishing a safe and reliable

environment, and;
v  (d) help families help the other

family members troubled by trauma.
v  (e) provide trauma-informed care.

What is a traumatized patient
family?
v  Family self identified as supporters of the

traumatized patient

v  Members are dealing with both primary

and the secondary trauma in their lives and
the interpersonal disruptions in family care,
protection, and stability.

v  The symptoms are primarily chronic stress

reactions associated with traumatic
memories that are often cued by other
family members.

What is Trauma-Informed Care?
v  An
approach
to
engaging
people
with

histories
of
trauma
–
including
patients

with
major
mental
illness
–

v 
in
a
way
that
recognizes
the
presence
of

v  trauma
symptoms
and

v  acknowledges
the
role
that
trauma
has

played
in
their
lives.

v  Trauma-informed human service

programs

v Include every part of its organization,

management, and service delivery
system

v Services represent at least a basic
understanding of how trauma affects
the life of an individual seeking
services.

What is Trauma-informed Care for
communities, families, and organizations?
v  Based on an understanding of the

vulnerabilities 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.

v  Referral
services
for
mental
health,

substance
abuse,
housing,
vocational
or

employment
support,
domestic
violence,

victim
assistance,
and
peer
support.

v  Trauma-‐informed
care
involves
NOT

asking
"What's
wrong
with
you?"

v  But
rather
asks,
"What
has
happened
to

you?
And
How
can
we
help?

Retraumatization may lead to
treatment
v  Some people, however, experience

retraumatization 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

Retraumatization symptoms
v  Nightmares and flashbacks,
v  Re-experience many of the initial

negative 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

Retraumatization Triggering
Events
v  A triggering event is something that

immediately reminds you, your family, or
your community of a fear that was
experienced during the original trauma.
v  These events can include anniversary time

frames, news stories of similar incidents,
similar disasters or threats of disaster, and
sometimes even experiences that seem
unrelated.

Retraumatization Symptoms
v  Often relived it in any or all of the following five

ways:

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.

Retraumatization Symptoms (cont.)
3.  Social withdrawal and isolation or an

excessive 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.

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.

Managing Retraumatization
v  Once there is recognition a patient is

experiencing 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.

Managing Retraumatization (cont.)
v  Appreciate ways to prevent the impact

by 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 patient’s
trauma memories.

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 patient’s
trauma memories and eliminate the
retraumatization symptoms.

Trauma Resilience and Protective
Factors
v  Resilience is the degree to which a person

or group of people effectively cope with a
traumatic event without experiencing
retraumatization.
v  Protective factors can also be considered

“signs of resilience” and can help you
prevent retraumatization from occurring in
the first place.

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.

Factors
3.  Good coping skills, such as, being effective at

managing 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.

What are Trauma-informed
Interventions?
v  Trauma-speciﬁc interventions are designed

speciﬁcally 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

•

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

Example:
Trea,ng
Trauma,zed

Families
v  The model (Figley & Kiser, 2013) is intended for

use by social workers and others working with
families with chronic challenges.

v  The model guides the collection and discussion

of key data to determine the family clients’
resilience (i.e., adaptation to trauma).

v  The model helps determine where the family ﬁts

on a spectrum of adaptation.

The Bowles Chapel Lecture for 2014

Conclusion
v  Violence is fundamentally traumatic.
v  Traumatized patients and their families, irrespective of

the 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 caregiver’s

secondary traumatization and promoting resilience.

Lecture 3
Promoting Resilience in the Compassionate Healer
v  Objectives: Identify the secondary affects upon the

medical 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 resilience

in the health professional who works with the
traumatized and those affected by violence.

Violence Impact on Trauma
Workers (see 17 min video)
v  Identify the symptoms of secondary trauma as it

affects trauma workers

v  Listen to the Norwegian psychologist who worked

with traumatized children

v  Listen for what these trauma workers, including

healers here in hospitals, need to build up their
resilience

v  Available at http://www.giftfromwithin.org/html/

When-Helping-Hurts-Sustaining-TraumaWorkers.html#4

Lecture 3
Promoting Resilience in the Compassionate
Healer
v  What is promoting resilience?
v  Who are compassionate healers?
v  How are resilience levels among healers

determined?

Lecture 3
Promoting Resilience in the Compassionate Healer
v  Who are compassionate healers?
v  Those who display compassion as

professionals working in the health
professions – physicians, nurses,
administration personnel who also work
with patients and their families.

Resilience Level of Functioning
Spectrum
v  Most professionals operate at the

top resilience levels of functioning
(Levels 1 or 2)
v  But those who are functioning at

Level 3 or below require attention
that is often not provided

Spectrum-specified Services
Knowing the level of functioning will

v  Help quickly determine who needs help that

stimulate trauma resilience.
v  Help promote thriving in both the

traumatized and the worker
v  Table 1 is a guide to determining where we

are on the spectrum of resilience functioning

Resilience Capabilities
The capacity to utilize critical
protective factors of trauma resilience
in five domains.
See Figure 2.

Figure 1. Capabilities Contributing
to Resilience
Interpersonally
Psychologically

capable (measured by
level of social support
and cohesion with
group)

level of enthusiasm,
intellectual capability,
morale, spiritual
support)

Physically

capable (measured

by level of energy due
to sleep, health)

Technically

standard productivity,
client satisfaction, and
competence scales)

Personally

Resilience

Capable (measured by

the self care plan and
following; other measures
of self regulation
competencies)

Five trauma resilience
capabilities
1. 

Physically capable (measured by level of energy due to sleep,

2. 

Psychologically capable (measured by level of

3. 

Interpersonally capable (measured by level of social

4. 

Technically capable (measured by standard productivity, client

5. 

Self (Care) Regulation capable (measured by the

nutrition, 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)

Spectrum Resilience Levels
Determined by the 5 Capabilities
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
capabilities

Challenged in
1 of the 5
capabilities

Challenged in
2 of the 5
capabilities

Challenged in
3 of the 5
capabilities

Failing in 1 or
more
capabilities

Action:
Provide
coaching and
peer support

Action:
Implement
Explicit plan
immediately

Action:
Immediate
behavioral
health
services

Action: Train Action:
and coach
Maintain
others on the
team

Level 5 - Highly
Resilient

v  No challenges in the five capabilities
v  Train and coach others on the team
v  Important to determine how best to

recruit and retain highly resilient
workers

Level 4 - Resilient
v  Good functioning
v  Challenged in 1 provider capability

element (e.g., lowered physical
capabilities perhaps due to lack of
sleep or health challenges)

Level 3 – Challenged
Resilience
v  Challenged in 2 functions (e.g., lowered

psychological 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 and

peer support

Level 2 – Supported
Resilience
v  Unacceptable functioning with clear message of

concern to the survivor/worker and specific
requirements for improvement associated with
specific help in making the improvements

v  Challenged in 3 or 4 functions (e.g., Self Care

Regulation)

v  Explicit plan implemented for addressing resilience

promotion

Level 1 – Failed
Resilience
v  Failing in 1 or more capabilities
v  (e.g., significant reduction in the worker’s Technical

capabilities 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

Building Resilience -Assessment
v  Self capabilities to identify

strengths and weaknesses
v  Mutual Support System Inventory
v Work-based support
v Friends of the same gender
v Love relationships

Building Resilience –
Self Care Plan Development
v  Limiting the stressors
v Both at home and at work
v  Building stress management

capabilities

v Monitoring and reducing stress

during the day
v Able to go to sleep and stay
asleep

v Review all capabilities and

determine where you are on the
chart
v  Eliminating unhealthy habits
v Eating, drinking, with moderation

v  Building in joy and a program for

increasing it

Special Note to Physicians and
Nurses

v  Sir William Osler spoken to young doctors in 1889

v  A distressing feature in the life which you are about to

enter, 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]

Conclusions
v  The traumatized deserve our best technical

and personal care;
v  they must learn to bolster their own

resources;
v  to take the lessons of being traumatized and

surviving;
v  To answer the five questions and plan their

lives accordingly.

Conclusions (cont.)
v  Community violence workers sometime

wonder how they are functioning, concerned
about the symptoms they are experiencing;
v  Now there is a way of assessment and

investigating capability inadequacies to guide
worker training and preparation, including
doctors.

Conclusions (cont.)
v  Trauma resilience is being well-prepared for

future traumas
v  The focus here is on building up worker

resilience for better stress management – of
both acute and chronic stressors.

v  Trauma resilience capabilities indicators

direct trauma resilience development

Conclusions
Trauma Resilience Promotion is the
responsibility of all of us for each
other.
This is especially the responsibility of
leadership.

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.

Questions and
Observations
Contacts: 504-862-3473
Slides available: contacting

FIGLEY@TULANE.EDU

The Bowles Chapel Lecture for 2014

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