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TREATING THE WOUNDED HEALER
Audio-Digest Psychology
Volume 02, Issue 01
January 7, 2013

Review of crises, stressors, and traumas, Work culture for health care professionals, “Mentalizing” and attachment theory, Process of narration, Educational experiences and Promote healing and sustain wellness – Michael D. Groat, PhD
  
From Leadership In Healthcare Education: Recalibrating Our Ethical Compass, From The 42nd Anniversary Meeting Of The Association For The Behavioral Sciences And Medical Education
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Psychology Program Info  Accreditation InfoCultural & Linguistic Competency Resources

<p class="Title2">Treating the Wounded Healer</p> <p class="subtitle para-style-override-1">From Leadership in Healthcare Education: Recalibrating Our Ethical Compass, from the 42nd Anniversary Meeting of the Association for the Behavioral Sciences and Medical Education</p> <p class="subtitle para-style-override-1"><span class="char-style-override-1">Michael D. Groat, PhD, </span>Assistant Professor of Psychiatry and Behavioral Sciences, Baylor College of Medicine, and Director, Professionals in Crisis Program, The Menninger Clinic, Houston, TX</p> <p class="EOsh">Educational Objectives</p> <p class="EOs">The goals of this program are to improve treatment of medical professionals in distress and to minimize clinician distress and burn-out by fostering a healthier professional culture. After hearing and assimilating this program, the clinician will be better able to:</p> <p class="EOsl">1. Describe common causes of stress and distress faced by individuals working in the health care professions.</p> <p class="EOsl">2. Identify a patient’s attachment style and how his or her attachments affect levels of distress.</p> <p class="EOsl"><span> 3. Teach professionals how to apply mentalizing and mindfulness to reduce their own stress, as well as the stress of others.</span></p> <p class="EOsl">4. Establish a health care culture that removes shame and stigma associated with seeking mental health care.</p> <p class="EOsl">5. Promote “authorship” as a means of helping patients play a role in their own recovery.</p> <p class="EOsh">Faculty Disclosure</p> <p class="EOs">In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Groat and the planning committee reported nothing to disclose.</p> <p class="Bold"><span class="char-style-override-2">Process of narration: </span><span class="char-style-override-3">allows individuals to bear experiences of joy, pain, difficulty, and stress</span></p> <p class="Bold"><span class="char-style-override-2">Common issues in physicians seeking psychiatric care: </span><span class="char-style-override-3">high levels of stress; depression (most common complaint; frequently comorbid with substance abuse); insomnia; disturbances in subjective experience of “peacefulness, tranquility, and contentment”</span></p> <p class="Bold"><span class="char-style-override-2">Speaker’s inpatient program for medical professionals in crisis: </span><span class="char-style-override-3">length of stay averages 6 to 8 wk; has psychotherapeutic focus; program duration allows time to build deeper familiarity, explore patients’ stories, and process their crises into larger narrative context; treats professionals contemplating suicide due to “intolerable emotional and psychologic pain”; helps build resilience toward suicidal despair (addresses drivers of suicidality)</span></p> <p class="Bold"><span class="char-style-override-2">Most common stressors: </span><span class="char-style-override-4">physicians</span><span class="char-style-override-3"> — increased administrative burdens; limited resources; pressures to cut costs; </span><span class="char-style-override-4">nurses</span><span class="char-style-override-3"> — “compassion fatigue”; staff shortages (typically resulting in longer hours); high workloads; difficulties with teamwork (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">not feeling heard and respected); </span><span class="char-style-override-4">pharmacists</span><span class="char-style-override-3"> — high workloads; uncooperative patients; lack of information when dealing with complex pharmacology</span></p> <p class="Boldf"><span class="char-style-override-2">Distress: </span><span class="char-style-override-3">frequently accompanies stress; represents anguish, anxiety, pain, and affliction; often becomes intolerable; capable of inducing lasting trauma; in order to release stress accumulated over constant encounters with suffering, professionals require space to contain and receive support </span></p> <p class="First"><span class="char-style-override-3">Drivers of distress:</span><span class="char-style-override-2"> </span><span class="char-style-override-3">attempting to address enormous needs without necessary resources; work-related demands; requirements for documentation; compassion fatigue (from, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">attempting to help patients trapped in deplorable circumstances); accountability for situations beyond any physician’s control; intense identification with or empathy for patients; unprocessed traumatic experiences (contribute to stress, exhaustion, distancing or detachment); time spent with patients experiencing suicidal ideations and deep despair; sense of great traumatic loss and doubt after patients complete suicide</span></p> <p class="Bold para-style-override-2"><span class="char-style-override-1">The Role of Secure Attachment in <br /> Reducing Distress and Illness</span></p> <p class="Bold"><span class="char-style-override-2">Attachment and developmental challenges: </span><span class="char-style-override-3">according to attachment theory, individuals cannot manage distress entirely by themselves; expectation of support from others (particularly when distressed) forms during early childhood; this support enables development of sense of freedom to explore our world; substantial research documents persistence of need for attachment throughout lifespan; stress regulation through attachment begins immediately after birth (</span><span class="char-style-override-4">ie</span><span class="char-style-override-3">, infants have their basic needs and sense of security fulfilled through caregivers); as children mature, they require assistance with new types of regulation (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">identity formation, sustaining relationships and careers, feeling generative instead of stagnant); later in life, attachment helps individuals feel that they stayed true to their values and accomplished meaningful goals (as opposed to feeling despair and regret); those who attempt these challenges alone typically struggle</span></p> <p class="Bold"><span class="char-style-override-2">Benefits of reaching out: </span><span class="char-style-override-3">research continually reaffirms enormous power of sharing experiences with relatable and understanding peers; sharing prevents individuals from feeling alone and cultivates sense of belonging; exchanging stories can help members of groups empathize with one another by revealing common experiences; individuals who process their experiences by sharing show lower rates of psychopathology, fewer signs of distress, and greater resilience (over time)</span></p> <p class="Bold"><span class="char-style-override-2">Conclusions on attachment: </span><span class="char-style-override-3">humans have innate needs for contact with other humans; developing relationships with individuals who provide support and “safe havens” helps mitigate day-to-day stress </span></p> <p class="Bold"><span class="char-style-override-2">Speaker’s definition of trauma: </span><span class="char-style-override-3">unbearable emotional experience dealt with alone</span></p> <p class="Bold"><span class="char-style-override-2">Assessing attachment: </span><span class="char-style-override-3">critical component of speaker’s practice; requires detailed assessment of patient’s history (including nature of connections to others, use of others while facing distress); 87% of patients in speaker’s clinic demonstrate insecure forms of attachment, and therefore have difficulty managing distress</span></p> <p class="Bold"><span class="char-style-override-2">Prototypes of insecure attachment: </span><span class="char-style-override-4">fearful-avoidant</span><span class="char-style-override-3"> — individuals who desire contact when distressed, but avoid seeking help due to anxiety about, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">losing face, appearing weak, rejection, disapproval, ostracization, stigmatization; may manifest as lifelong fear, and keep patients from receiving necessary care; </span><span class="char-style-override-4">avoidant-dismissive</span><span class="char-style-override-3"> — most common attachment pattern in physicians; these individuals view themselves as experts who can tirelessly provide support for others, and maintain their role until faced with collapse due to overwhelming stress and accumulated trauma; patients who avoid seeking help often feel intense embarrassment, shame, and humiliation about needing assistance; failure to access necessary help leaves individuals with increased vulnerability to stress-related disorders (including depression)</span></p> <p class="Bold"><span class="char-style-override-2">Depression and stress: </span><span class="char-style-override-3">research provides abundant evidence of link between depression and accumulated stressful life experiences; stress may arise from internal pressures (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">, self-imposed pressures and demands related to performance) and external pressures; data show that individuals have greater vulnerability to illness in absence of supportive relationships</span></p> <p class="Bold para-style-override-3"><span class="char-style-override-5">Mentalizing</span></p> <p class="Bold"><span class="char-style-override-3">Background: large bodies of research link process of mentalizing to development of secure attachment; originally described general mental states; more recently applied to “theory of mind” in children with autism spectrum disorders (in reference to their difficulty understanding minds of others, lack of social cognition, inability to comprehend internal experiences [in themselves and others]); studies of autism have spurred new literature on impairments in mentalizing, and how to promote mentalization as defense against psychopathology; individuals develop greater attachment after perceiving they have been mentalized </span></p> <p class="Bold"><span class="char-style-override-2">Mindfulness: </span><span class="char-style-override-3">promoted as stress management tool; focuses on induction of relaxation response through, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">deep breathing, increased awareness of present moment and total sensorium (including, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">lights, temperature, sounds); mentalizing requires individuals to maintain mindfulness by seeking better comprehension of their internal experiences through their own efforts and insights of others</span></p> <p class="Bold"><span class="char-style-override-2">Benefits of mentalization:</span><span class="char-style-override-3"> developmental and clinical research strongly links effective self-directed mentalization with greater degrees of self-regulation (</span><span class="char-style-override-4">ie</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">greater management of distress); helps individuals recognize when stress cannot be managed solely by themselves; this recognition fosters connections with peers, who can help reduce stress through assisting with mentalization (</span><span class="char-style-override-4">ie</span><span class="char-style-override-3">, by providing empathic understanding and demonstrating concern) </span></p> <p class="Bold"><span class="char-style-override-2">Helping others through mentalization: </span><span class="char-style-override-3">reflecting on experiences of others allows linking of traumatic events (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">death of patient) with negative emotions and morale; helping individuals link external events with internal experiences and reactions can help relieve distress </span></p> <p class="Bold"><span class="char-style-override-2">Mentalizing stance: </span><span class="char-style-override-3">ability to maintain attitude of “inquisitiveness, curiosity, and wonder” while attempting to understand others; requires that practitioners avoid assumptions and allow others to share their stories and experiences</span></p> <p class="Bold"><span class="char-style-override-2">Traumatic stress: </span><span class="char-style-override-3">overwhelming form of stress; leads to despair, angst, and insomnia; results from singular experience with strong significance or accumulations of smaller stressors; all forms of trauma evoke distress, and lead to hyperactivated limbic systems and downregulation of activity in prefrontal cortex (area primarily responsible for self-reflection, judgment, foresight, and slow and precise deliberation); receiving support from others helps individuals to cope, process traumatic events, find perspective, and form cohesive narratives from their experiences</span></p> <p class="Bold"><span class="char-style-override-2">Importance in promoting health: </span><span class="char-style-override-3">health care cultures can create insecurity by encouraging professionals to deal with their traumas and stressors alone; to prevent this, employees must know where to find support, empathy, and mentalization (</span><span class="char-style-override-4">ie</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">others who notice and mind their experiences); institutional deficits in mentalization can promote distrust, insecurity, and feelings of isolation</span></p> <p class="Bold"><span class="char-style-override-2">Long-term goals: </span><span class="char-style-override-3">recognize concrete value of trust and human connections while attempting to meet increasing service needs and demands; creating situations and contexts in which subjective experiences can receive empathic consideration and responses (in environments in which individuals feel safe and free to take risks by sharing); once accomplished, these goals provide professionals with basic tools necessary to replicate these benefits for others</span></p> <p class="Bold"><span class="char-style-override-2">Speaker’s debriefing process for traumatic events: </span><span class="char-style-override-3">when improperly processed, trauma leaves lasting impressions on clinicians and affects interactions with future patients; speaker frames process as educational, and conducts in-depth interviews about clinicians’ experiences of traumatic events (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">suicide of patient); attempt to isolate common themes from interviews and present themes to entire group for reaction (while maintaining confidentiality in any shared statements); this sharing creates space for discussion and relieves distress</span></p> <p class="Bold"><span class="char-style-override-2">Goals when mentalizing another individual: </span><span class="char-style-override-3">listening to and understanding experiences; assessing how they define their experiences; validating subjective experiences</span></p> <p class="Bold"><span class="char-style-override-2">Authorship: </span><span class="char-style-override-3">driven by need to assist in one’s own recovery and examine one’s role in perpetuating personal difficulties (in order to understand and optimize responses); promotes conscious reflective awareness by encouraging individuals to consider how they would choose to verbalize their experiences; requires patients to evaluate any routines or “scripts” they regularly follow, how these scripts contribute to their condition, which aspects of script remain under personal control, and whether scripts may be shifted to, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">include greater self-care; these shifts allow change, but getting patients to consider alternatives often requires deep contextual knowledge of their personal narrative and history</span></p> <p class="Bold para-style-override-4"><span class="char-style-override-5">New Patients</span></p> <p class="Bold"><span class="char-style-override-2">Evaluating attachment styles: </span><span class="char-style-override-3">important during early treatment; </span><span class="char-style-override-4">secure attachment</span><span class="char-style-override-3"> — fosters confidence in availability of supportive and emotionally responsive individuals; seen in minority of speaker’s patients; these individuals typically seek help after first serious depressive episode (sometimes during late life), and do not have personal objections to reaching out for help; </span><span class="char-style-override-4">avoidant-dismissive attachment</span><span class="char-style-override-3"> — associated with reluctance to ask for help or perceiving one’s need for help as weakness; these individuals often seek help only when forced to do so by external pressures (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">, possible loss of privileges, insistence by spouse); </span><span class="char-style-override-4">fearful-avoidant attachment</span><span class="char-style-override-3"> — individuals often appear healthy during superficial assessments but may harbor tremendous amounts of hidden distress (due to fears about reactions of others)</span></p> <p class="Bold"><span class="char-style-override-2">Treatment based on attachment styles: </span><span class="char-style-override-3">understanding how patients relate to others provides insight into how to best manage distress and encourage healing;</span><span class="char-style-override-4"> avoidant-dismissive</span><span class="char-style-override-3"> </span><span class="char-style-override-4">style — </span><span class="char-style-override-3">since these patients strive to maintain independence during distress, clinicians must consider how to best respect their autonomy (by, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">emphasizing how receiving treatment makes them more effective, rather than dependent); begin by offering these patients more practical help (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">career advice), before slowly attempting to engage them in their narrative experiences (by, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">telling stories about sources of stress)</span><span class="char-style-override-2">; </span><span class="char-style-override-3">find ways to destigmatize seeking help and developing attachments (by, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">providing statistics on “burn-out” in physicians)</span></p> <p class="Bold"><span class="char-style-override-2">Tools for combating shame and stigma: </span><span class="char-style-override-3">normalization (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">communicating that issue shared by many others); contextualization (</span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">acknowledging modeling of unhealthy work practices by teachers and mentors of health care professionals); demystification (</span><span class="char-style-override-4">ie</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">banishing fears about emotional processing by providing full explanation of it)</span></p> <p class="Bold"><span class="char-style-override-2">Cues for engaging and promoting authorship: </span><span class="char-style-override-3">ask about imagery patients would use to describe, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">their work, job-related stressors; discuss recent stressful situations and inquire about how they coped; ask them to select title for imaginary book about their (work) life</span></p> <p class="Bold"><span class="char-style-override-2">Final stage of speaker’s treatment: </span><span class="char-style-override-3">requires patients to re-enter community while attempting to live differently (by, </span><span class="char-style-override-4">eg</span><span class="char-style-override-3">,</span><span class="char-style-override-4"> </span><span class="char-style-override-3">attending group therapy); focuses on building more active forms of external support into routines and finding individuals who can hold patients accountable for their own wellness</span></p> <p class="EOsh">Acknowledgements</p> <p class="EOs">Dr. Groat spoke at <span class="char-style-override-6">Leadership in Healthcare Education: Recalibrating Our Ethical Compass</span>, from the 42nd Anniversary Meeting of the Association for the Behavioral Sciences and Medical Education, held October 4-6, 2012, in San Antonio, TX, and presented by the Association for the Behavioral Sciences and Medical Education. For information on other meetings hosted by the Association for the Behavioral Sciences and Medical Education please visit absame.org. The Audio-Digest Foundation thanks Dr. Groat and the sponsor for their cooperation in the production of this program.</p> <p class="EOsh">Suggested Reading</p> <p class="EOs"><span class="char-style-override-7">Daneault S:</span> The wounded healer: can this idea be of use to family physicians? <span class="char-style-override-6">Can Fam Physician </span>54:1218, 2008; <span class="char-style-override-7">Dyrbye LN et al: </span>Utility of a Brief Screening Tool to Identify Physicians in Distress. <span class="char-style-override-6">J Gen Intern Med </span>2012 Nov 6.[Epub ahead of print]; <span class="char-style-override-7">Gilbert P et al:</span> Fears of compassion: development of three self-report measures. <span class="char-style-override-6">Psychol Psychother </span>84:239, 2011; <span class="char-style-override-7">Graves L:</span> Teaching the wounded healer. <span class="char-style-override-6">Med Teach </span>30:217, 2008; <span class="char-style-override-7">Groat M, Allen JG: </span>Promoting mentalizing in experiential psychoeducational groups: From agency and authority to authorship. <span class="char-style-override-6">Bull Menninger Clin </span>75:315, 2011; <span class="char-style-override-7">Gullestad FS:</span> Mentalization as a moderator of treatment effects: Findings from a randomized clinical trial for personality disorders. <span class="char-style-override-6">Psychother Res </span>2012 May 2.1. [Epub ahead of print]; <span class="char-style-override-7">Rakel DP, Hedgecock J:</span> Healing the healer: a tool to encourage student reflection towards health. <span class="char-style-override-6">Med Teach </span>30:633, 2008; <span class="char-style-override-7">Surcinelli P et al: </span>Adult attachment styles and psychological disease: examining the mediating role of personality traits. <span class="char-style-override-6">J Psychol </span>144:523, 2010; <span class="char-style-override-7">Vrticka P et al:</span> Individual attachment style modulates human amygdala and striatum activation during social appraisal. <span class="char-style-override-6">PLoS One </span>3:e2868, 2008; <span class="char-style-override-7">Wu CH, Yang CT:</span> Attachment and exploration in adulthood: The mediating effect of social support. <span class="char-style-override-6">Int J Psychol </span>47:346, 2012; <span class="char-style-override-7">Zerubavel N, Wright MO:</span> The Dilemma of the Wounded Healer. <span class="char-style-override-6">Psychotherapy (Chic)</span> 2012 Sep 10 [Epub ahead of print].</p>
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