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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