The Difficulty of Taking a Break

In our Risking Connection© training, we emphasize the importance of vicarious traumatization (VT). Because VT can destroy our hope and optimism, and because hope and optimism are so crucial to our work, paying attention to VT is an ethical imperative. One aspect of the discussion is: what can we do at work to decrease VT? There are many answers, and one is: take breaks.

I have recently been experimenting with actually trying to take a break for lunch. Instead of eating while I do email, write or talk, I am trying to sit and eat my lunch. I brought in a placemat and a nice bowl, and I sit away from my desk. And what I have discovered is that this is extraordinarily difficult.

Some of the difficulties are within me. I am jumpy and want to keep working. I am thinking about what I have to do. I am responsive to all interruptions. I am interested in what I am doing and do not want to stop. I feel guilty. This segment on NPR (http://www.npr.org/templates/story/story.php?storyId=129384107&sc=nl&cc=es-20100829) relates

the physical addiction we get to responding to our many media.

Some of the difficulties are external- people want to talk, meetings are scheduled at noon, there are many things to be done. We have an “always available” culture.

When I do manage to take a break, I feel refreshed and calmer. I am more thoughtful in my work.

But it is hard.

Now I am on vacation- and for me, it is also difficult to tear myself away for the vacation. It isn’t that any one is pressuring me. It is more that I love my work, find what I am doing very interesting, and I am involved in some exciting initiatives right now. I do not want to miss anything! And yet I know the value of taking some time to turn my mind in other directions, relax and absorb some of this beautiful sunshine.

How about you? Do you take breaks during the work day? Is it difficult? If you have found good ways to do so, share them! Do you find it makes a difference? Click on “comment” and share your experiences.

Visit to Seven Hills Foundation

This week I visited an agency in Massachusetts named the Seven Hills Foundation. This organization is helping us create and run our new unit, Webster House, which will serve children with both psychiatric and medical disabilities. The staff at Seven Hills have been universally generous, helpful, kind and knowledgeable with us. We visited the Seven Hills Pediatric Center, which provides long-term care. Children enrolled in their long-term care receive all the necessary medical, nursing, therapy, and leisure services to enhance their quality of life. Many residents come to them with a history of congenital birth defects, past infections, or trauma. Cognitively, residents are under the age of 12 months and non-ambulatory. The staff at SHPC has many years of experience working with residents who are ventilator-dependent, have tracheostomies, or require gastrointestinal feeding. For children who require additional monitoring, they have a state-of-the-art individual monitoring system. We also visited a group home in which six individuals live. This house looks like a regular house in a lovely neighborhood on the outside, but was specially constructed by Seven Hills to have space for reclining wheelchairs, tracks for lifts, special bathrooms and many other adaptations. The mission statement of the organization is “Dignity by Design.”

The children that are served in these two facilities are generally unable to respond differentially to life. A few may have the ability to signal yes or no. They may have some differences of responsiveness to people they have known a long time. Any positive changes in their condition are microscopic. They cannot say thank you or I appreciate what you did. It is not clear at all that what happens to them makes a difference in their experience.

Yet, the staff at these facilities are loving and interactive with the children. They constantly talk with them, interact with them. The children are well dressed, clean, and obviously cared for. Their rooms are decorated like any child’s room. They participate in school and make many trips into the community. When I asked where they go, I was told they go anywhere anyone else would go- the post office, grocery shopping, the hardware store. Staff was proud that the children had marched in the Memorial Day Parade this year. The children attend school, and the walls are lined with their art activities. When a child cooks or creates a craft project, that means that the staff moves their hand in order for them to do so. Yet these children’s lives are filled with activity, even though it is not obvious whether they can understand what is happening.

The staff was happy, friendly smiling and greeted us warmly. The facility was sparkling clean and attractive. It was an inspiring visit.

It seems to me that we can be inspired in our work by the work that Seven Hills does. We often tell staff to judge their day by what they did, not by how the kids responded. If they were caring, empathetic, playful, flexible, then it was a good day no matter how the kids behaved. At Seven Hills, staff have to do that. I am sure that they give each other a lot of support. But they cannot see immediate (or even long term) responses to their efforts from the kids. And they make the effort any way. How do they do that? How do they remain hopeful and find meaning in their jobs, when they cannot see results?

The second area is something I have written about before, in clear focus here. When a child has an obvious physical disability, we do not get angry at him for what he cannot do. We do not think that if we punish him for not doing it, he will change. Instead, we make modifications and change our expectations. At Seven Hills this is the essence of every activity. The staff finds a way that their efforts can make it possible for a child to do something or have a certain experience. They literally move the child’s hand so that the child creates art or food. They do not use rewards or punishments. If a child can get better, they gradually allow them to do more, in minute steps.

What if we could more clearly see the physical changes trauma has caused our children? What if we could see their damaged brains and body chemistry? Could we more easily lend them our brains, our thinking and planning, and provide them the support they need for success? Could we be surer that through positive experiences they would grow and that gradually they would become more capable?

Our visit to Seven Hills was moving and inspiring, and led to some thinking about how their philosophy could apply to the work we do.

Restraint and Seclusion Experiences of Youth

In response to a previous post about our restraint and seclusion reduction initiative, one reader wanted to learn more about youth reaction to the experience of restraint. We asked several of our kids of all ages to fill in the end of open sentences about both being restrained and seeing others be restrained. We then recorded oth kids reading these aloud, and played them at our kickoff event for our “Got Restraint? More healing, less holding” initiative.
Answers from children to open ended sentences about their experiences of restraint and seclusion

When I get restrained, I feel scared.
When I am in a seclusion, I feel trapped.
When I get restrained, it reminds me of when they had to hold my uncle back.
When I am in a seclusion, it reminds me of watching my mom get in the police car.
When I get restrained, staff try to help.
When I am in a seclusion, staff ignore.
After a restraint I feel guilty.
After a seclusion I feel guilty.
When other kids get restrained I feel like I need to be in a restraint too.

When I get restrained, I feel even more angry than I did before.
When I get secluded, I feel really upset, mad, and angry.
When I get restrained, it reminds me of home, because I used to get into a lot of trouble at home and my mom would restrain me.
When I get secluded, it reminds me of my mother.
When I get restrained, staff get really mad and hurt you, a little bit, but not purposely.
When I get secluded, staff open the door quickly, most of the time, when I’m calm.
After I get restrained I feel scared, angry, and hot. I get scared it’s going to happen again, sad that it happened, and angry that it happened.
After I get secluded I feel even more angry.
When I see other kids get restrained it scares me.

When I get restrained, I feel scared because everything’s going so fast, and my emotions are a roller coaster, and hurt and frustrated. I feel angry because I start to hate the staff because they put their hands on me and they put me down and I don’t like to be touched. Sometimes I’ll purposely hit them so they’ll restrain me. Sometimes I’ll be like “why didn’t you guys just talk to me instead of going straight down.”

When I get secluded, I feel angry, I feel like hurting myself because I’m only by myself and there’s nothing for me to use to cope and there’s just walls. The quiet room would freak me out cause it was all scabbed up and had writing on it.

When I get restrained, it reminds me of the past, people hurting me.
When I get secluded, it reminds me of when I get grounded.
When I get restrained, staff can get hurt, and it depends on who’s in it, but sometimes staff hold onto me real tight or get frustrated with me.
When I get secluded, staff have to do paperwork.
After I get restrained I feel angry because I don’t like when people touch me.
After I get secluded I’m stressed still.
When I see other kids get restrained I feel no one should have to go through that.

When I get restrained I feel angry, like I’m going to pay them back, cause I hate when people put their hands on me. I don’t like to be a loser-it’s like getting beat up.
When I get secluded, I feel like I will I throw up.
When I get restrained, it reminds me of my past.
When I get restrained, it makes me angry.
When I get secluded, staff shut the door.
After I get restrained, I think F all you people, are you listening to me?
When I see other kids get restrained It makes me very upset and sad.

When I get restrained I feel like I can’t breathe.
When I get secluded, I feel like the walls are closing in on me.
When I get restrained, it reminds me of when I was hit as a little girl.
When I get restrained, staff grab me too hard. They should hold us down and talk, or just talk.
After I get restrained I feel I’m even more angry, and I still have trouble breathing.
When I see other kids get restrained I think staff do it right, sometimes kids hit them and they have to get aggressive back.

Good reasons to work hard and reducing or eliminating these practices.

Transforming the Pain of Vicarious Traumatization

A central idea in the Risking Connection© approach to dealing with vicarious traumatization is the concept of transforming the pain. One important way that human beings deal with pain is to look for the good within it, to notice how going through a difficult experience changed our lives or strengthened us as people. An example of this would be the woman who says: "I certainly didn’t want to go through that breast cancer scare last year. But it did sharpen my sense of my priorities, and so I have gone back to school to finish my degree." If we can notice the transformative effects of the pain we experience in our work, we will be able to appreciate how the work changes us in positive as well as negative ways, and will build on those positive changes. This is an powerful way that we can combat vicarious traumatization and stay engaged and hopeful in our work.

One author and healer who has deepened our understanding of this process is Rachel Naomi Remen. Rachel Naomi Remen is medical director of the Commonweal Cancer Help Program, and a clinical professor of family and community medicine at the University of California Ð San Francisco School of Medicine. Her books include My Grandfather's Blessings, and Kitchen Table Wisdom. She was recently interviewed on Speaking of Faith with Krista Tippett (a show that has many episodes which illuminate our work). The podcast of the show, as well as supporting writings, can be found at:

http://speakingoffaith.publicradio.org/programs/2010/listening-generously/

In her RECAPTURING THE SOUL OF MEDICINE Rachel Naomi Remen speaks of the importance of finding meaning in one’s work:

In times of difficulty, meaning strengthens us not by changing our lives by transforming our experience of our lives, The Italian psychiatrist Roberto Assagioli tells a parable about 3 stone cutters building a cathedral in the Middle Ages. You approach the first man and ask him what he's doing. Angrily he turns to you and says, "Idiot! Use your eyes! They bring me a rock, I cut it into a block, they take it away, and they bring me another rock. I've been doing this since I was old enough to work, and I'm going to be doing it until the day that I die." Quickly you withdraw, go the next man, and ask him the same question. He smiles at you warmly and tells you, "I'm earning a living for my beloved family. With my wages I have built a home, there is food on our table, the children are growing strong." Moving on, you approach the third man with this same question. Pausing, he gives you a look of deep fulfillment and tells you, "I am building a great cathedral, a holy lighthouse where people lost in the dark can find their strength and remember their way. And it will stand for a thousand years!" Each of these men is doing the identical task. Finding a personal meaning in your work opens even the most routine of tasks to the dimension of satisfaction and even joy. We may need to recognize meaning for the resource it is and find ways to pursue it and preserve it.

Meaning is a human need. It strengthens us, not by numbing our pain or distracting us from our problems, or even by comforting us. It heals us by reminding us of our integrity, who we are, and what we stand for. It offers us a place from which to meet the challenges of life. Part of our responsibility as professionals is to fight for our sense of meaning — against fatigue and numbness, overwork, and unreasonable expectations — to find ways to strengthen it in ourselves and in each other. We will need to rebuild the medical system, not just on sound science or sound economics, but on the integrity of our commitment. It has become vital to remember the essential nature of this work and renew our sense of calling to preserve the meaning of the work for ourselves and for those who will follow.

Here are some quotes from her interview on the show:

You know, sometimes what appears to be a catastrophe, over time, becomes a strong foundation from which to live a good life. It's possible to live a good life even though it isn't an easy life. And I think that's one of the best-kept secrets in America.

I was going to say the great joys of working with people on the edge of life. The view from the edge of life is so much clearer than the view that most of us have, that what seems to be important is much more simple and accessible for everybody, which is who you've touched on your way through life, who's touched you. What you're leaving behind you in the hearts and minds of other people is far more important than whatever wealth you may have accumulated….

We thought we could cure everything, but it turns out that we can only cure a small amount of human suffering. The rest of it needs to be healed, and that's different. It's different. I think science defines life in its own way, but life is larger than science. Life is filled with mystery, courage, heroism, and love. All these things that we can witness but not measure or even understand, but they make our lives valuable anyway.

People who are physicians have been trained to believe that it is a scientific objectivity that makes them most effective in their efforts to understand and resolve the pain others bring them, and a mental distance that protects them from becoming wounded by this difficult work. It is extremely demanding training. Yet objectivity makes us far more vulnerable emotionally than compassion or a simple humanity. Objectivity separates us from the life around us and within us. We are wounded by that life just the same; it is only the healing which cannot reach us. Physicians pay a terrible price for their objectivity….

No one is comfortable with loss. Being that we're a technological culture, our wish or our first response — let's put it this way: Our first response to loss is try and fix it. When we are in the presence of a loss that cannot be fixed, which is a great many losses, we feel helpless and uncomfortable and we have a tendency to run away, either emotionally or actually distance ourselves. Yeah. And fixing is too small a strategy to deal with loss, you know.

We teach them the power of their presence, of simply being there and listening and witnessing another person and caring about another person's loss, letting it matter.

This is a quote from Krista Tippett, the host:

“The following passage from Naomi Remen's Kitchen Table Wisdom, … was written with physicians in mind. But it holds a resonant caution and challenge for all of us, I think, as we struggle to face yet not be overwhelmed or numbed by — the pain and suffering that are a fact of human existence near and far.”

"The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present to life more than anything else. The way we protect ourselves from loss may be the way in which we distance ourselves from life… We burn out not because we don't care but because we don't grieve. We burn out because we've allowed our hearts to become so filled with loss that we have no room left to care."

Let’s begin a conversation about how these concepts apply to us within our work, and how we can create opportunities to discuss these ideas within our workplaces.

Do You Like These Kids?

As part of our new restraint and seclusion reduction initiative, I recently completed two focus groups with clients to ask them what they felt staff could do to decrease restraints and seclusions. Their answers can be summed up in the directive: ask me what is wrong and listen to my response.

I was dismayed by the feeling that the kids had that the staff did not really like them or enjoy being with them. They spoke of staff wanting to get away from them, have breaks from them. They said staff were at times involved in their own interests and not willing to be interrupted by the kids. They noticed staff sitting and talking together. On the other hand, they described how much it meant when staff participated in games and activities with them. They felt close to staff who listened when they spoke, remembered what they said and asked them about it later. They were quick to blame themselves for staff not wanting to be with them, because of the way they acted. But they described acting better around staff who genuinely care.

One of my colleagues remarked recently that what our kids need, and have never had, is someone whose face lights up when they come into a room. Think of your own children or those of friends. They are celebrated in so many ways! Their pictures are on the refrigerator, their events are attended, their performances little and big are applauded. But more than that, they constantly receive feedback that they are delightful. Someone loves them, wants to see them, wants to hug them, and wants to hear about their day.

Some research has shown that a critical factor in school success is the proportion of positive to negative comments a child hears during a day. How many times do our children hear their own name used in joy, as in "Stephanie I am so glad to see you!" or "Stephanie what a wonderful math paper!" In contrast, how often is their name used as a warning: "Stephanie, stop that!" or "Stephanie, don’t do that!" In their lives I am afraid it has mainly been the later.

Martha Holden of the CARE project told me that she teaches staff that their main job is to make sure that the child they are caring for has a marvelous day. What if we organized everything we do around that goal? That our goal is to help the children be happy?

The children we work with are marvelous. Every day they demonstrate strength, courage, intelligence, wit, creativity and humor. Of course, they can also be obnoxious and even scary. But if we don’t see the marvel in them, who will? And how can they possibly change and grow if they have no one who is delighted by them?

The kids in my focus group were clear what they needed. What would it take for each of us to become that staff who listens, who joins with the children in games and activities, who laughs with them, who creates positive memories? How can we become the person who shows the child that she is worthwhile by looking forward to our time together, seeking her out and obviously wanting to be with her? This engagement can’t be faked and I am not sure it can be taught. But it is what makes our jobs meaningful and what heals the children.