On Friday,  Dr. Tim Kearney, Chief Behavioral Health Officer, Community Health Centers, Inc. shared information about Talking with children about the recent school shooting in Sandy Hook.  Today, we are sharing information from Dr. Kearney about talking with adults.  The primary audience for this is for clinical staff at CHC, however, it is an important resource we want to share with the wider public.

In the coming days, the impact of the recent shootings will be felt in nearly every conversation.  We will all need to be able to:

– help those we see deal with what has happened

– identify those who need a referral for more help

– manage the secondary trauma associated with sharing another person’s pain and hearing about the tragedy over and over again, and

– care for those in our own personal sphere who have been impacted by the recent events.

This series of tips is designed to help us to do so.  We are all in this together, so please share your own suggestions with colleagues and other staff as well so that we can be effective with our patients and continue to heal ourselves.  These comments are focused on talking with adults, though some of the ideas apply to children as well.  Please look at the material sent out last Friday for some ideas on talking to children.  While these remarks are addressed firstly to the clinical staff at the Community Health Center, Inc. a statewide primary care network in Connecticut, I hope that they will be helpful beyond that circle as well.  Italics are used in this material to highlight examples of ways to phrase comments to others and are not meant to be a script but rather to inspire thoughtful discussion.

I. Talking to adult patients

Most people will need to talk about it: Many of those who come in to see us for other reasons will have this tragedy foremost in their minds and need to talk about it.  Offer them the chance to do so without insisting that they do.  Expecting this prepares us to be ready to assist the whole person who is in front of us.  Ask open ended questions that allow the patient to share their feelings.  Do not express yours first but give them a chance to talk. “Mr. Jones, nice to see you today.  How are you doing with everything that has happened?”.   For most people this will be a brief conversation you can have while you transition into the work you have to do with the patient.  If someone cannot stop talking about it and is unable to focus on the medical, dental, or behavioral health issue that brought them in today, it may be sign they need a referral for more care.  And remember “most” is not “all” – some may not want to talk about it and this choice should be respected.

Turn attention to the task at hand:  Structure and focus on issues other than the news helps people to contain their emotional response and continue to live their lives. Patients are here today for dental work, medical care, or a behavioral health appointment that most likely was made before Friday.  Help them with the issues which brought them here. For some it may be helpful to say what you are doing and why, “Ms. Smith, I am glad we have had a chance to talk a little about the tragedy.  I know you were coming in for us to follow up on your blood pressure today, so let’s turn to that now.  Who do you have in your life you can talk to after you get home?  It seems like that is really helpful to you know and I am glad we got the chance to talk some.”

Offer hope:  Trauma research has taught us the importance of offering hope and broadening the focus beyond the tragedy itself.  You will not be able to address all your patient’s fears, sadness, and anger today.  But you can listen and maintain a hopeful stance.  Be careful not to deny their feelings with an easy answer, “Don’t feel bad -I am sure it will all be better soon” but rather validate their feelings and offer some encouragement: “This is really a hard time.  What have you found that makes it easier for you to manage it?”  Encourage them to do more of what helps.

Coping skills:  Some practices help people manage their reactions to trauma, and we can suggest some of them.  It is important not to tell people what will work for them- they will likely feel unheard and push back with why it won’t work.  Make suggestions instead, “Many people find it helpful to turn off the television and do something else instead:  watch a movie, go for a walk, and spend time with family and friends.”  Reconnecting with spiritual and religious communities and practices are also helpful to many.

II.Spotting those who may need more help:

Some of those we talk to will need more than the brief, hopefully positive, encounter we can have with them.  These will include those with direct personal connection with people impacted by the shootings, people with a history of trauma and loss who are reminded by this tragedy of their own experiences and feel the feelings that they had then all over again, and those who already had issues with which they struggled such as anxiety or depression who find that the recent news is just too much for them to bear.  Keep in mind that they guidelines mentioned below are normal responses that are extreme, applied across the board to all areas of life, no longer under the control of the person experiencing them, or in some other way keeping the person from being able to live life fully.  The presence of one or even all is not positive proof of a problem that needs professional help, but should raise awareness of the possible need for additional help.

Possible indicators of the need for professional help include:

1. Symptoms of anxiety or depression including trouble sleeping, nightmares, loss of energy and/or sleeping too much, overwhelming feelings of despair or helplessness, irritability,  fear of leaving home or a generalized sense of discomfort and unease, exaggerated fears of strangers, guns, sending children to school or other issues related to the shooting.
2. Flashbacks or vivid memories of previous traumatic events that intrude into every day life and make it hard for a person to do their daily activities.  Hearing about the death of the people in Sandy Hook can remind people of their own losses, picturing the feelings of fear or being exposed to life threatening events beyond their control that the victims may have felt can trigger reactions that cannot be easily controlled in those who have had similar experiences.  The event does not need to be similar, just the feeling of danger and fear.  People especially at risk of having this tragedy set off responses they cannot control without help include domestic violence and child abuse survivors, those who have been in wars or have experienced violent events, and first responders who have witnessed similar events in the past.
3. A wish to die or kill others, while much more rare, needs to be taken seriously. People already at risk of harming themselves or others may be pushed beyond their ability to cope by their responses to these tragic events.  If you feel comfortable and equipped to follow up and ask about a plan or a means do so, or suggest that they talk to a primary care provider, clergy person, or counselor.
4. Statements that a person just cannot cope or failure to meet the demands of home or work indicate an level of discomfort that show that a person’s usual coping skills have been overloaded by their response.  Find out who they usually turn to in times of stress and encourage them to do so, or suggest that they reach out to a primary care provider, clergy person, or counselor.

Telling someone that you think they need to talk to a specialist can be seen as a rejection or as being called “crazy”, especially for people who come from cultures where seeking professional help is not as accepted.  Make sure your suggestions come out of your concern for the well being of the person in front of you.  Place the suggestion in a cultural context as much as you can, and make it a suggestion rather than a demand.  “Mr. Vasquez, I am concerned for how you are doing with handling your response to this.  I am glad we got the chance to talk, and I am thinking it might be helpful for you to talk with someone who knows more than I do about how to help people cope with these events.  Do you have someone in your world that might be of help for you to talk to?  Maybe a spiritual leader?  Or we could set up a time for you to talk to one of our counselors here.”

III.Taking care of yourself

If you are in professional role that involves listen to other people’s pain around the shootings or just someone who people naturally talk to, you will need to be careful to manage the impact of bearing other’s burdens.

1. Remind yourself that is it perfectly normal and acceptable to have feelings when you hear about other people’s pain.  If you are moved to tears, cry with them.  Reassure them that it is good that they are telling you (so that they do not stop talking because they see you are crying too) and tell them of the healing power of tears as you  model an acceptance of crying as a coping skill.  If you are moved to anger by their story, be sure to tell them that you are mad at the circumstances and what has happened, not at them for telling you.  (Many people who are themselves trauma survivors and whose own issues are trigged by the recent events will have had the experience of being blamed for talking about traumatic events, so take care not to set them up to feel the same way again.)
2. Know your limits.   You may need to take a break. Lean on others around you for support when someone needs more than you can give.  Use a team approach to meet the needs of others so that you are not carrying the entire burden yourself.  If the issues presented are outside of the range of your knowledge or ability to handle, be prepared to refer someone along to another person who can be of more help.
3. Watch out for compassion fatigue.  If you find yourself getting irritable, mocking those who come to talk to you behind their backs, feeling exhausted and responding in ways that “just aren’t me” listen to that.  Sometimes caring people are so focused on the needs of others and desire to help just one more person that we miss the cues that might tell us we are at our limit.  Compassion fatigue is a sign that we need to get ourselves off the front line for a period and recover so that we can give our best again.
4. Do what keeps you whole.  Many who are great at caring for others and can even give the best advice to others on how to take care of them do not do what they know would help.  If going for walks, curling up with a good book, watching a movie, spending time with family or friends, or quiet contemplation and prayer keep you centered and whole, take the time to do this.  Do not let the overwhelming demands of the moment pull you off center.  You will be of no use to yourself or any one else if you do not take the time to be well.  Knowing what works to keep you healthy is not the same as doing it.  Be sure that you do it.

IV. Caring for those who are important to us

It is next to impossible to take care of others while worrying about those who are closest to us.  Take time to listen and talk to your children, family members, and friends who have been impacted by this horrible event.  Use the tips on this sheet and last week’s sheet on talking to children to help to assure that those you care about around you are able to do their best to manage their own reactions and know that they are safe and loved.  I highlight this to remind us all to attend to what should be obvious but can be lost as we take care of those who come to us.  Listen to those who are a part of your life, give and accept support, and know that we will make it through together.

For additional resources throughout Connecticut, call 211.