Resiliency-Focused Clinical Care and Supervision on Campus

1. Resiliency-Focused Clinical Careand Supervision on Campus 2019 NECCD Conference The Space Between: The Power of Connection, Community, and Self Care SuEllen Hamkins, MD

2. Landscape of Meaning • Not acting on violence, is that linked to any values you have?  • Are you worried you might act on your anger? • How do you know you won’t?  • You sound clear about your commitment to not using violence. • What are roots of your pacifism in your life? • “Martin Smith” • hitting and cutting himself • at times overcome with anger • violent fantasies about maiming • and killing other people and himself SuEllen Hamkins, MD, 2019

3. SuEllen Hamkins, MD, 2019

4. Today’s talk • Resiliency-focused care and clinical supervision: Martin • Demonstration • Exercise • Resiliency-focused practices on campus • Exercise • Q and A

5. Disclosures: Royalties from Oxford University Press. SuEllen Hamkins, MD, 2019

6. Taking a both/and perspective Our task: To simultaneously • Recognize the student’s strengths and resilience • Understand their problems • Hold them accountable for their actions • And help them get the support they need to succeed

8. resiliency

9. Skills • Strengths • resiliency

10. Values • Intentions Skills • Strengths • resiliency

11. Values • Intentions Skills • Strengths • Context • Culture • resiliency

13. Trauma-Informed Care • Safety • Trustworthiness and Transparency • Peer support • Collaboration and mutuality • Empowerment • Attention to Cultural, Historical, and Gender Issues • Resiliency and Strength SuEllen Hamkins, MD, 2019

14. Resiliency-focused Care • Connect • Get to know the person without the problem • Externalize the problem • Understand the problem as separate from the student’s identity • Develop a narrative of resilience • understand the student’s skills, resources and efforts to overcome the problem • Collaborate with the student in determining next steps SuEllen Hamkins, MD, 2019

15. Begin with emotional attunement and getting to know the person without the problem • Compassionate connection and emotional attunement • Get to know the person without the problem • first year student • majoring in English and film • goal was to be a novelist • Getting to know the person without the problem is especially important when the problem is serious, such as psychosis, suicidal urges or threat of violence SuEllen Hamkins, MD, 2019

16. S: What are your hopes for our meeting today? M: I am hoping to find a solution for the issues I have been dealing with. I’ve been using Celexa 20 mg daily since July in the hopes that it could mitigate my depression. SuEllen Hamkins, MD, 2019

17. Define the problem separate from the student’s identity SuEllen Hamkins, MD, 2019

18. S: What’s the depression like? M: Usually apathy and hopelessness, but now I am also having anger issues. I am concerned that the medicine is lowering my inhibitions. My anger is out of proportion to the situations I am facing. S: I’d like to understand more what your experience is of the depression and anger. SuEllen Hamkins, MD, 2019

19. M: With the depression, it’s as if I am on a boat, sometimes just ordinarily riding the waves, but sometimes I get caught in a storm and get tossed out of the boat. SuEllen Hamkins, MD, 2019

20. M: I struggle to stay above the surface, desperately clinging to sanity. All that’s there is darkness and apathy. If I slip below I don’t care about anything at all.  SuEllen Hamkins, MD, 2019

21. M: When I’m struggling for the surface it’s all despair and pain, but otherwise, when I give up that struggle, it’s numbing. SuEllen Hamkins, MD, 2019

22. M: This past spring, I had good friends, good work, things I enjoyed, but the depression and anger could still be overpowering. That was the first time I engaged in self-harm, hitting myself, hitting the wall, cutting myself to get some relief. SuEllen Hamkins, MD, 2019

23. M: I have always done martial arts. I found that hitting my hands against hard objects to deaden the nerves gave me relief. S: Any suicidal urges? M: I have passing suicidal thoughts, but I know they are pointless and stupid. I would not actually do it. It would crush my parents. It’s not an option. SuEllen Hamkins, MD, 2019

24. M: When I get that overpowering anger I have violent images of unleashing my martial art capabilities against someone, even just someone who is mildly irritating to me. S: And have you ever acted on those images of violence? SuEllen Hamkins, MD, 2019

25. Narrative of resilience • How has this person been active in seeking to overcome the problem and why? • Agency • Narrative: Events over time according to a theme or plot. • What and why SuEllen Hamkins, MD, 2019

26. Narrative of resilience • How and why are you able to resist or overcome this problem? • What are the roots of those strengths and values in your life and childhood? SuEllen Hamkins, MD, 2019

27. Action What happened? When, how, with whom? • Events • Skills • Knowledge • Relationships • Resources SuEllen Hamkins, MD, 2019

28. Meaning “Why?” The plot or theme • Intentions • Values • Vision • Hopes • Dreams • Commitments SuEllen Hamkins, MD, 2019

29. Story of resilience: action and meaning meaning action______________________________________________ past present future SuEllen Hamkins, MD, 2019

30. S: And have you ever acted on those images of violence? M: No. S: You have not ever acted on the violent urges? How have you been able to do that? What do you do to manage the anger? [action] SuEllen Hamkins, MD, 2019

31. M: Mostly I try to vent it in some way. S: What kinds of ways do you try to vent it? SuEllen Hamkins, MD, 2019

32. M: Exercise is one way, riding my bike, for example. Or singing, I love to sing, and that can help. Sometimes reading or writing works, or cuddling with my dog when I’m home. Here, hanging out with friends helps. SuEllen Hamkins, MD, 2019

33. S: Not acting on violence, is that linked to any values you have? [meaning and values] SuEllen Hamkins, MD, 2019

34. M: I am a pacifist, except for self-defense. I believe that you can resolve issues in a more productive way. SuEllen Hamkins, MD, 2019

35. M: Since I started the Celexa, I am not feeling apathy, but I am struggling to keep myself from fury and rage. I have had anger issues since I was a kid, it’s always been an issue. The worst case was last week. I felt like I couldn’t talk with anyone for fear of snapping. I was seething. I tried to keep a poker face. I couldn’t focus on my work. I felt ill, like a rat on fire was gnawing in my stomach. SuEllen Hamkins, MD, 2019

36. S: How did you deal with that? [action] M: I tried to vent into writing, but I couldn’t, so I took hurled chopsticks at my door. Then I sprinted on my bike, and at midnight I started screaming. The idea was to work myself to exhaustion, but I was still simmering, so I went to the bathroom and beat on the wall and cut myself, and finally I felt better. SuEllen Hamkins, MD, 2019

37. S: Are you worried you might act on your anger? M: Partly worried, but mostly I feel sick. I get these images of brutality, of beating someone to death. But I know I won’t. SuEllen Hamkins, MD, 2019

38. S: How do you know you won’t? M: I am a martial artist, and you never start with violence. There is a tenet: “If you are in a violent situation and you can run away, do it. If you can’t run away, injure the person, if you can’t injure them, maim them, and only as a last resort, kill them.” SuEllen Hamkins, MD, 2019

39. S: You sound clear about your commitment to not using violence. M: I was bullied all of my life. I was excluded and taunted. For years there was a game at my school of throwing things at the back of my head, like basketballs or other objects but I responded with pacifism.   SuEllen Hamkins, MD, 2019

40. S: With all that, you responded with pacifism. What are roots of your pacifism in your life? M: I would say, family values.  In dealing with the bullying, my mother would say to me, “do what Jesus did” and turn the other cheek.  SuEllen Hamkins, MD, 2019

41. M: I personally am inspired by Gandhi and Buddha, they had the right idea.  Be peaceful. If people see you act with violence, that reputation never goes away. If I ever did engage in any kind of violence, it would permanently change how people saw me and I don’t want that. SuEllen Hamkins, MD, 2019

42. What has changed in how we are feeling about Martin’s risk of violence? SuEllen Hamkins, MD, 2019

43. Collaboratively consider next steps in light of the person’s values and vision SuEllen Hamkins, MD, 2019

44. Follow up with Martin SuEllen Hamkins, MD, 2019

45. Resiliency-focused Care • Connect • Get to know the person without the problem and their vision of wellbeing • Understand the problem as separate from the student’s identity • Develop a narrative of resilience • understand the student’s skills, resources and efforts to overcome the problem • Collaborate with the student in determining next steps SuEllen Hamkins, MD, 2019

46. What, how and when:Action questions • Can you describe what you did to resist the problem in more detail? • Have you ever done that before? When? Where? What happened? • What did you do to get ready to be able to do that? • Whose help did you enlist? • When was the first time you succeeded in that way? • What did you have to overcome to be able to do that? SuEllen Hamkins, MD, 2019

47. Why?Meaning and Intention Questions • Is there a name you could give to this ability/value of yours? • What does that say about what you stand for? • What is it like to see yourself be able to do that? • Is that linked to hopes or dreams you have for yourself? • Would that be evidence of a commitment you have for your life? • How is it for you to think that you were able to overcome that difficulty then? • What is that feeling of despair a testimony to? SuEllen Hamkins, MD, 2019

48. Resiliency-focused Clinical Documentation Introduction to the person without the problem: (Include passions, interests, values, skills, accomplishments and sources of inspiration) The person’s goals for treatment and vision of well-being: Chief concern: History of the problem and efforts and successes in managing it: Family history: (Include family values, skills, and resources, what family members admire about the person and the problems that family members have faced and/or overcome)

49. Resiliency-focused Clinical Documentation (cont.) Medical wellbeing and problems: Observations/Mental Status: Summary: (Include strengths, skills, relationships, supports, values, successes in achieving their vision of wellbeing, and problems that are a focus of treatment) Risk assessment: (Include risks for harm to self or others and protective factors) (Diagnoses, discussed with the person): Collaborative treatment plan:

50. Resiliency practices whenspeaking about students • Keep a respectful perspective on the student. • Use respectful, hopeful language to describe students at all times • Speak about the student as if the student were in the room. • Keep in mind that staff members may be dealing with some of the same challenges • Reduce staff burnout by taking a hopeful and respectful stance toward the students. • Find ways to laugh together that do not involve disrespect to students. SuEllen Hamkins, MD, 2019