16  Enhancing Resilience/
Performance and Preventing
Compassion Stress Injury

In this chapter, we will examine how modified EMDR protocols may be effective in strengthening resilience and improving work performance of members in the military population, as well as vital self-care for warrior healers.

RESILIENCE AND POST-TRAUMATIC GROWTH IN THE MILITARY

The concept of resilience has been defined as the capacity to resist and bounce back from adversity. Since antiquity, military powers worldwide have had a vested interest in the physical and mental strengthening of its armies to avert the ravages of war stress, while at the same time devising new methods of delivering the potent effects of combat stress to break the resilience of its enemies. Historically, after every major conflict since the First Great War (1914–1918) to end all wars, military organizations and their supportive governments have gone to great lengths to prevent the scourge of escalating rates of war stress injury.

Contemporary Approach to Building the Resilient Warrior

In the January 2011 issue of the American Psychologist, Brigadier General Rhonda Cornum, Comprehensive Soldier Fitness, Headquarters, Department of the Army, indicated that psychology’s “business as usual” reaction to war stress injuries has missed the mark by overemphasizing treatment of a problem that it should be preventing. The Army’s “all-in” adoption of the relatively untested fruit of positive psychology has yet to prove capable of steeling human minds to resist and bounce back from the toxic adversity of war. History does not appear to be on the Army’s side, but we pray to be wrong. Meanwhile an all-out effort is underway to develop new strategies for improving resilience and post-traumatic growth within the military population. According to Zoellner and Maercker (2006, cited in Tedeschi & McNally, 2011), posttraumatic growth may be nurtured via psychotherapy through cognitive processing, supporting attempts at mastery of new experiences, and enhancing relationships. Tedeschi and McNally (2011) delineated a strategy for the U.S. Army’s massive Comprehensive Soldier Fitness program to promote posttraumatic growth by enhancing certain key elements such as emotional regulation, constructive self-disclosure, and organizing a war narrative that includes central domains of personal strength, enhanced relationships, spiritual change, appreciation of life, and openness to new possibilities. As Congress and the Department of Defense have invested $125 million into researching nascent interventions to avert war stress injuries, we thought it appropriate to add similarly unproven, yet highly promising approaches to strengthening resilience and enhancing performance of military personnel. In particular, two modified EMDR protocols have demonstrated considerable untapped potential to assist service members: Resource Development and Installation (RDI) and Brief Intervention Focusing Protocol (BIFP).

EMDR APPLICATIONS FOR IMPROVING RESILIENCE AND PERFORMANCE

In regards to the prevention of war stress injury, the DVA/DoD Clinical Practice Guidelines for the Management of Post-Traumatic Stress (2010) indicate that little is directly known about our capacity to prepare individuals or communities for trauma exposure, but it is possible to identify principles of preparation that are consistent with empirical research on risk and resilience factors and with current theories of PTSD development. Such pre-trauma preparation can include attention to both the ability to cope during the trauma itself and shaping the post-trauma environment so that it will foster post-trauma adaptation. Other theories suggest that individuals who develop negative trauma-related beliefs (e.g., about personal guilt) will be more likely to experience continuing trauma reactions because such beliefs will maintain a sense of threat and personal incompetence. Research on risk factors for PTSD indicates that post-trauma social support and life stress affect the likelihood of development of the disorder.

A few EMDR-related protocols have been developed with the purpose of increasing resilience and work performance, some with published case studies to support their replication. Interested readers are referred to Luber (2009). We selected RDI (Korn & Leeds, 2002) because it has been incorporated in standard EMDR trainings and shown to have clinical effectiveness in stabilizing chronically distressed clients by increasing access to their adaptive neural networks-which is the essence of resilience. Lendl and Foster’s (2009) Brief Intervention Focusing Protocol has instant appeal by offering a quick, simple intervention to potentially reduce internal and external distractions such as performance anxiety, fear of failure that prevent military personnel from performing to the best of their ability in high-stress operational environments. Unfortunately, the body of research for either technique is waning. However, published case studies in peer-reviewed journals indicate that therapists and researchers are justified to replicate their use and expand the empirical literature on future innovation and human resilience.

Resource Development and Installation (RDI)

RDI is an effective, brief intervention, modeled after EMDR that was originally designed to prepare emotionally and behaviorally unstable clients for the intensity of trauma-focused therapy (Korn & Leeds, 2002). Adult clients who experienced years of childhood abuse, neglect, and other adverse childhood experiences may develop conditions known as “complex PTSD” “Borderline Personality Disorder,” or “Disorders of Extreme Stress Not Otherwise Specified (DESNOS)” all characterized by poor affect tolerance, impulsivity, insecure attachment, suicidal ideation, inadequate self-regulation and coping, poor self-esteem and self-worth, and so on. It would be an understatement to label this a high-risk group for the emotionally potent and painful trauma-focused therapy. RDI has been shown clinically to significantly help stabilize this high at-risk group of adult clients to acquire sufficient levels of self-control, stress-coping, mastery, confidence, and self-esteem skills to undergo trauma-focused treatment like EMDR.

Would a brief, relatively simple, strength-based protocol, coupled with short-sets of eye movements or other bilateral stimulation have any application for building resilience and enhancing performance of military personnel—absolutely. What are resources? Leeds (2009) describes resources as natural experiences that develop out of three categories of experience: mastery memories, relational resources, and symbols. Recollections of past successes and achievement, assertiveness, and self-care are examples of mastery experiences. The supportive people in our life, those who have taken care of us, showed us kindness, mentored, nurtured, or coached us, helped celebrate our victories, and consoled us in our defeats, have become internal “resources” in our lives, their legacy resonating in the adaptive neural networks that we have been working throughout this text. Other types of relational resources are people we look up to and revere, or marvel at their strength, stamina, honesty, humility, integrity, or courage. These role models often inspire us to follow in their worthy footsteps. Role models may also be historical figures, superheroes, or an action-movie star. The third category of resource pertains to the symbols and metaphors that originate out of our cultural, religious, or spiritual worlds, including dreams and archetypes, as well as a future goal or sense of self that beckons (see Chapter 6, this volume, for the RDI protocol).

BRIEF INTERVENTION FOCUSING PROTOCOL

Jennifer Lendl and Sandra Foster (2009) have developed an EMDR variant, the Brief Intervention Focusing Protocol (BIFP). The BIFP is a rapid, time-sensitive, task-oriented protocol that utilizes bilateral stimulation (BLS) and the future template from EMDR but emphasizes only strengthening or enhancing future-oriented performance issues by decreasing performance-related anxiety, fear of failure, self-defeating beliefs, worries of past setbacks, and other behavioral inhibitions which can interfere with individuals performing at their full-potential. The BIFP was initially developed for creative artists and professional performers but has since been implemented successfully with Olympic athletes and business leaders. Case studies (e.g., Foster & Lendl, 1996) and controlled research on master swimmers (Linebarger, 2005, cited in Lendl & Foster, 2009) lend some empirical support. It was designed to enhance imminent performance—by reducing internal and external distractions and fostering self-confidence that lead to off-task behaviors. Anything outside of the present task is regarded as an intrusion. Internal distractions (e.g., self-defeating thoughts, worrying, performance anxiety, or fear of failure) and external distractions from environmental conditions (e.g., crowd noise) are set aside as expediently as possible so the client can fully focus on the mission task. Client strengths as well as areas where improvement is needed are identified through a series of questions: (a) What abilities are needed? (b) What deficits exist in education, training, or emotional management? (c) Do they have the ability to stay present? (d) What distractions impair focus? (e) What motivates them? And (f) Do they have a sense of life purpose?

Brief Intervention Focusing Protocol (see Lendl & Foster, 2009)

1.  Establish the hours available to do the intervention and explain the protocol to the client. “We can work on past issues when we have more time. For now, we’ll focus on what you can do for this event. We will set aside any distractions and concentrate on the specific elements of your upcoming performance and what you are already prepared to do for it.”

2.  Quickly identify internal and external distractions. Have the client determine each distractions importance and immediacy in regards to the upcoming performance. “What thoughts or distractions get in the way of your having confidence in your upcoming event?” For example: “I’m worried about letting people down,” or “I’m not prepared.” Next, the therapist says, “Can you put them in order of importance?”

3.  Help the client problem solve around each distraction and do short saccades while they visualize the solution:

○  “What is the problem that is getting in the way of _______ (state what the goal is)?”

○   “What can you do to take care of _______ (state what the issue is) before the event?”

○  “Good; imagine ______ (state the solution).”—Do BLS (eye movement: 6–12 sets)

○  “What can you do during the event to make sure that _____ (state the issue) is taken care of?”

○  “Good, imagine ___ (state the solution).”—Do BLS (6–12 sets)

4.  Assist the client in letting go of the distractions when they intrude. “Think of your event. When an intrusion comes up, ask yourself, ‘Is this thought useful right now?’ Remember your solution ______ (state the solution), and then refocus on the task by saying, ‘What is my job right now for this event?’”—Do BLS (6–12 sets)

“Remember how important it is to stay focused on the event. There is limited time. You need to stay present and let go of any concerns to get the best possible results. To this end it is useful to hold the intention, ‘I will move through my performance, staying on task, no matter what comes up.’”

5.  Assist the client with installing an Expanded Future Template as follows: “Please imagine the entire performance. When a distraction intrudes, ask yourself, ‘Is this useful right now?’ Build in a plan. Go back on task by saying, ‘What is my job right now?’ And continue until you can visualize the entire event. Imagine the event as fully as possible and notice your posture, muscle movements, voice quality, gestures, and so forth. Let me know when a distraction arises, and we’ll use BLS to help move it to the background by putting a plan in place and returning to the task.”

6.  Continue this until the client can move smoothly through the entire performance.

7.  Using BLS, install the entire performance from start to finish with the client staying focused on the task throughout: “Now that you have your distractions under control, please run your performance from start to finish, feeling your body fully.” “We will use BLS let me know when you’re finished.” Do BLS (6–12 sets)

COMPASSION STRESS INJURY IN THE HEALERS OF WARRIORS AND EMDR

The occupational hazards in the military are regular exposure to chronic, inescapable, and potentially traumatic stress. Exposure to stressors such as war or combat does not predestine one to cultivate war stress injury. In fact, many who have gone to war report quite positive stress effects and even post-traumatic growth. A similar two-sided coin exists with other vocations. Helping professions, particularly psychotherapists and the healers of warriors, endure occupational hazards of exposure to chronic stress and traumatic events that may lead to compassion-stress injury such as compassion fatigue or burnout, as well as increased compassion satisfaction or traumatic growth (Figley, 2002). The variety of labels used to describe the phenomenon (e.g., secondary, vicarious, and fatigue) are accurate, but incomplete. They imply that the exposure to someone’s trauma or PTSD symptoms was either somehow internalized or ingested by the witnessing person, or that the helper is temporarily in a tired or exhausted state, just needing rest—precisely the military’s thinking when terms like “battle fatigue” and “combat exhaustion” were adopted in favor of shell shock and traumatic neurosis. Anyone with the capacity for experiencing compassion, empathy, concern and caring is vulnerable to compassion-stress injury. We try to stay within professional boundaries and adhere to training guidelines, but our greatest strength (empathy) is also our greatest vulnerability. Not a characteristic most in the helping professions want to give up.

The Healer Occupational Hazards

There is a dose-response relationship with the more intense the traumatic circumstances of the clients, the cumulative effects pose greater risk to the therapist. Other risks include: (a) repeated exposure to traumatic events, (b) exposure to intense emotional or physical pain, (c) carrying out difficult and exhausting tasks, (d) exposure to unusual demands to meet others’ needs, (e) feelings of helplessness, (f) frequently facing moral/ethical dilemmas, (g) exposure to anger and/or lack of gratitude, (h) frustration with bureaucratic policies, (i) heightened sense of lack of control, and (j) being reminded of one’s own traumatic experiences. In terms of symptoms, compassion stress and fatigue invoke the similar spectrum of physical, cognitive, social, emotional, spiritual, and behavioral effects of human adaptation to chronic, inescapable, and potentially traumatic stress (e.g., Figley, 2002).

Therapists’ Potential Impairment Indicators (The Silencing Response)

In regards to their relationship with clients, therapists experiencing compassion fatigue sense a reduction in their baseline empathy for others, feel numb to patients’ and families’ pain, are cynical regarding clients’ ability to change, and/or perceive them as being responsible for many of their problems. In addition, certain “silencing behaviors” may be evident: (a) avoiding certain topics, (b) providing pat answers, (c) minimizing client distress, (d) suggesting the client “get over it,” (e) feeling boredom during sessions, (f) expressing anger or sarcasm towards clients, (g) using humor to change or minimize the subject, (h) feeling incompetent, (i) faking interest or pretending to listen, (j) fearing what the client may say, (k) blaming clients for their experiences, (l) difficulty paying attention, (m) being reminded of one’s own traumatic experiences.

Prevalence of Compassion Fatigue

•  Thirty-three percent of behavioral health personnel reported a “high level” of burnout (U.S. Army, 2008).

•  Fifty percent of workers suffered from high or very high levels of trauma from helping others (Conrad & Kellar-Geunthar, 2006).

•  Thirty-seven percent of child protective workers experienced clinical levels of emotional distress associated with secondary traumatic stress (Meyers & Cornille, 2002).

Prevention of Compassion Stress Injuries

As with other stress injuries, healers can be proactive and take steps to reduce risk factors and increase protective factors as a means to prevent cumulative effects of compassion stress. Those protective variables are: (a) be well rested, (b) utilize your positive supportive connections to process your feelings, (c) take negatives and turn them into positives, (d) know how to turn off thoughts about work to be more resilient during your career, (e) exercise, and (f) have good social support. Like war stress injuries, early identification and intervention is key to avoid chronic or long-term health effects.

USING EMDR TO PREVENT AND TREAT COMPASSION STRESS AND FATIGUE

Preventing Compassion Stress Injuries with EMDR

After the author’s (Mark Russell) unceremonious introduction to the stark consequences of not practicing adequate self-care and taking compassion fatigue seriously, a search was made to ensure there would be no recurrence. Warning! If therapists allow a compassion-stress injury to progressively worsen to the point of collapse, there will usually be some modest to serious long-term health and professional repercussions. Transient, intermittent periods of compassion fatigue, like any stress-injury, are a common and often unavoidable hazard of the mental health occupation. However, unlike combat veterans and other survivors of traumatic stress injuries, compassion-stress injuries are entirely preventable.

Regular self-screening for compassion stress injury can be an effective way to monitor things, but we all need to have other means to assure the balance of protective factors far outweighs the inescapable risks. We all know that activities like regular physical exercise, recreation, social engagement, spirituality, relaxation, and moderation of diet are essential to keep us healthy, but they are absolutely critical to thwart the preventable type of chronic stress injury.

Case-Study: EMDR Compassion-Stress Prevention “Protocol”

Therefore, a compassion-stress EMDR “protocol” was researched, designed, and pilot tested by the author to avert the cumulative effects of exposure to chronic, inescapable, and potentially traumatic stress. After 3 years of implementing the self-care model, it is ready to be published in the public domain. The build-up is really overselling. In a nutshell, in addition to the traditional stress-management package, every day after work, or after a particularly stressful or demanding day, the author puts on the headphones from a Neurotek portable EMDR device and listens to the rapid bilateral tone, while recalling the daily events in mind. The images, thoughts, and visceral reactions are concentrated upon while listening to the BLS. On average, approximately 10 minutes a day will suffice, but if needed or on especially troublesome days, maybe a few minutes more. While still on active-duty, there was an old Neurotek in the work office, one of the first generations, but it still worked fine.

In 2008, a year before leaving, it was decided to incorporate EMDR into the compassion-stress management program in order to prevent the cumulative effects of ongoing stress and exposure to traumatic stress reactions from triggering a relapse. Therefore, every day at work, during the short breaks, in between seeing traumatized combat veterans, 10 minutes after the clinic closed (before returning home), and, upon arrival at the office, 10 minutes before the first client, time was devoted to the BLS—10 minutes of focusing on the BLS and sympathetic arousal, while thinking about the to-do list, specific clients, picturing answering the phone, or pager, and other stimuli that came to mind. Having implemented this “protocol,” it has reduced the amount of total persistent war- and compassion-stress symptoms from a 9 to maybe a 3 on average. That may not sound impressive, but a steady 3 is well within the functional range. There have been no further seizures or the other debilitating compassion stress symptoms for the past 3 years despite maintaining a fairly high stress load. Whenever traumatic scenes either witnessed first-hand or internalized from patients arise, the headphones come on and the intrusions are put-down. It needs replication, clearly—and probably hundreds of providers have done the same for years. No false illusion of discovery here—it just needs to be researched. For the enterprising reader, review the earlier section on occupations and prevalence of compassion-stress injuries.

Case Study: EMDR Treatment of Compassion Stress Injury

A fourth issue in treating compassion fatigue is assessing and enhancing social support. Psychotherapists gradually view themselves as others view them: someone who is an expert at helping others cope with life’s challenges. They seem to forget that they are human beings as well. A physician sometimes gets sick and needs another physician’s services, for example. Often the therapist has a rather limited social support system composed of colleagues and only a few intimate relationships. It is vital to increase the therapist’s support system in both numbers and variety of relationships so that she or he is viewed apart from the therapist persona. Moreover, some relationships may be a source of strain and stress. These toxic relationships are an additional demand and should be addressed (Figley, 1997).

Mitigating Mike’s Compassion Fatigue

A man in his late thirties (Mike) sought treatment from the second author (Charles Figley). His presenting problem was his feelings of guilt about his mother’s life-threatening condition and his inability to address his dysfunctional relationship with her.

Test results confirmed our assessment that he was suffering from compassion fatigue, a restricted social support network, and that he suffered from considerable traumatic stress. But rather than being the classic struggle between mother and son, it became obvious that there was some secret he had not disclosed yet. This secret was the fact that his mother was attacked by a dog and nearly killed and he felt somehow guilty about letting it happen, being the male.

During the next session, the treatment team shared the results with Mike, discussed the treatment options, and agreed upon a treatment plan. The plan was to increase his self-soothing and stress management skills (e.g., workbooks, video training), increase the number and variety of social supporters (e.g., through volunteer work and involvement in extracurricular activities), and utilize a cognitive-behavioral therapy approach that minimized exposure and clinical time that would result in desensitization (i.e., reduction or elimination of traumatic stress). He selected EMDR and the dog attack as the traumatic event. As an indicator of success, we would use the same case material he used in class (the young college student adjusting to being away and feeling guilty about leaving his anxious mother).

For the next five sessions, using EMDR, Mike worked through the dog attack, the first signs of his mother’s chronic illness, his sacrifices, feelings of resentment toward his mother, and the embarrassments he felt—particularly during his teenage years—having to take care of her mother.

By the final session Mike’s symptoms subsided (desensitization). He shifted from self-blame and self-hatred to a more realistic view of himself and his mother. The team discussed the clinical cases he found challenging were now interesting but rather routine. He recognized that he still has work to do; that he remains reactive around his mother. He is, however, patient with himself and confident that he knows that practice is necessary to be fully differentiated from his mother emotionally and, as a result, finds it easier to love and appreciate her.

Final Observations

It is vital that today’s psychotherapists continue to work with empathy and compassion. Yet, there is a cost to this work that is obvious to any practitioner working with the suffering. As the evidence mounts proving the negative consequences of a lack of self-care and the presence of compassion stress injury, so will the ethical imperative for the suffering practitioner to do something or something will be done for him. We cannot afford to not attend to the mistakes, misjudgments, and blatant clinical errors of psychotherapists who suffer from compassion fatigue. It is, therefore, up to all of us to elevate these issues to a greater level of awareness in the helping professions. Otherwise we will lose clients and compassionate psychotherapists.

Resources for Compassion Fatigue Prevention and Treatment
When Helping Hurts: Sustaining Trauma Workers
Produced by Gift From Within
(207) 236-8858 www.giftfromwithin.org

Compassion Fatigue Self-Tests
Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales-
III (Hudnall Stamm 1995–2002)
Secondary Trauma Scale (Figley, 1995)