1 of 33

Towards Trauma Informed:

Predictable Communication, Debriefing, and Responding to Stress Responses in Yourself and Others

Kim Griswold, MD, MPH and Medical Student Members of Human Rights Initiative

2 of 33

Speakers

Kim Griswold, MD, MPH, RN, FAAFP is Professor Emerita of Family Medicine, Psychiatry, and Public Health and the Health Professions at the University at Buffalo, and is Medical Director of the Human Rights Initiative. Dr. Griswold is an expert on providing care for refugees, asylum seekers, and survivors of torture.

Dora Kolin is a third year medical student at the Jacobs School of Medicine and is Director of Public Relations for Human Rights Initiative.

Elizabeth Kubiniec is a third year medical student at the Jacobs School of Medicine, Fulbright-García Robles scholar, and is Director of Community Outreach for Human Rights Initiative.

3 of 33

Towards Trauma Informed:

Predictable Communication, Debriefing, and Responding to Stress Responses in Yourself and Others

Kim Griswold, MD, MPH, RN, FAAFP and Medical Student Members of Human Rights Initiative

4 of 33

Who we are
Trauma informed care already at Jericho Road
Opening patient case
Suggestions to expand trauma informed care at Jericho Road
Clear and predictable communication with patients and clients
Debriefing practices and considerations
Recognizing and responding to stress responses in self and others
Closing patient case

Agenda

Elizabeth

We’ll be spending about 50 minutes together today. This will be our agenda:

Who we are and a brief overview of the ways we implement trauma informed care in our work
Like I mentioned, much of what you all do at Jericho Road is already trauma informed. We’d like to briefly review those areas
We’ll review a patient case and discuss some ways that you might use trauma informed practices when interacting with his patient
We’ll dive into some of the areas where trauma informed practices at JR might be expanded

Clear and predictable communication (could be as simple as what we’re doing right now - providing an agenda so a patient or client knows what to expect)
Debriefing practices and considerations
Recognizing and responding to stress responses

Closing patient case so you’ll be able to consider how to apply some of what we talk about today to provide trauma informed care

5 of 33

Who We Are

Forensic evaluations for asylum seekers

Through medical evidence, we increase the likelihood of an individual being granted asylum

Eliza and Dora

The Human Rights Initiative at UB was founded over 10 years ago by our fearless leader Dr. Kim Griswold, and is a medical student-run asylum clinic that provides forensic medical and psychiatric evaluations for asylum seekers. We work with physicians to document the physical and psychological torture that clients have been subject to and submit our findings to immigration court. Attorneys that we work with have told us that our work often makes the case for their clients.

This graph indicates the percent of our clients being granted asylum across recent presidencies, at acceptance rates ranging from 65-77%, asylum seekers with medical documentation of the ill-treatment they experienced are significantly more likely to be granted asylum than individuals without this documentation.

Here today to speak with you we have Dr. Kim Griswold, a family medicine physician and Jacobs School of Medicine Professor Emerita of Family Medicine and Psychiatry. She oversees Human Rights Intiiative and is an expert in caring for survivors of trauma and torture.

My name is Elizabeth Kubiniec, I’m a third year medical student that conducts these forensic evaluations with Dr. Griswold. Very briefly I’d like to thank Jericho Road as an organization, but specifically to my mentors here including Roseline, Nigist, Han Moe, Joyce, and Dr. Glick. I wouldn’t be in medical school without you

Other med students present??

6 of 33

Mollica, R., Brooks, R., Ekblad, S., & McDonald, L. (2014). The new H5 model of refugee trauma and recovery. In J. Lindert & I. Levav (Eds.), Violence and Mental Health. New York, New York: Springer Publishing Company.

H⁵ Model of Refugee Trauma and Recovery

Dr. Griswold

The H5 model includes 5 dimensions to recovery from trauma, with each dimension overlapping and the trauma story being central. This model was developed for refugees but may be applied to all communities traumatized by crime, poverty, etc…

Trauma Story:

-Central to the model

-Recounting the trauma story may be healing for the individual, and teaching for the listener

-4 elements of the trauma story include: The factual recount of events, the cultural meaning of the trauma experienced, enlightened view of the world as a result of having processed the trauma through their cultural lens, the development of a listener-storyteller relationship (may also be conceptualized as a student-teacher relationship)

Human Rights

- Human rights violations include both violence that an individual may have experienced outside of the U.S., as well as any transgressions against their humanity here in the U.S. (racism, failure to meet basic needs such as appropriate health care services)

Humiliation

-Humiliation is an instrument of violence, and any violation of one’s human rights may cause one to feel humiliated

-Humiliation may produce feelings of worthlessness and loss of self-efficacy

-Feelings of humiliation must be identified and addressed in order for an individual to heal and become situated once again in their power. The result of addressing feelings of humiliation may be a new and better worldview.

Healing (Self-Care)

-Just as our bodies heal following physical injury, our minds also being to heal following mental and emotional injury. Self-healing is the body and mind’s work done in an effort to construct new meaning from violence

-Trauma Story is an example of self-healing as it permits the release of thoughts and feelings that may be stalling the individuals healing

Health Promotion

-Survivors of trauma are at increased risk for many physical and mental health conditions.

-A preventive medicine and health promotion approach is needed to ensure health equity for the individuals

-These health promotion efforts should be made available to all survivors of trauma and address diet, exercise, stress reduction, sleep promotion, and beyond

Habitat

-A new area of research

-Quality of housing may be linked to an individual's ability to heal or lack thereof. Housing in safe neighborhoods, housing in buildings that are free of contaminants, and access to private spaces within housing are ideal to promote healing.

7 of 33

“No healing without justice”

Forms of justice that may promote healing include:

To have your story heard

To have your story believed

Recognizing and addressing humiliation

Achievements and accomplishments despite great adversity

8 of 33

What is Trauma Informed Care?

9 of 33

Clervil, R., Guarino, K., DeCandia, C.J., & Beach, C.A. (2013). Trauma-Informed Care for Displaced Populations: A Guide for Community-Based Service Providers. Waltham, MA: The National Center on Family Homelessness, a practice area of American Institutes for Research Health and Social Development Program.

Eight Core Principles of Trauma Informed Care

10 of 33

Trauma

Informed

Care is already in practice at Jericho Road!

11 of 33

Trauma

Informed

Care is already in practice at Jericho Road!

12 of 33

Trauma

Informed

Care is already in practice at Jericho Road!

13 of 33

Trauma

Informed

Care is already in practice at Jericho Road!

14 of 33

Trauma

Informed

Care is already in practice at Jericho Road!

15 of 33

Ms. Ali is a 25 year old female from Somalia here for a doctor’s appointment.

Many of our clients are patients of Jericho Road or current/past residents of Vive. The following case is not based on a real client, but has experiences similar to real clients.

16 of 33

Trauma history includes:

Victim of female genital cutting
Escaped an abusive romantic relationship and fled to South America
Traveled through the Darien Gap, arrived at the US-Texas border, and came to Buffalo
Her application for asylum is pending.

Many of our clients are patients of Jericho Road or current/past residents of Vive. The following case is not based on a real client, but has experiences similar to real clients.

You open Ms. Ali’s chart and see this history. What would you do next in each of these roles?

Front desk receptionist Nurse

Medical assistant Clinician

17 of 33

Many of our clients are patients of Jericho Road or current/past residents of Vive. The following case is not based on a real client, but has experiences similar to real clients.

We are often unaware of the trauma that others have experienced.

Trauma informed care is a systems approach to promoting safety, choice, collaboration, empowerment, and healing for all, regardless of trauma history.

18 of 33

Expanding Trauma Informed Care at Jericho Road: Clear and Predictable Communication

Clervil, R., Guarino, K., DeCandia, C.J., & Beach, C.A. (2013). Trauma-Informed Care for Displaced Populations: A Guide for Community-Based Service Providers. Waltham, MA: The National Center on Family Homelessness, a practice area of American Institutes for Research Health and Social Development Program.

Switchboard. (2023). Trauma Informed Care: A Primer for Refugee Service Providers. https://www.switchboardta.org/wp-content/uploads/2020/01/Trauma-informed-Care-A-Primer-for-Refugee-Service-Providers.pdf

Provide an agenda for the day/appointment

Set expectations together

Provide as accurate as possible information regarding timelines

19 of 33

Expanding Trauma Informed Care at Jericho Road: Clear and Predictable Communication

Clervil, R., Guarino, K., DeCandia, C.J., & Beach, C.A. (2013). Trauma-Informed Care for Displaced Populations: A Guide for Community-Based Service Providers. Waltham, MA: The National Center on Family Homelessness, a practice area of American Institutes for Research Health and Social Development Program.

Switchboard. (2023). Trauma Informed Care: A Primer for Refugee Service Providers. https://www.switchboardta.org/wp-content/uploads/2020/01/Trauma-informed-Care-A-Primer-for-Refugee-Service-Providers.pdf

Provide an agenda for the day/appointment

Explain confidentiality and how their information may or may not be used

Set expectations together

Provide as accurate as possible information regarding timelines

20 of 33

Expanding Trauma Informed Care at Jericho Road: Clear and Predictable Communication

Clervil, R., Guarino, K., DeCandia, C.J., & Beach, C.A. (2013). Trauma-Informed Care for Displaced Populations: A Guide for Community-Based Service Providers. Waltham, MA: The National Center on Family Homelessness, a practice area of American Institutes for Research Health and Social Development Program.

Switchboard. (2023). Trauma Informed Care: A Primer for Refugee Service Providers. https://www.switchboardta.org/wp-content/uploads/2020/01/Trauma-informed-Care-A-Primer-for-Refugee-Service-Providers.pdf

Provide an agenda for the day/appointment

Explain confidentiality and how their information may or may not be used

Obtain consent throughout and remind patients/clients that they may say no at any time

Set expectations together

Provide as accurate as possible information regarding timelines

21 of 33

Expanding Trauma Informed Care at Jericho Road: Debriefing Practices and Considerations

Hawker, D. (2018). The Debriefing Toolkit for Humanitarian Workers. https://www.chsalliance.org/get-support/resource/debriefing-toolkit-for-humanitarian-workers/

Alfonsi, A., Cottone, C., Hobika, K., Reese, A., Funez-dePagnier, G., Lazarov, V., Griswold, K., Cook-Cottone, C. (2023). Debriefing Student Volunteers after Medical Affidavit Interview: A Unique Student Oriented Approach. North American Refugee Health Conference. Calgary, Canada.

Our team has adapted the Debriefing Toolkit for Humanitarian Workers to suit the needs of Human Rights Initiative. Here we will present highlights from the Toolkit that may be adapted to suit the needs of Jericho Road staff, volunteers, and other personnel.

22 of 33

Expanding Trauma Informed Care at Jericho Road: Debriefing Practices and Considerations

Humanitarian workers are at increased risk experiencing psychological distress both during and after their service
Debriefing is effective in reducing this psychological distress

Hawker, D. (2018). The Debriefing Toolkit for Humanitarian Workers. https://www.chsalliance.org/get-support/resource/debriefing-toolkit-for-humanitarian-workers/

23 of 33

Expanding Trauma Informed Care at Jericho Road: Debriefing Practices and Considerations

What is debriefing?

Reflecting on work done

Principal objective is to reflect on accomplishments and identify areas for improvements

Reflecting on an individual's experiences and how they feel about them

Principal objective is to facilitate the individuals integration of experiences into their greater life experience and future endeavors

Operational Debriefing

Personal Debriefing

24 of 33

Expanding Trauma Informed Care at Jericho Road: Debriefing Practices and Considerations

During the first 24 hours following a significant adverse event, as individuals have not had enough time to process the occurrence, may be counter productive

At timed intervals such as once annually
At the end of an individual’s time at the organization
As requested

When to debrief?

When not to debrief?

25 of 33

Expanding Trauma Informed Care at Jericho Road: Debriefing Practices and Considerations

Debriefing for short periods of time of 20-60 minutes may feel rushed and may be counterproductive
Debriefs of minimum one hour, but preferably longer, are more likely to be beneficial

Quiet, well-lit space

At Jericho Road
At appropriate community spaces such as churches

One-on-one, couples/partners (even if a partner is not directly involved with Jericho Road), in affinity groups

How long to debrief?

Where to debrief?

26 of 33

Expanding Trauma Informed Care at Jericho Road: Debriefing Practices and Considerations

Who should lead debriefing?

Some individuals may prefer to be debriefed by folks that are apart of the organization, others may prefer an external debriefer

Individuals who are warm, affirming, non-judgmental, can maintain confidentiality, and have some experience working with populations like those served by Jericho Road.

Professional training in mental health is not required.

Two debriefers may be appropriate when working with groups

27 of 33

Expanding Trauma Informed Care at Jericho Road: Responses to Stress Responses in Self and Others in the Short Term

Piccolo, A. (2021, September). Trauma-Informed Primary Care of Refugees. University of Virginia School of Medicine, Family Medicine. https://med.virginia.edu/family-medicine/wp-content/uploads/sites/285/2021/11/PIccolo_Trauma-Informed-Care-of-Refugees_Final-October-2021.pdf

Validate

“Your response is normal for the stress you have experienced.”

Make Space for Emotion

Allow for silence
Offer to take a break
Offer to postpone the service to a later date
Ask the individual how they would like to proceed

Identifying Strengths to Facilitate Coping and Healing

Resilience!
Family and friends
Skills and hobbies

Real-Time Interventions

Box breathing
54321 grounding
Encourage regular practice of these skills

28 of 33

Long-Term Efforts to Prevent Stress Responses in Patients and Providers: Balint Groups

The American Balint Society. What is a Balint Group? https://americanbalintsociety.org/what_is_a_balint_group.php

Regular, structured meetings for a group of individuals that hold the same professional role to discuss patient cases and explore the interpersonal elements of their relationship to patients.

The principal goal of Balint Groups is to better service providers’ ability to build meaningful relationships with clients and patients.

29 of 33

Balint Groups

Clinical case presentation

Facilitated discussion on interpersonal aspects of patient care

Improve communication between patients/clients and providers

Promote provider empathy

Grow community around providers to decrease isolation

The American Balint Society. What is a Balint Group? https://americanbalintsociety.org/what_is_a_balint_group.php

30 of 33

Trauma history includes:

Victim of female genital cutting
Escaped an abusive romantic relationship and fled to South America
Traveled through the Darien Gap, arrived at the US-Texas border, and came to Buffalo
Her application for asylum is pending.

Many of our clients are patients of Jericho Road or current/past residents of Vive. The following case is not based on a real client, but has experiences similar to real clients.

Think about what we discussed today:

What might you say to provide Ms. Ali a trauma informed experience?
What might you do to provide Ms. Ali a trauma informed experience?
What might you do if you, a colleague, or Ms. Ali experienced a stress response during your time together?

31 of 33

Wrap-Up

Today’s session was a brief survey of trauma informed care and how it may be expanded at Jericho Road
Many critical topics such as Adverse Childhood Experiences and Adverse Community Environments were not addressed during this short time
The references section includes resources you may review

Questions, Comments, Discussion?

32 of 33

References and Resources

Mollica, R., Brooks, R., Ekblad, S., & McDonald, L. (2014). The new H5 model of refugee trauma and recovery. In J. Lindert & I. Levav (Eds.), Violence and Mental Health. New York, New York: Springer Publishing Company.

Clervil, R., Guarino, K., DeCandia, C.J., & Beach, C.A. (2013). Trauma-Informed Care for Displaced Populations: A Guide for Community-Based Service Providers. Waltham, MA: The National Center on Family Homelessness, a practice area of American Institutes for Research Health and Social Development Program.

Hawker, D. (2018). The Debriefing Toolkit for Humanitarian Workers. https://www.chsalliance.org/get-support/resource/debriefing-toolkit-for-humanitarian-workers/

Alfonsi, A., Cottone, C., Hobika, K., Reese, A., Funez-dePagnier, G., Lazarov, V., Griswold, K., Cook-Cottone, C. (2023). Debriefing Student Volunteers after Medical Affidavit Interview: A Unique Student Oriented Approach. North American Refugee Health Conference. Calgary, Canada.

Switchboard. (2023). Trauma Informed Care: A Primer for Refugee Service Providers. https://www.switchboardta.org/wp-content/uploads/2020/01/Trauma-informed-Care-A-Primer-for-Refugee-Service-Providers.pdf

Piccolo, A. (2021). Trauma-Informed Primary Care of Refugees. University of Virginia School of Medicine, Family Medicine. https://med.virginia.edu/family-medicine/wp-content/uploads/sites/285/2021/11/PIccolo_Trauma-Informed-Care-of-Refugees_Final-October-2021.pdf

The American Balint Society. What is a Balint Group? https://americanbalintsociety.org/what_is_a_balint_group.php

33 of 33

Thank You!

Please contact us with questions or to get involved with our work performing forensic evaluations for asylum seekers

Email: wnyhrc@gmail.com

Instagram: @hribuffalo

Website: www.hribuffalo.com