Spirituality, Silence, Lament & CISM: Lessons to Last a Lifetime

By: Rev. Heather McDougall, BCC & Rev. Dr. Sarah Samson, BCC

Despite being part of a prior generation’s music, Simon & Garfunkel’s 1964 hit single, “The Sound of Silence”, still strikes a chord of truth. Don Saliers, Emory University Professor of Theology, spoke of the prophetic purpose that silence can serve in our world. “Silence can be a friend in the midst of chaos, but it can also point us towards a difficult ambiguous reality,” Saliers noted.[1]

Silence points to the reality that, since the beginning of time, we are wounded healers living in a lamentable world seeking ways to express sorrow, mourning or regret. Within the theological context of Jewish and Christian Scripture, lament, like silence, serves a prophetic purpose. The Psalms are intended to express empathy for people suffering because of great loss. For many writers of Psalms, it was the need to ventilate a lived experience that gave them permission to cry out. The purpose of lament is to help us remember while also giving permission to name our rhetorical “why” question. It allows us to ask why, while clinging to the promise of hope in the midst of living and working in a lamentable world.

As chaplains and part of Beacon Health System’s SHINE Team[2], we have become very aware of the prophetic purpose of both silence and lament. The Mitchell model is similar to the psalmist style in that it gives value to silence and space for the lamentable. In facilitating debriefings, especially during this pandemic, the most valuable ones have utilized silence as a debriefing technique. The Mitchell model is the peer support model that helps teams come together, allowing space for silence creating the space for team members to access feelings, thoughts and emotions while honoring their work and skill offered in the midst of lamentable circumstances. In our hospital CISM context, silence as a debriefing technique has proven essential in three main ways in this difficult, anxiety-fraught time.

First, silence offers a means to gather one’s self; to be present with a group to process and debrief in an increasingly noisy setting. The work of dedicated frontline healthcare professionals during the pandemic that is ongoing and resurging is exhausting. Seven months in and many have personally dealt with COVID-19 only to rejoin the frontlines upon recovery. This pandemic is the abnormal global health crisis consistently reminding us every day that we live in a lamentable world. The Mitchell model offered a process to gather staff.

Instead of holding debriefings spurred by a particular critical incident, our SHINE Team held debriefings of the experience of weeks of a pandemic – knowing that we are only in the middle of this experience. One particularly meaningful SHINE Pandemic debriefing was with our respiratory therapy team providing them with the opportunity to lament the uncertainty and questioning regarding the level of personal protective equipment, anger at misleading comments on social media venues, and fears when conducting aerosolizing procedures on COVID-19 positive patients. The debriefing space, with times of silence and lament, allowed our respiratory therapists to find space to gather themselves in the midst of ventilator alarms, phones and rapid assessment team pages.

Secondly, silence in the context of debriefing allows emotions to catch up to cognitive thoughts helping them be formed into words. As a group silently laments, emotions can mindfully work themselves out. One of the Mitchell model questions, “if you could change anything, but not the outcome what might that be for you”, holds particular weight in our setting. This question helps clarify what, for each person, is most lamentable. After they name that, allowing time for silence can give the space to acknowledge and cry out for that which is beyond our control, to dwell with the hard and difficult. Mindfulness, as Dr. Kristen Neff describes it, means that “when you focus on the fact that you are having certain thoughts and feelings, you are no longer lost in their story line.”[3] The story line of coronavirus is a lot to get lost in and our frontline workers can easily be buried in the rising numbers, media coverage, positivity rates, CDC changes and so much more. Silence in a debriefing session gives their thoughts a rest; their minds have an opportunity to be mindful that they are having a normal response to an abnormal situation.

The teaching phase of the process is a reminder not only to the team, but to the debriefers as well, to practice mindfulness in self-care. One specific part of the teaching phase honors our uniqueness while normalizing a framework for healing by talking about the five T’s of the healing and recovery process. These five T’s include time as we all find ways to navigate in pandemic fatigue and, at times, holding space with others. Tears, the ability to normalize and give permission to cry, are valuable as a sign of lament, debunking the myth that tears are a sign of weakness. Tolerance, is simply extending grace to others on the team and ourselves to be patient and understanding as pandemic fatigue is impacting us all in different ways. Talk which translates into creating space for teams to come together for support, care, honoring the way they give tirelessly shift after shift. This space allows us to pause and process on a thoughts, feelings and reactions level of what we have experienced and what anxieties come up in order to build resiliency and strengthen team work. And, finally, Touch as a means of creating safety and security.

Thirdly, silence is a helpful way to bookend and frames a debriefing session. In the hospital setting there is such a continual sense of noise and alarm fatigue.   Sacred space can be hard to come by in the hospital and to hold silence seldom happens. A national study conducted in 2017 found that 20% of intensive care nurses showed high levels of depersonalization and 40% felt a low sense of personal accomplishment. And yet, despite showing signs of burn-out, two thirds of ICU staff nationally work in intensive care settings until retirement.[4] As hospital budgets get tighter and reimbursements from Medicaid and Medicare shrink, healthcare staff is moving away from the ‘my job is a calling’ mindset to the ‘in it for the paycheck’ mindset. This shift in staff’s sense of purpose has distinct burnout indicators according to the Maslach Burnout Inventory.[5]

Healthcare professionals have a unique situation: complex settings of public-facing jobs with high-risk decisions. This setting of high stress and constant scrutiny contributes to the anxiety as there are no ‘quiet mistakes’. Healthcare staff with direct patient contact experience stress, burnout, and vicarious trauma that lead to a decrease in staff wellness, low staff retention rates, and, ultimately, poorer patient outcomes.[6] The hospital environment is becoming more intense with greater illness acuity and a push for quicker discharges. The effectiveness of mindful practices for managing healthcare staff stress and burnout is a quickly growing field of interest in light of the growing intensity.[7]

A contributor to www.mindfulness.org, Jennifer Wolkin, wrote, “by charting new pathways in the brain, mindfulness can change the banter inside our heads from chaotic to calm.”[8] The practice of mindfulness has the capacity to shape and rewire our brains which can then impact our functioning.[9] The hospital environment is a breeding ground for excessive banter and chaotic mental clutter. As Wolkin goes on to describe,

The impact that mindfulness exerts on our brain is born from routine: a slow, steady, and consistent reckoning of our realities, and the ability to take a step back, become more aware, more accepting, less judgmental, and less reactive. Just as playing the piano over and over again over time strengthens and supports brain networks involved with playing music, mindfulness over time can make the brain, and thus, us, more efficient regulators, with a penchant for pausing to respond to our worlds instead of mindlessly reacting.[10]

Although patterns of reactivity may be well-established and influential, we are not stuck in those patterns; our brains have the capacity to change and be responsible versus reactive.[11]

The practices of mindfulness and of the five T’s of recovery are not possible without inserting silence into one’s debriefing sessions and creating a sense of sacred space. In an increasingly tense workplace that has higher acuity patients, more patients, less staff and a pandemic, it brings a stark awareness to the reality that silence can be a friend in the midst of chaos and can point us towards difficult ambiguous realities while living and working in a lamentable world. The Mitchell model when it prophetically utilizes silence creates the space for lament, for peer support in a way that helps to support and sustain clinical teams in the short-term with eyes on sustaining and supporting them in their long-term vocational calling.

Rev. Heather McDougall, BCC

Rev. Dr. Sarah Samson, BCC

References:

[1] Saliers, Don. (2015) Psalms in Our Lamentable World. Yale Journal of Music & Religion. Vol.1. No.1 Article 7.

[2] SHINE is an acronym for “Supporting Health in Negative Events” and is our debriefing program based off Mitchell’s CISM model.

[3] Neff, Kristin. Self-Compassion: The Proven Power of Being Kind to Yourself Harper Collins (New York): 2011, 87.

[4] Mirjana Cubrilo-Turek, Roman Urek, and Stjepan Turek, “Burnout Syndrome – Assessment of a Stressful Job among Intensive Care Staff,” Collegium Antropologicum 30.1 (Mar 2006): 131.

[5] The Maslach Burnout Inventory is an internationally recognized measure of staff burnout that developed in response to chronic emotional strain. “Maslach Burnout Inventory (MBI),” Statistic Solutions: Advancement Through Clarity, accessed November 24, 2016, http://www.statisticssolutions.com/maslach-burnout-inventory-mbi/.

[6] Matthew J. Goodman and John B. Schorling, “A Mindfulness Courses Decreases Burnout and Improves Well-Being Among Healthcare Providers,” The International Journal of Psychiatry in Medicine 43, no. 2 (2012): 121, http://doi:10.2190/pm.43.4.1.

[7] Paramabandhu Groves, “Mindfulness in Psychiatry – Where Are We Now?” BJ Psych Bulletin 40, no. 6 (December 2016): 289, http://doi: 10.1192/pb.bp.115.052993.

[8] Jennifer Wolkin, “How the Brain Changes When You Meditate,” September 20, 2015, accessed February 28, 2018, https://www.mindful.org/how-the-brain-changes-when-you-meditate/.

[9] Mindfulness is the Apostle Paul’s call in Romans 12 to be transformed by the renewing of our minds.

[10] Wolkin, “How the Brain Changes When You Meditate.”

[11] Daniel J. Siegel, The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are, (New York, NY: Guildford Press, 1999), 75.