Creating Positive Cultures of Care Trauma Informed Workforce Development: Healing the Healers Raul Almazar Senior Consultant SAMHSA’s National Center for Trauma Informed Care National Assoc of State Mental Health Program Directors Compassion Fatigue Compassion Fatigue refers to the profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate. Vicarious trauma has been used to describe the profound shift that workers experience in their world view when they work with clients who have experienced trauma. Helpers notice that their fundamental beliefs about the world are altered and possibly damaged by being repeatedly exposed to traumatic material. www.workshopsforthehelpingprofessions.com Trauma Exposure Response is the professional and personal effect of exposure to other people’s suffering; imposed on our personal history. Burnout is a term that has been used a great deal to describe the physical and emotional exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work. Burnout does not necessarily mean that our view of the world has been damaged, or that we have lost the ability to feel compassion for others. Biological Trauma lives in the body. The body has ways to indicate to us that a threat cue is perceived. Stress/Trauma Lives in the Body • A chronic overreaction to stress overloads the brain with powerful hormones that are intended only for short-term duty in emergency situations. • Serum cortisol levels • Chronic hyperarousal – nervous system does an amazing job of preparing the individual to deal with the stress but: almazarconsulting.com Growth, reproduction and immune system all go on hold Leads to sexual dysfunction Increases chances of getting sick Often manifests as skin ailments Increases permeability of the blood brain barrier Dr. Robert Sapolsky: “Why Zebras Don’t Get Ulcers” – study on salmon Serum Cortisol • Bruce Perry • Cortisol Response to a Cognitive Stress Challenge in PTSD Related to Childhood Abuse Finding: There were elevated levels of cortisol in both the time period in anticipation of challenge (from time 60 to 0) and during the cognitive challenge (time 0–20). PTSD patients and controls showed similar increases in cortisol relative to their own baseline in response to the cognitive challenge.(Bremner, Vythilingam, et al 2002) almazarconsulting.com Some Stressors: Fiscal and funding cuts Downsizing/organizational changes/ mergers DIfferent payor systems Regulatory changes Role changes Reimbursement changes Do more with less Practice changes New metrics Natural organizational events almazarconsulting.com Impact on the Individual Loss of meaning and purpose Decreased creativity Inability to innovate Absenteeism Retreating into the familiar Distracted, unfocused Physical health effects almazarconsulting.com Organizational Impact Turnover Workers Compensation Loss of market advantage Decreased productivity Creation of additional positions to supplement lagging productivity Increased training costs With an unhappy workforce - more susceptible to litigation Sustained stress response imbedded in the organizational culture almazarconsulting.com 2009 GALLUP POLL EMPLOYEE ENGAGEMENT INDEX • 33% - Engaged in their jobs • 49% - Are not Engaged • 18% - Actively Disengaged almazarconsulting.com Inverted “U” Response • At optimum levels, the biochemical changes allow us to function at a higher capacity during stressful events. However, if the stress continues too long or is too overwhelming, functioning becomes impaired rather than enhanced Biochemical changes during and after the traumatic event • Damage of the neuroreceptors that control the stress response • Increase of receptors for cortisol, with the result that it is easier to be triggered – Vicious cycle - less able to switch off the stress, which produces more of the stress hormones that damage the neuroreceptors that control the stress response…. More on changes as the result of too much stress • Chronically high cortisol levels – Insulin resistance, poor sleep patterns – reinforces bad eating habits – no energy to exercise – Can produce cytokines, a protein that promotes inflammation – linked to heart disease, depression, arthritis and fibromyalgia – Impacts regulation adrenalines – implications for hippocampus and addiction Biochemical changes during and after the traumatic event • Increased opioid levels during traumatic memory triggers – equivalent of 8 mg morphine • Acoustic startle response (when ya jump at loud, unexpected noises) • Vasopressin - stress headaches? • Oxytocin - Damage to traumatic memory recall. Bonding to a perpetrator • Reduction of the hippocampus Parallel Process between Traumatized Individuals and Traumatized Organizations (Adapted from Organizational Trauma as Barrier to Implementing Trauma Informed Care by Sandra Bloom) almazarconsulting.com Individual Organization Lack of Basic Safety Lack of Emotional Management Dissociation, Amnesia, Fragmentation of Function Erosion of trust Lack of physical self-care Lack of psychological safety Crises driven, hypersensitive to minor threats Responds with counter-aggression – increased rules, etc Regular forums to manage emotions cease to function Fragmented service delivery – increased silos Reverting to old ways of doing things Identity confusion – failure to get on the same page almazarconsulting.com Individual Organization Systematic Error Communication networks break down Organizational boundaries become overly rigid or overly permeable Failure to mobilize as a system Increased Authoritarianism Failure of leaders to apply different leadership styles commensurate to demands Informal leadership usurps the power Impaired Cognition and Silencing of Dissent Disorder, hypocrisy and chaos Poor judgments, failure to consider alternative viewpoints almazarconsulting.com Individual Impoverishment of Relationships Organization Communication failures lead to decreased conflict resolution Problems cannot be openly discussed Lack of transparency Making the same mistakes over and over Learned helplessness Extremely risk avoidant Increased Aggression Using a system of rewards and punishment that do not address core issues Staff “self-injures” through increased absenteeism, poor performance, increased use of workers’ comp Vicious gossip and malicious rumors almazarconsulting.com Disempowerment and Helplessness Individual Organization Unresolved Grief Failure to evaluate effectiveness of treatment Focus is on Quality Assurance vs. Performance Improvement More attention on what’s going wrong Failure to address losses Continued reenactment (practice) of ineffective treatment strategies Loss of Meaning and Demoralization Hopeless, helpless and demoralized staff Leadership that is burned out that becomes cynical of their staff and people served Loss of vision and true purpose almazarconsulting.com 16 Warning Signs of Trauma Exposure Response From “Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others” 2009 Laura van Dernoot Lipsky with Connie Burk almazarconsulting.com ORGANIZATIONAL Climate vs. Culture • Organizational Climate – shared perceptions of policies, practices and procedures present within an organization. (Reichers & Schneider, 1990) Observable manifestations of the organization • Organizational Culture - underlying core values of an organization that are inherent, rather than observable. ( Bochner, 2003) Psychosocial Safety Climate The shared belief held by workers that their psychological safety and well-being is protected and supported by senior management. Defined as an organization or team level construct that refers to policies, practices and procedures that are upheld by managers and leaders for the protection of worker psychological health and safety (Dollard and Bakker, 2010) 16 Warning Signs… 1. Feeling Helpless and Hopeless “Why am I even getting out of bed?” First – individual hold himself responsible for a situation when no one could reasonably be expected to master it. Two – Individuals perceive the traumatic event will be long-lived Three- Individual believe they are likely to repeat their current struggles 2. A Sense that One Can Never Do Enough Internalized oppression almazarconsulting.com 3. Hypervigilance Wholly focused on our job, focusing on anything else seems impossible Always “on” 4. Diminished Creativity The deeper we sink into a culture of trauma, the less flexible and original our thinking becomes. Creativity requires embracing a certain amount of chaos, demands some leaps of faith. almazarconsulting.com 5. Inability to Embrace Complexity Clear signs of good and bad, right and wrong, needing to take sides Need to be certain 6. Minimizing Comparing situations to more dire events Putting suffering in a hierarchy almazarconsulting.com 16 Warning Signs 7. Chronic Exhaustion/ Physical Ailments Bone-tried, soul-tired, heart-tired Can’t remember the time you were not tired You have been around the block – wary of optimism Body keep the score 8. Inability to Listen/ Deliberate Avoidance Cup runneth full Highlight of your workday is when you don’t have to do your job almazarconsulting.com 9. Dissociative Moments Cut ourselves off from our internal experience 10. Sense of Persecution Profound lack of efficacy in one’s life Choosing to remain powerless in the face of adversity Martyrdom 11. Guilt Survival, good fortune almazarconsulting.com 16 Warning Signs 12. Fear Intense feelings Personal vulnerability Potential victimization 13. Anger and Cynicism Afraid of anger 14. Inability to Empathize/ Numbing Amp up feelings or numb Adrenaline crush almazarconsulting.com 15. Addictions Adrenaline rush addiction 16. Grandiosity: An Inflated Sense of Importance Related to One’s Work Work is the center of our identity almazarconsulting.com Exercise – Choose Your Focus • Think of a challenging work situation. Write down 3 things that make it challenging. Write down 3 things that you appreciate about it. • Look at your list and ask yourself, “Where am I more likely to focus and why?” almazarconsulting.com Culture is…. A pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and therefore, to be taught to new members as the correct way you perceive, think and feel in relation to those problems. Edgar Schein Organizational Culture and Leadership almazarconsulting.com Healing Organization Adjective An organization whose mission is to help people get well Verb An organization actively restoring its health, making itself whole almazarconsulting.com Healing Organizations • Emphasize humanity and the worth of people as whole human beings • Emphasize the flexibility in the system - a system that values people can give flexibility to those who are in pain without losing its ability to function at a high level • Emphasize the value of the organization as a community - work organizations are among people's primary communities of support. People often find comfort and worth in coming together. People will take great comfort and feel less uncertain about their own lives if the workplace offers them a chance to come together with others and to acknowledge the stressors. almazarconsulting.com Healing Organizations contd. • Emphasize that range of emotions are normal – A wide range of emotions is normal under stress. When leaders emphasize that a wide range of emotions is normal, it allows people more freedom to use their emotions as a part of their work, instead of spending energy ignoring them. • Emphasize the organization's core values - Each organization will have a different set of core values that guide the response to a crisis. People in the organization will look to these values as a framework in which they can act. Emphasizing these values and the way they are guiding the organization's response will free people to think creatively about the values and how they fit within them. (Michigan – Ross School of Business) almazarconsulting.com Why Compassion Counts in Organizations • Compassionate responses create attachment to the organization - people who talk about working in a compassionate environment invariably also talk about the importance of their work and their commitment to the job and the employer. • Compassionate responses create resilience in the organization - organizations that are nimble in response to trauma help to generate additional effort from some to make up for reduced effort from othersin essence maintaining a high-performance capability even while allowing people flexibility. In addition, because they allow people the flexibility and emotional responses necessary for healing, they create resilience in people and bounce back from losses more quickly. almazarconsulting.com • Compassionate responses generate ongoing capability in the system - when people in the organization experience the healing capacity of the system, they also learn and generate response capability that can be put to use in their day-to-day work and in response to other events that affect the organization. People in the workplace meet new colleagues, learn new routines and re-establish the importance of the values of the organization as they respond to a trauma. This learning builds the ongoing capability of the organization as a whole. almazarconsulting.com Protective Factors • • • • • Connectedness Social Support Shared Values Commitment Self Determination Workforce Development Components • Training • Staff Appreciation • Staff Empowerment almazarconsulting.com Training • Training needs to be viewed within an organizational context • Training for knowledge acquisition vs. as catalyst for change • Training organizations under stress • Although "selling" positive visions is an essential element for successful change, focusing on it solely may lead an organization to ignore those who are "broken" from the changes and in need of healing. (De Klerk, 2007) almazarconsulting.com Barriers to Training Implementation • Parallel Process – People served, staff and administration • Training occurs in the absence of a clear organizational vision/ framework • Failure to develop/implement infrastructures for transforming training into practice • Leadership failure to market training • Organizational Stress as Barrier to Trauma Sensitive Change (Bloom, 2006) almazarconsulting.com Leaders need to: • Honor the past • Understand the past • Accepting leadership’s role and responsibility for the present culture • Understand the development of silos for selfpreservation almazarconsulting.com Staff Healing • Staff Appreciation – reinforce the belief that one is cared for and valued • Staff Empowerment – having choices and control of one’s life promotes selfdetermination almazarconsulting.com • Help staff find hope and meaning in their work • Ignite the passion! • Trauma-informed for everyone • Develop a coherent and cohesive model of inpatient treatment • Physical, psychological, moral, social safety (Bloom) almazarconsulting.com Physical Safety Sense of being safe, living in a physically safe space Physical/Biological Safety Good health practices Occupational security and sound financial management almazarconsulting.com Psychological Safety Sense of mastery over one’s life Living in a world that has some predictability Ability to express ones’ creativity Self-efficacy Presence of structure and organization within which one can try new ideas Ability to make sense of what has happened/ is happening almazarconsulting.com Moral Safety Having a sense of meaning and purpose Sense of hope and empowerment Firm belief in Recovery, Recovery as a moral imperative Sense of integrity, courage and justice Providing and receiving the most effective treatment Appropriate use of power to promote health and healing Practicing democratic principles almazarconsulting.com Social Safety Sense of feeling secure, cared for, trusted Ability to express oneself Ability to be safe with other people Acceptance of differences and diversity almazarconsulting.com Staff Support and Appreciation Strategies and Examples Revisit and reiterate expected program practices and staff skills (emotional safety is enhanced when people know what is expected of them) Establish or revise staff competencies based on program model and values Pay attention to middle management (supervisors) • Role model almazarconsulting.com Staff Appreciation and Support • • • • • Formal and informal Recognition of individuals who exhibit values Values-based hiring Constant praise and feedback Resources are made available for people to do their work • Task forces/workgroups run by staff to solve issues (peer council) almazarconsulting.com Staff Appreciation and Support • Respect for staff’s time • Showing flexibility and individual attention • Coach on clinical issues, competency and play Significant attention to self-care, individual and organizational wellness almazarconsulting.com Staff Autonomy Having control of one’s life and choices promotes self-determination • Shared decision making • Staff are experts at what they do • Self scheduling, designing their own environment • Ask staff to design these initiatives almazarconsulting.com Supervision Strength-based and resiliency-based supervision • Distinguish between clinical and administrative supervision • Supervision structure/ coaching framework that is clearly defined • Planned and spontaneous supervision • Formal 1:1 supervision almazarconsulting.com Supervision cont. • Supervision for values clarification • Supervision times sacred • Supervision is what sustains initiatives Administrative supervision: Amabile of Harvard Business School: “Intrinsic motivation is conducive to creativity; controlling extrinsic motivation is detrimental” almazarconsulting.com Examples • All staff meeting after a significant incident – grieving, debriefing , processing and healing • The more intense and frequent the exposure, the longer the recovery time • Friday in the Park, staff – led task forces, administrative coverage in the programs • Understand the natural biological reactions – cortisol, adrenaline, cortical shutdown • Understanding and addressing community trauma • Partnerships within the community (Virginia) –explore external issues • Dallas County Program almazarconsulting.com Resilience Resilience is the ability to adapt well to stress, adversity, trauma or tragedy. It means that, overall, you remain stable and maintain healthy levels of psychological and physical functioning in the face of disruption or chaos The key is to not try to avoid stress altogether, but to manage the stress in our lives in such a way that we avoid the negative consequences of stress! Accept the fact that there will be certain levels of stress in your life, and work to manage it in a way that you avoid or minimize the negative consequences of the stress (Daniel, 2007) almazarconsulting.com Strategies for Building Resilience 1. 2. 3. 4. 5. 6. 7. 8. Maintain flexibility and balance in your life as you deal with stressful circumstances and traumatic events Let yourself experience strong emotions, and also realize when you may need to avoid experiencing them at times in order to continue functioning Step forward to take action, and also step back to rest yourself Rely on others, and also rely on yourself Make connections-- Family, friends, civic groups, faith-based organizations, other local groups Avoid seeing crises as insurmountable problems. You can change how you interpret and respond to stressful events Accept that change is a part of living. The only thing that is constant in life is change Do something regularly, even if it seems small, which enables you to move toward your goals (Daniel, 2007) almazarconsulting.com Strategies for Building Resilience 9. Take decisive actions rather than detaching completely and wishing problems and stresses would go away 10. Look for opportunities for self-discovery. People often grow in some respect as a result of their struggle with loss 11. Nurture a positive view of yourself. Develop confidence in your ability to solve problems; trust your instincts 12. Keep things in perspective. Keep a long-term perspective-avoid blowing things out of proportion (Daniel, 2007) almazarconsulting.com Strategies for Building Resilience 13. Maintain a hopeful outlook. Expect that good things will happen in your life; visualize what you want rather than worrying about what you fear 14. Take care of yourself. Pay attention to your own needs and feelings. Engage in activities you enjoy and find relaxing (Daniel, 2007) almazarconsulting.com Effective Stress Management Strategies almazarconsulting.com Healing is a matter of time, but it is sometimes also a matter of opportunity. Hippocrates almazarconsulting.com almazarconsulting.com